Respiratory Medicine Made Simple : Pneumonia

Get 23 % Discount on Dr Najeebs Lectures Life time Subscription at just 79 US Dollars. Go to the following Link: https://members.drnajeeblectures.com/#!/registration Fill in the details and enter Affiliate ID for discount : 1095912 and clickon Apply Affiliate Discount button during checkout to get a 23% discount for life subscription at a very reduced cost

PNEUMONIA:

An acute lower respiratory tract illness associated with fever,symptoms and signs in the chest and abnormalities on Chest X ray.

An inflammation of lungs caused by acute infection and characterized by recently developing signs of consolidation both clinically and radiologically.

CLASSIFICATION AND CAUSES

COMMUNITY ACQUIRED PNEUMONIA:

May be primary or secondary to underlying disease.

Most common cause is Streptococcus pneomonia.

This is followed by Haemophilus Influenzae and Mycoplasma pneumoniae

Other organisms include : Staphylococcus aureus,Legionella species,Morexalla catarrhalis and Chlamydia.

Rarer causes include : Coxiella Burnetti and anaerobes.

Viruses account for 15 % of causes.

Flu may be complicated by community acquired MRSA pneumonia (CA-MRSA)

HOSPITAL ACQUIRED PNEUMONIA

Occurs more than 48 hours after hospital admission.

Most commonly cased by Gram negative enterobacteria or Staphylococcus aureus.

Other organisms include the following :

Pseudomonas Aeuroginosa

Klebsiella

Bacteroides

Clostridia

ASPIRATION PNEUMONIA

This occurs due to poor swallowing and unwell patients with low GCS.

Increased incidence occurs in the following patients:

Stroke

Septicemia.

Bulbar palsies

Myasthenia

Decreased consciousness (post ictal)

Oesophageal diseases (Achalasia and reflux)

PNEUMONIAS IN IMMUNOCOMPROMISED PATIENTS

These are caused by the following organsims:

Streptococcus pneumonia

H.Influenzae

Staphycoccus aureus

Mycoplasma oneumonia

Gram negative bacilli

Pneumocystic Jirovecii/carinii

Fungi

Mycobacteria

Viruses: CMV , HSV

CLINICAL FEATURES

SYMPTOMS:

Fever

Rigors

Malaise

Anorexia

Cough

Dyspnoea/shortness of breath.

Purulent sputum

Haemoptysis

Pleuritic chest pain

SIGNS

Fever

Cyanosis

Confusion

Tachypnoea

Tachycardia

Hypotension

Signs of consolidation :Diminished expansion,dull percussion note,increased tactile vocal fremitus and increased vocal resonance,bronchial breathing and  pleural rub

INVESTIGATIONS

Objective is to:

Establish diagnosis

Identify the pathogen

Assess severity

CXR:

Lobar or multilobar infiltrates,cavitation or pleural effusion.

Assess oxygen saturation

Arterial blood gases if SaO2 less than 92 %

BLOOD TESTS: FBC,CRP,U&Es,BLOOD CULTURES

SPUTUM FOR MICROSCOPY AND CULTURE

ATYPICAL RESPIRATORY SEROLGY IN SEVERE CASES:

VIRAL SEROLOGY/COMPLEMENT FIXATION TESTS

PNEUMOCOCCAL ANTIGEN IN URINE

LEGIONELLA : SPUTUM CULTURE AND URINE ANTIGEN

PLEURAL FLUID ASPIRATION FOR CULTURE

BRONCHOSCOPY AND BRONCHOALVEOLAR LAVAGE IF PATIENT IS IN ITU OR

IMMUNOCOMPROMISED

ASSESSMENT OF SEVERITY

CURB – 65 SCORE IS USED TO GUIDE SEVERITY

1 SCORE FOR EACH OF THE FOLLOWING BELOW :

CONFUSION : ABBREVIATED MENTAL TEST SCORE LESS THAN OR EQUAL TO 8.

UREA > 7 MMOL/L

RESPIRATORY RATE  MORE THAN OR EQUAL TO 30/MIN

SYSTOLIC BLOOD PRESSURE LESS THAN 90 MM HGOR DIASTOLIC LESS THAN 60 mmHg

AGE MORE THAN OR EQUAL TO 65

MANAGEMENT OF PNEUMONIAS:

ANTIBIOTICS:

These are given orally if not severe pneumonia,and intravenous in case of sec=vere pneumonia

COMMUNITY ACQUIRED PNEUMONIAS:

MILD:

STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE:

Oral Amoxicillin 500 – 1 Gm 8 hourly or

Clarithromycin 500 mg 12 hourly or Doxycycline 200 mg loading and 100 mg 12 hourly

MODERATE:

STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE/MYCOPLASMA PNEUMONIAE:

Oral amoxicillin 500 mg – 1 Gm 8 hourly or Doxycycline 200 mg loading then 100 mg 12  hourly.

COMMUNITY ACQUIRED PNEUMONIA

SEVERE

STREPTOCOCCUS PNEUMONIAE/HAEMOPHILUS INFLUENZAE/MYCOPLASMA PNEUMONIAE

Co-amoxiclav 1.2 Gm / 8 hourly IV  or

Cephalosporin IV eg Cefuroxime 1.5 Gm IV 8 hourly and

Clarithromycin 500 mg 12 horly IV

Add flucloxacillin if staphylococcus is suspected

ATYPICAL PNEUMONIAS:

LEGIONELLA PNEUMOPHILIA :

Consider adding Rifampicin,Treaat for 14 – 21 days

Chlamydophilia species : Tetracyclines

Pneumocystis Jiroveci : High dose co-trimoxazole

MANAGEMENT OF PNEUOMONIAS

HOSPITAL ACQUIRED PNEUMONIAS:

GRAM NEGATIVE BACILLI:/PSEUDOMONAS/ANAEROBES

AMINOGLYCOSIDE IV PLUS ANTIPSEUDOMONAL PENICILLIN IV OR 3RD GENERATION CEPHALOSPORIN IV

ASPIRATION PNEUMONIA:

CAUSED BY ANAEROBES AND STREPTOCOCCUS PNEUMONIAE : CEFUROXIME 1.5 GM/8HOURLY IV PLUS METRONIDAZOLE 500 MG 8 HOURLY IV

NEUTROPENIC PATIENTS :

GRAM POSITIVE COCCI AND GRAM NEGATIVE BACILLI :

AMINOGLYCOSIDE IV PLUS ANTIPEUDOMONAL PENICILLIN IV OR 3RD GEN CEPHALOSPORINS IV

CONSIDER ANTIFUNGALS FOR FUNGAL PNEUMONIAS IN NEUTROPENIC PATIENTS

MANAGEMENT OF PNEUMONIAS

OXYGEN:

To keep PaO2 > 8.0 Kpa and saturation > 94 %

IV FLUIDS:

In case of dehydration,anorexia,shock

ANALGESIA:

In case of pleurisy eg by paracdetamol 1 Gm PO 6 hourly.

ITU TREATMENT:

|In case of shock,hypercapnea or uncorrected Hypoxia.

Look for complications in case of failure to improve or persistent elevation of CRP.

FOLLOW UP:

In 6 weeks time with CXR.

COMPLICATIONS OF PNEUMONIA

PLEURAL EFFUSION

LUNG ABSCESS

EMPYEMA

RESPIRATORY FAILURE

BRAIN ABSCESS

SEPTICEMIA

MULTIPLE ORGAN FAILURE

PERICARDITIS

MYOCARDITIS

CHOLESTATIC JAUNDICE

Respiratory Medicine Made Simple: COPD / Chronic Obstructive Airways Disease

Get 23 % Discount on Dr Najeebs Lectures Life time Subscription at just 79 US Dollars. Go to the following Link: https://members.drnajeeblectures.com/#!/registration Fill in the details and enter Affiliate ID for discount : 1095912 and clickon Apply Affiliate Discount button during checkout to get a 23% discount for life subscription at a very reduced cost


COPD/CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD is a common progressive disorder characterized by airway obstruction with little or no reversibility.

It includes 2 diseases :

Chronic bronchitis and Emphysema

CHRONIC BRONCHITIS:

This is clinically defined as cough and sputum production on most days for 3 months of 2 successive years.

Symptoms improve when patients stop smoking.

EMPHYSEMA:

This is defined as enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls.

COPD GENERAL CONSIDERATIONS:

FEV1 ( Forced Expiratory Volume in 1 second ) is less than 80 % predicted and FEV1/FVC is less than 0.7

COPD  is usually seen in smokers and air pollution is also an important contributory factor.

Age of onset is usually > 35 years

There is minimal day to day variation.

Patients present with Chronic Dyspnoea

SYMPTOMS:

Cough

Increased sputum production.

Dyspnoea

Wheeze

SIGNS:

Tachypnoea

Cyanosis

Use of accessory muscles of respiration.

Hyperinflation of chest

Reduced cricosternal distance < 3 cm

Reduced chest expansion.

Hyperresonant percussion note

Quiet breath sounds

INVESTIGATIONS:

FBC : Increased WCC and PCV

CXR :

Hyper inflation (> 6 anterior ribs seen above diaphragm in mid-clavicular line)

Flat hemidiaphragms

Large central pulmonary arteries

Decreased pulmonary vascular markings

Bullae

ECG:

Right axis deviation,

Right ventriucular hypertrophy/cor pulmonale.

ARTERIAL BLOOD GASES :

Low PaO2 and Increased PaCO2.

LUNG FUNCTION TESTS:

Obstructive and air trapping

FEV1 <  80 % of predicted

FEV1/FVC < 70% predicted

Raised TOTAL LUNG CAPACITY

Raised RESIDUAL VOLUME

COMPLICATIONS:

Acute exacerbations +/- Infections

Respiratory Failure

Polycythemia

Cor pulmonale

Pneumothorax

Lung carcinoma

MANAGEMENT/BTS GUIDELINES:

ASSESSMENT OF COPD:

Spirometry

Bronchodilators may improve FEV1 slightly.

Trial of steroids : Look for > 15 % increase in FEV1.

CXR : Bullae or any other pathology? Consolidation/Abnormal shadowing

SEVERITY OF COPD :

MILD: FEV1 :  50 – 80 % of predicted

MODERATE : FEV1 30 – 49 % of predicted

SEVERE : FEV1 < 30 % of predicted.

MANAGEMENT

TREATING  STABLE  COPD:

GENERAL MEASURES:

Stop smoking

Encourage exercise

Treat poor nutrition or obesity

Influenza and pneumococcal vaccinations.

Pulmonary rehabilitation/palliative care.

NIPPV : NON  INVASIVE  INTERMITTEMT POSITIVE  PRESSURE  VENTILATION

MILD COPD:

ANTIMUSCARINICS : Ipratropium or BETA 2 AGONIST inhalations :Salbutamol as per need

MODERATE: Regular anticholinergic eg Ipratropium or Tiotropium or Long acting beta 2 agonists such as salmetrol + inhaled corticosteroids esp if FEV1 < 50 % and more than or equal to 2 exacerbations / year.

SEVERE : LABA + INALED STEROIDS + ANTICHOLINERGICS AND SPECIALIST REFERRAL

PULMONARY HYPERTENSION:

Treat Oedema with Diuretics,Assess the need for LTOT

MORE ADVANCED COPD:

PULMONARY REHABILITATION

LONG TERM OXYGEN THERAPY TO MAINTAIN PAO2 > 8.0 Kpa for more than 15 hours a day.

LTOT should be used if PaO2 < 7.3 kpa

INDICATIONS FOR SURGERY:

Recurrent pneumothoraces

Isolated bullous disease

Lung volume reduction surgery

NIV in case of severe diasese

PINK PUFFERS AND BLUE BLOATERS:

These are two variants seen in COPD

PINK PUFFERS:

They have increased alveolar ventilation,a near normal PaCO2 or low PaCO2.

They are breathless but not cyanosed.

They may progress to Type 1 Respiratory failure

BLUE BLOATERS:

They have reduced Alveolar ventilation.

There is low PaO2 and high PaCO2.

They are cyanosed but not breathless and may go on to develop cor-pulmonale.Thir respiratory centres are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort.

Hence supplemental oxygen should be given with care.

Respiratory Medicine/pulmonolgy Made Simple : Asthma

Asthma:

Recurrent episodes of Dyspnoea cough and wheeze cuased by reversible airways obstruction.

PATHOPHYSIOLOGY:

Three factors contribute to airway narrowing :

Mucosal swelling/

Inflammation caused by mast cell and basophil degranulation resulting in release of inflammatory mediators.

Bronchial muscle contraction triggered by a variety of stimuli

Increased mucus production

Symptoms:

Intermittent Dyspnoea

Wheeze

Cough ( mostly at night)

Increased Sputum  production.

PRECIPITATING FACTORS:

These include:

Exercise

Cold Air

Emotional Stresses

Allergens ( house dust mite,pollens,fur)

Infection

Smoking and Passive smoking

Pollution

NSAIDS,Beta blockers

Quantification:

Exercise Tolerance

This needs to be quantified and evaluated.

Disturbed Sleep:

Quantified as nights/week : a sign of severe Asthma

ASSOCIATIONS:

ACID REFLUX:

40 – 60 % of patients with Asthma have reflux.

Treating it improves spirometry but not necessarily symptoms.

OTHER ATOPIC DISEASES:

Frequently Asthma  co-exists with other atopic diseases such as Eczema,Hay fever allergies and Family History of atopic diseases.

CHURG STRAUSS SYNDROME

POLYARTERITIS NODOSA

ABPA : ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

OCCUPATIONAL ASTHMA/JOBS:

More common in occupations such as Paint sprayers,food processors,animal handlers and welders.

Symptoms are resolved during holidays when away from work.

Patients are advised to measure their peak flow at work and at home.

Signs:

Tachypnoea

Audible wheeze

Hyperinflated chest

Hyperresonant percussion notes.

Diminished Air Entry

Poly phonic wheeze

SEVERE ATTACK:

Inability to complete sentences

Pulse > 110 bpm

Resp Rate >25/min

PEFR 33 – 50 % of predicted

LIFE THREATENING ATTACK:

Silent Chest

Cyanosis

Bradycardia

Exhaustion

PEFR < 33% of predicted

Confusion

Feeble Respiratory Effort

Investigations:

ACUTE ATTACK:

Sputum culture & Sensitivity

PEFR

FBC

U & Es

CRP

ABGs : Normal or slightly reduced PaO2 and low PaCO2 due to hyperventilation.

If PaCO2 is raised,transfer to HDU or ITU for ventilation as this signifies failing Respiratory Effort.

Blood Cultures

CXR : To exclude pneumothorax and infection.

CHRONIC ASTHMA:

PEFR MONITORING:

This shows a diurnal variation of > 20 % on more than or equal to 3 days a week for 2 weeks,

SPIROMETRY:

This shows an obstructive defect : Reduced FEV1/FVC ratio and increased Residual volume.

Usually > 15 % improvement in FEV1following B2 agonists or steroid trial.

CXR : This shows hyperinflation.

Skin prick tests help identify allergens.

Histamine or methacholine chalenge.

MANAGEMENT:

BEHAVIOUR AND LIFE STYLE MODIFICATIONS:

Quit smoking

Avoid precipitants

Check Inhaler technique

Monitor PEFR twice a day by Peak Flow meter.

Train about a relaxed breathing technique to avoid dysfunctional breathing

Specific Management/ BTS Guideline

Start from the step most appropriate to severity.

Move up if necessary or down if control is good for > 3 months.

Rescue courses of prednisolone may be used at any time.

STEP 1 :

Occasional short acting B2 agonist as required for symptom relief.If being used more than once daily or night time symptoms,go to step 2.

STEP 2 :

Add standard dose inhaled steroid eg Beclometasone 100 -400 mcg/12 hrs or start at the dose appropriate for disease severity and titrate as appropriate.

STEP 3:

Add long acting B2 agonist eg salmeterol 50 mcg/12 hrs.If of benefit but still inadequate control,continue and increase dose of beclometasone to 400 micrograms/12 hrs.If no effect of Long Acting B2 agonist,it should be stopped.Diagnosis should be reviewed and Leukotriene receptor antagonists or oral theophylline may be tried.

STEP 4:

Consider trials of beclometasone of upto 1000 micrograms/12 hours,modified release oral theophylline,modified release oral Beta 2 agonist.

STEP 5 :

Add regular oral prednisolone 1 dose daily at lowest possible dose.

Gastroenterology Made Simple : Causes of Colonic Bleeding :

Angiodysplasia:

Also called as vascular ectasia

It occurs due to degenerative changes in walls of vessels in colon and also partly contributed by

intramuscular hypertrophy.

It occurs in old age and has association with Aortic stenosis.

Diagnosis can be made by Endoscopy and angiography.

Colon Carcinoma:

It usually causes painless bleeding.

It can involve both right and left side of colon.

Usually associated with weight loss and painless bleeding.

Can cause occult bleeding.

FOB stool test for occult blood can aid diagnosis

Haemorrhoids/Piles:

Can cause either painless or painful rectal bleeding.

They may be visible externally.

Can present with fresh blood per rectum.

Inflammatory Bowel Disease

These include Ulcerative colitis and Crohn”s disease.

It causes lower GI bleeding associated with passage of mucus and pain in abdomen and raised inflammatory

markers.

There may be systemic involvement as well including fever and systemic symptoms.

Diagnosis is made by Endoscopy with biopsy and barium enema that shows characteristic findings.

They can get complicated causing : Cancer,perforation and toxic megacolon.

Treatment is mainly with Surgery

Gastroenterology Made Simple : Causes of Colonic Bleeding : Diverticulosis

Diverticulosis:

The colonic bleeding in diverticulosis occurs due to rupture of artery at the neck of diverticulum.

This leads to a massive bleeding which is usually painless.

It usually occurs in elderly.

It mostly involves the left colon and may be accompanied by fever and pain in abdomen.

Diagnosis can be made by CT scan of abdomen.

Treatment mainly involves antibiotics.

A high fibre diet is useful in prevention of recurrence.

Colonoscopy Is contraindicated in acute state.

Computer Studies Made Simple : Introduction to Computer and its components

Definition of A Computer:

A computer is a machine that is programmed to receive data and process it into a meaningful information and store that information for use whenever required.

Components Of a computer:

Two main components of a computer are :

Hardware

Hardware is the physical part of the computer.

Software

Software refers to the programmes installed in the computer or the non-physical part of the computer that

processes the input to output.

Hardware components of a computer:

These include:

Input devices:

These devices input data into a computer and send data into the CPU / processing Unit.

Examples include : Keyboard and mouse

Processing Devices or the CPU

The central processing Unit processes the data

Main memory :

This stores the data before it is processed by the CPU and also stores the processed dadta as well.

Output Devices:

These devices display the results of processed data.

Example include Printer and monitor.

Storage Devices

These devices are used to store data.

Some examples include : Floppy disks,hard disc drives and CD ROM etc.

Computers Studies made Simple: Information And Data

Information And Data

Data:

This means a collection of  raw facts and figures.

Raw means the facts have not been processed yet to give them a meaningful form.

Data is collected from different sources for different purposes.

It may consist of numbers,letters,pictures,symbols etc

Information:

This term refers to a processed form of data to get a meaning ful outcome.

The information is used for various important applications.

Data Processing/Computing

This is the process of converting data into a meaningful form/ information .

It consists of the following steps:

Input / Data

Processing

Output/Information

Gastroenterology Made Simple : Mallory Weiss Syndrome

Mallory Weiss Syndrome

This term refers to acute upper GI bleed as a result of a longitudinal tear in the mucosa of distal oesophagus or proximal part of the stomach.

Usually,it preceeds a history of retching or vomiting prior to the episode of Upper GI Bleed.

Associated / Predisposing Factors:

It is associated with condition causing a sudden and repeated rise in intra-abdominal pressure.

Common precipitating factors include:

Repeated retching / vomiting

Excessive alcohol abuse

Frequent hiccups/coughing

Old age

Presence of hiatus Hernia

Management:

Upper GI Endoscopy to evaluate the cause and to implement therapeutic intervention and assess the damage is usually mandatory.

Prognosis:

Prognosis is usually good.

Bleeding is mild and self limited and most lesions heal with conservative treatment.

PPIs/Proton Pump Inhibitors are given to all patients to promote healing

Boerhaave”s Syndrome:

This is a term that refers to rupture/perforation of esophagus along with air in mediastinum (pneumomediastinum)

This is an acute emergency.

Clinical Features:

Patients will present with severe chest pain and pain in abdomen.

There would be clinical findings of haemodynamic compromise (Low blood pressure,Tachycardia)

Investigations:

An urgent Chest X-ray lateral and PA views will show pneumo-mediastinum

Management:

This condition requires immediate emergency surgery.

Computer Studies Made Simple : Applications of Computer

Applications of Computer

Office Automation:

This refers to the process of automating office tasks using computers.

There are a number of office tasks that can be performed using computers such as:

Handling of documents.

Decision making

Data manipulation

Communications

Storage

Computerized Systems used in Office:

Some computerized systems used in he office are below:

Document Management Systems:

This includes a number of applications such as:

Reprographics:

This is process of reproducing multiple copies of a document

Image processing:

This is application to scan and store an image in a computer.

It canbe used to modify and improve the quality of images as well.

Word processing:

This application is used to create documents electronically.

It canbe used to  produce high quality letters and reports etc.

Desktop publishing:

This application can be used to add photos and other content and graphics to the documents generated by

Word processing.

Spreadsheet application:

This is used to maintain records and calculate expenses,profits and losses.

It is also used to perform mathematical,statistical and logical processing

Endocrinology Made Simple : Paget”s Disease

Paget”s Disease:

Definition

Paget disease is a  disorder of bone remodelling characterized by excessive bone resorption followed by an increase in bone formation.

Etiology:

Some studies suggest a genetic linkage for Paget disease located on chromosome arm 18q.

Although the etiology of Paget disease is unknown, both genetic and environmental contributors have been suggested. Ethnic and geographic clustering of Paget disease is well described.

Pathophysiology:

There is  osteoclastic overactivity followed by compensatory osteoblastic activity leads to a structurally disorganized mosaic of bone (woven bone), which is mechanically weaker, larger, less compact, more vascular, and more susceptible to fracture than normal adult lamellar bone.

Clinical Features:

Approximately 70-90% of persons with Paget disease are asymptomatic; however, a minority of affected individuals experience various symptoms, including the following:

 Bone pain (the most common symptom)

 Secondary osteoarthritis (when Paget disease occurs around a joint)

 Bony deformity (most commonly bowing of an extremity)

 Excessive warmth (due to hypervascularity)

 Neurologic complications (caused by the compression of neural tissues)

Sites of involvement:

Paget disease may involve a single bone but is more frequently multifocal. It has a predilection for the axial skeleton (ie, spine, pelvis, femur, sacrum, and skull, in descending order of frequency), but any bone may be affected.

After onset, Paget disease does not spread from bone to bone, but it may become progressively worse at pre-existing sites.

Indications for Treatment :

Intolerable pain

Involvement of weight bearing joints

Neurological involvement

Hypercalcemia

Hypercalcinuria

Congestive Cardiac Failure

Management Guidelines:

Several bisphosphonates : Alendronate,Risedronate and Pamidronate are approved for treatment of Pagets”s Disease.

Six months of treatment with oral alendronate and two months of treatment with oral risedronate lead to sustained remission in a large number of patients.

Intravenous pamidronate canbe used for patients with contraindications to use of oral bisphosphonates.

A 2014 Endocrine Society Clinical Practice Guideline on Paget disease recommends the following : 

Plain radiographs of the pertinent regions of the skeleton in patients with suspected Paget disease

A radionucleotide bone scan to determine the extent of the disease if the diagnosis is confirmed

Measurement of serum total alkaline phosphatase or, when warranted, a more specific marker of bone

formation or bone resorption to assess the response to treatment or evolution of the disease in untreated patients 

Consider treatment with a bisphosphonate for most patients with active Paget disease who are at risk for future complications

Consider a single 5-mg dose of intravenous zoledronate as the treatment of choice in patients who have no contraindication

Consider measurement of a specific marker of bone formation and bone resorption in patients with monostotic disease who have a normal serum total alkaline phosphatase

Consider serial radionuclide bone scans to determine the response to treatment if the markers are normal

Bisphosphonate treatment may be effective in preventing or slowing the progress of hearing loss and osteoarthritis in joints adjacent to Paget disease and may reverse paraplegia associated with spinal Paget disease

Consider treatment with a bisphosphonate before surgery on pagetic bone

Computer Studies Made Simple : Applications & Uses Of Computers

Applications & Uses Of Computers

Computers have beneficial uses in every walk of life.

They have transformed the way of our dealings.

They have numerous applications in various spheres of life and have simplified and helped our lives to get better and helped us in solving our problems pertaining to health care,business,banking shopping ,travelling ,office management and what not.

Offices and Businesses:

Business offices keep records of their transactions and customers on computers.

It can be accessed easily and has thus saved a lot of time

Banking:

Banks use computers for facilities such as online banking.

Customers can transfer money abroad or to other banks using online internet facilities.

These transactions are fairly quick and easy and synchronized via online software linking banks such that amount can be transferred with in seconds accurately.

Customers can in addition order cheque books and debit or credit cards to their registered address using online internet banking.

Bills can be paid online as well.

Financial planners and Travel Planners

Numerous intelligent softwares now available online have enabled customers to plan their budget adequately

There are also nice online websites that help to plan travelling between different cities using trains or other means of transport such as airplanes.

They also allow to make payment online and delivery of tickets for travelling online as well within matters of minutes making travelling arrangements easier than they ever were.

Computer Studies Made Simple : Types Of Modems

Types Of Modems

The following are different types of modems:

External Modem

They are connected to the computer externally.

They are more expensive than internal modems.

They are easy to setup and need external power supply.










Internal modems

These are inserted into the main mother board.

They derive their power supply from the main computer.

They are cheaper than external modems.

They are difficult to set up than external modems

Wireless Modems:

They transmit the data signals through air with out the need of a cable.

They are also called as radio-frequency modems.

They are part of wireless local area networks

Endocrinology Made Simple : Medications used for improving BMD : Bone Mineral Density

The following are major risk factors for fragility factors :

Low bone density

History of fragility fractures

Family history of osteoporosis

Smoking

Body weight less than 127 pounds

Medications used for improving BMD : Bone Mineral Density

Following medications are used to improve BMD and hence to reduce risk of fragility fractures.

Calcium and Vitamin D supplementation

Adequate vitamin D supplementation and Calcium is the single most important intervention for prevention of osteoporosis.

Anti-resorptive medications/Alendronate :

These are indicated to prevent risk of fragility fractures.

This is a bisphosphonate.

It improves BMD by reducing bone resorption.

It specifically increases BMD at the hip and lumbar spine.

Another example of bisphosphonates is risedronate which is also used for treatment of osteoporosis but it has more GI side effects.

Calcitonin

This also inhibits bone resorption

It causes improvement in vertebral BMD and hence reduces the incidence of vertebral fractures.

It has slight analgesic effect as well and hence can reduce pain from vertebral fracture.

PTH subcutaneous injections/Parathyroid hormone:

This is very effective in increasing BMD at the lumbar spine and in significantly reducing the incidence of vertebral fractures.

It is an expensive treatment and is used only if a failure by bisphosphonates to improve BMD occurs.

HRT is no longer used for treatment of post menopausal osteoporosis due to it causing increased risk of the following :

Stroke

DVT and Pulmonary embolism

Myocardial infarction

Ca breast

Endocrinology Made Simple : Bone mineral density, T score and Z scores

Bone mineral density, T  score and Z scores

T score is the Bone mineral density BMD of a patient in comparison to young healthy adults around 25 – 30 years of age.

The Z score is the BMD  score of a patient in comparison to age matched normal controls.

The BMD is categorized according to T score as below according to WHO CRITERIA FOR

POSTMENOPAUSAL CAUCASIAM WOMEN :

Normal T score > 1

Osteopenic  T score between – 1.0 and 2.5

Osteoporosis T score of less than – 2.5

As T score decreases,the risk of fracture increases without any threshold effect.

The diagnosis of osteoporosis in men and young premenopausal females by bone densitometry is not clear.

Apart from measuring BMD,some basic workup is needed to rule out secondary causes of osteoporosis.

This includes :

Full / complete blood count.

Routine chemistry profile : Serum calcium and phosphorus levels.

Urinary calcium

Serum protein electrophoresis

PTH

TSH

Bone turnover markers such as N tekopeptide for bone resorption and alkaline phosphatase for bone

formation.

Computer Studies Made Simple : Modems

Modems

Modem is a device that converts digital signals into analogue signals and analog signals into digital signals.

They send and receive data from one computer to another using telephone lines.

In order for the data to be received and sent, both computers should have modems

The term modem stands for Modulation and Demodulation.

Modulation:

The process of converting digital signal into analogue signal is called modulation.

The computer stores data in digital form.

It is converted into analog form by the modem in order to be transmitted via telephone lines to another computer.

Demodulation:

The process of converting analogue signal into digital signal is called as demodulation.

The modem of the receiving computer receives data in analogue form and then converts it into digital form to be received by the computer.

Characteristics of modem:

Speed

This is the rate at which modem can send data in bypes per second.

The speed of modems varies from 300 bps to 56 kbps.

Testing

The modems can test the digital connection with a computer and they can also test analog connection with

remote modem.

Voice over Data

Modems can provide the facility of voice conversation while the data is being transmitted.

Error control:

Modems use different methos of controlling errors for transmitted data.

Computer Studies Made Simple : Types of communication Media used in computer Networks:

Types of communication Media used in  computer Networks

The path along which data is transmitted from one place to another  is called as communication medium or communication channel.

Following are the types of communication media:

Guided Media:

In this method,the communication devices are directly connected to one another by some form of physical media such as wires.

It is also called as bounded media.

Some examples of this type of medium include:

Twisted pair

Co-axial cable

Fiber optics

Unguided Media:

In this type of medium,communication devices communicate with each other using air or space via broadcast signals.

Some examples of these broad cast signals include:

Radio signals

Microwave signals

Infrared signals.

This type of medium is used in places where it is not possible to install cables.

Some examples of unbounded media are as follows:

Microwave

Communication satellite

Mobile communications. 

Endocrinology Made Simple : Amiodarone Induced Thyroid Dysfunction

Amiodarone Induced Thyroid Dysfunction

Amiodarone causes thyroid dysfunction through its high iodine content.

Hypothyroidism is more common and is seen in 85 % cases.

Thyrotoxicosis occurs in 10 – 15 % cases.

Amiodarone induced thyrotoxicosis occurs by one of the following two ways:

1.Activation of Grave”s disease : Type 1 thyrotoxicosos

2.Destructive Thyroiditis : Type 2 Thyrotoxicosis

Grave”s disease induced by Amiodarone is generally treated with high dose thionamides: Methimazole and 

Propylthiouracil.

Perchlorate can be used to reduce further uptake by Thyroid gland.

Steroids are given for treatment of Type 2 Thyrotoxicosis.

Thyroid functions are monitored every 6 months in euthyroid patients on Amiodarone.

In patients with significant coronary artery disease or those who are elderly,a lower dose should be started.

Amiodarone induced Hypothroidism can cause fatigue as  a side effect.

Patients with Amiodarone induced Hypothyroidism should  be treated with levothyroxine to bring their TSH with in a normal range.

Other side effects of Amiodarone include:

Corneal deposits

Skin discoloration

Hepatotoxicity and

Pulmonary Fibrosis

Computer Studies Made Simple : Types of Communication Media Used in computer Networks

Types of Communication Media Used in computer Networks

The path through which data is transmitted from one place to another is called communication media or communication channel.

There are different types of communication media:

Guided Media:

In this type of medium,communication devices are directly connected with each other by using some physical media like wires.

It is also called as bounded media.

Some examples of bounded media are as follows:

Co-axial cable

Twisted pair

Fibre optics

Unguided Media:

In this medium,communication devices communicate with each other through air or space using broadcast 

radio signals,microwave signals and infrared signals.

Unbounded media is used where it is impossible to install cables.

Data can be transferred all over the world using this medium.

It is also called unbounded medium.

Some examples of this type of medium includes:

Communication satellite

Microwave

Mobile communication

Endocrinology Made Simple : Alcoholic ketoacidosis

Alcoholic ketoacidosis:

This is seen in overuse of alcohol.

It is characterized by anion gap acidosis,increased osmolal gap,ketonemia,or ketonuria and variable blood glucose levels.

Blood glucose levels are mostly higher than 250 mg/dl in patients with diabetic ketoacidosis.

Clinical features:

Impaired mental function with ketonuria.

Mildly elevated plasma glucose levels.

Plasma glucose levels can be low,high or normal.

High plasma glucose levels can be due to impaired insulin secretion combined with increased insulin resistance.

Biochemically the patients with alcoholic ketoacidosis will have increased anion and osmolal gap.

Complications

Potential complications in Alcoholic ketoacidosis includes the following:

Alcohol withdrawal

Electrolyte imbalance

Aspiration pneumonia

Wernicke”s encephalopathy :

This can occur due to administration of glucose that can increase utilization of thiamine and thus aggravating thiamine deficiency and causing Wrnicke”s encephalopathy.

Management:

Most patients will respond to an administration of intravenous dextrose containing normal saline and thiamine.

All patients should be hospitalized for treatment.

Insulin is generally not required.

Dextrose leads to an increase in insulin secretion that leads to metabolism of ketone bodies to bicarbonate.

Thiamine is likely to be deficient in all will alcohol consumption unless proven otherwise.

Computer Studies Made Simple : Bandwidth

 Bandwidth

This refers to amount of data that canbe transferred through a communication medium in one second.

The bandwidth of a digital signal is measured in bits/second or bytes per second.

Bandwidth of analog signal is measured in cycles/second or Hertz.

Baseband:

This is a communication technique in which digital signalas are placed on transmission line without a change in modulation.

It means that digital signals are transmitted directly over a transmission line.

It transmits only one signal at a time

Digital signals are commonly called baseband signals.

Spectrum of a baseband signal, energy E per unit frequency as a function of frequency f. The total energy is the area under the line.

Broadband

This is a technique to transmit large amounts of data such as voice and video over long distance.

It can send data by modulating each signal onto a different frequency.

It transmits several streams of data simultaneously using FDM Frequency Division Multiplexing technique.

FDM divides the bandwidth of a communication line into smaller frequency bandwidths.

Each part of the communication line canbe used for transmitting data separately.

Broadband is faster than Base band.

It is used for direct communication between very high speed computers such as mainframe computers,

It includes microwave,satellite,co-axial cable and fibre-optic media.

Endocrinology Made Simple : Hypercalcemia

Hypercalcemia

Hypercalcemia  is an elevated calcium  level in the blood

Normal range: 9–10.5 mg/dL or 2.2–2.6 mmol/L.

Causes

Primary hyperparathyroidism and malignancy account for about 90% of cases of hypercalcaemia.

Abnormal parathyroid gland function

Primary hyperparathyroidism

Solitary parathyroid adenoma

Primary parathyroid hyperplasia

Parathyroid carcinoma

Multiple endocrine neoplasia (MEN)

Familial isolated hyperparathyroidism

Lithium use

Familial hypocalciuric hypercalcaemia/familial benign hypercalcaemia

Malignancy

Solid tumour with metastasis (e.g. breast cancer or classically squamous cell carcinoma, which can be PTHrP-mediated)

Solid tumour with humoral mediation of hypercalcaemia (e.g. lung cancer, most commonly non-small 

cell lung cancer or kidney cancer, phaeochromocytoma)

Haematologic malignancy (multiple myeloma, lymphoma, leukaemia)

Ovarian small cell carcinoma of the hypercalcemic type

Vitamin-D metabolic disorders

Hypervitaminosis D (vitamin D intoxication)

Elevated 1,25(OH)2D (see calcitriol under Vitamin D) levels (e.g. sarcoidosis and other granulomatous 

diseases)

Idiopathic hypercalcaemia of infancy

Rebound hypercalcaemia after rhabdomyolysis

Disorders related to high bone-turnover rates

Hyperthyroidism

Prolonged immobilization

Thiazide use

Vitamin A intoxication

Multiple myeloma

Renal failure

Severe secondary hyperparathyroidism

Aluminium intoxication

Milk-alkali syndrome

Signs and symptoms

The neuromuscular symptoms of hypercalcemia are caused by a negative bathmotropic effect due to the increased interaction of calcium with sodium channels. Since calcium blocks sodium channels and inhibits depolarization of nerve and muscle fibers, increased calcium raises the threshold for depolarization.

There is a general mnemonic for remembering the effects of hypercalcaemia: "Stones, Bones, Groans, 

Thrones and Psychiatric Overtones"

Stones (renal or biliary)

Bones (bone pain)

Groans (abdominal pain, nausea and vomiting)

Thrones (polyuria - also looks like Osborn wave on ECG)

Psychiatric overtones (Depression 30–40%, anxiety, cognitive dysfunction, insomnia, coma)

Other symptoms can include fatigue, anorexia, and pancreatitis

Limbus sign seen in eye due to hypercalcemia.

Hypercalcemia has a negative chronotropic effect (decrease in heart rate), and a positive inotropic effect (increase in contractility).

Abnormal heart rhythms can also result, and ECG findings of a short QT interval suggest hypercalcaemia.

Significant hypercalcaemia can cause ECG changes mimicking an acute myocardial infarction.

Hypercalcaemia has also been known to cause an ECG finding mimicking hypothermia, known as an Osborn wave.

Hypercalcaemia can increase gastrin production, leading to increased acidity so peptic ulcers may also occur.

Symptoms are more common at high calcium blood values (12.0 mg/dL or 3 mmol/l). Severe hypercalcaemia (above 15–16 mg/dL or 3.75–4 mmol/l) is considered a medical emergency: at these levels, coma and cardiac arrest can result.

The high levels of calcium ions decrease the neuron membrane permeability to sodium ions, thus decreasing the excitability, which leads to hypotonicity of smooth and striated muscle. This explains the fatigue, muscle weakness, low tone and sluggish reflexes in muscle groups.

The sluggish nerves also explain drowsiness, confusion, hallucinations, stupor and / or coma. In the gut this causes constipation. Hypocalcaemia causes the opposite by the same mechanism.

Treatments

The goal of therapy is to treat the hypercalcaemia first and subsequently effort is directed to treat the 

underlying cause.

Initial therapy: fluids and diuretics

Hydration, increasing salt intake, and forced diuresis.

Hydration is needed because many patients are dehydrated due to vomiting or renal defects in concentrating urine.

Increased salt intake also can increase body fluid volume as well as increasing urine sodium excretion, which further increases urinary potassium excretion.

Aafter rehydration, a loop diuretic such as furosemide can be given to permit continued large volume intravenous salt and water replacement while minimizing the risk of blood volume overload and pulmonary oedema. 

In addition, loop diuretics tend to depress renal calcium reabsorption thereby helping to lower blood calcium levels

Can usually decrease serum calcium by 1–3 mg/dL within 24 h

Caution must be taken to prevent potassium or magnesium depletion

Additional therapy: bisphosphonates and calcitonin

Bisphosphonates are pyrophosphate analogues with high affinity for bone, especially areas of high bone-turnover.

They are taken up by osteoclasts and inhibit osteoclastic bone resorption

Current available drugs include (in order of potency): (1st gen) etidronate, (2nd gen) tiludronate, IV pamidronate, alendronate (3rd gen) zoledronate and risedronate

All patients with cancer-associated hypercalcaemia should receive treatment with bisphosphonates since the 'first line' therapy (above) cannot be continued indefinitely nor is it without risk. 

Further, even if the 'first line' therapy has been effective, it is a virtual certainty that the hypercalcaemia will recur in the patient with hypercalcaemia of malignancy. 

Use of bisphosphonates in such circumstances, then, becomes both therapeutic and preventative

patients in renal failure and hypercalcaemia should have a risk-benefit analysis before being given bisphosphonates, since they are relatively contraindicated in renal failure.

Calcitonin blocks bone resorption and also increases urinary calcium excretion by inhibiting renal calcium reabsorption

Usually used in life-threatening hypercalcaemia along with rehydration, diuresis, and bisphosphonates

Helps prevent recurrence of hypercalcaemia

Dose is 4 Units per kg via subcutaneous or intramuscular route every 12 hours, usually not continued indefinitely

Hypercalcaemic crisis

A hypercalcaemic crisis is an emergency situation with a severe hypercalcaemia, generally above approximately 14 mg/dL (or 3.5 mmol/l).

The main symptoms of a hypercalcaemic crisis are oliguria or anuria, as well as somnolence or coma.

After recognition, primary hyperparathyroidism should be proved or excluded

In extreme cases of primary hyperparathyroidism, removal of the parathyroid gland after surgical neck exploration is the only way to avoid death.

The diagnostic program should be performed within hours, in parallel with measures to lower serum calcium.

Treatment of choice for acutely lowering calcium is extensive hydration and calcitonin, as well as bisphosphonates (which have effect on calcium levels after one or two days).