Complete Review of Surgery for NBE

Written by Subject specialist and leading Faculty of Surgery for more than 10 years and Author of more than 10 Medical books. Completely coloured edition with Picture-based Questions of Latest Pattern. Extra Edge and Recent Updates added at appropriate places. Hundreds of Mnemonics, Illustrations, Pictures, Flow charts created to make the retention of concepts easy. High yield points added at the beginning of each chapter that act as best aid for quick revision. All questions supported by explanations. Book is made concise and at the same time supported by explanations to all the necessary points. 1000+ Q's provided in the CD as Real-time CBT. Live video lecture on Picture based questions, Liver and Urology for 2.5 hrs. Online help by the author via Facebook page : " Rajamahendran".

Bleeding Sources

Cause -source
1)extradural hemorrhage EDH -
Middle meningeal artery
2)subdural hemorrhage SDH- bridging/dipole veins
3)SAH-rupture of congenital berry aneurysm
4)tennis ball injury to eye-circulus iridis major
5)epistaxis in little s area-sphenopalatine artery
6)during tonsillectomy-paratonsillar veins,tonsillar and ascending
Palatine arteries
7)tracheostomy-ishthmus and Inferior thyroid vein
8)hemoptysis,bronchiectasis-bronchial artery
9)gastric ulcer-Lt.gastric,splenic artery
10)duodenal ulcer-gastroduodenal artery
11)hemorrhoids-submucous venous plexus (formed by SRV + IRV)
12)retropubic prostatectomy-dorsal venous plexus
13)hysterectomy-internal iliac artery
14)menstruation-spiral arteries

Mission Indradhanush

Mission Indradhanush was launched by Ministry of Health and Family Welfare (MOHFW) Government of India on 25th December, 2014. The objective of this mission is to ensure that all children under the age of two years as well as pregnant women are fully immunized with seven vaccine preventable diseases.

The Mission Indradhanush, depicting seven colours of the rainbow, targets to immunize all children against seven vaccine preventable diseases, namely:

1. Diphtheria
2. Pertussis (Whooping Cough)
3. Tetanus
4. Tuberculosis
5. Polio
6. Hepatitis B
7. Measles.

In addition to this, vaccines for Japanese Encephalitis (JE) and Haemophilus influenzae type B (HIB) are also being provided in selected states.

First Phase of Mission Indradhanush:

For the first phase, 201 high focus districts across 28 states in the country that have the peak number of partially immunized and unimmunized children were identified by the Government.

There were total four rounds in the first phase of the mission. The first round of the first phase was started from 7th April, 2015 and continued for more than a week.

Further, second, third and fourth rounds were held for more than a week in the month of May, June and July starting from 7th of each month. The first phase of this mission was very successful.

The main highlights of the first phase of Mission Indradhanush are as given below:

•   Total 9.4 lakh sessions were organized during these four rounds of Mission Indradhanush
•   About 2 crore vaccines were given to the children as well as pregnant women.
•   Tetanus Toxoid vaccine was given to more than 20 lakh pregnant women
•  75.5 lakh children were vaccinated and about 20 lakh children were fully vaccinated.  
•   More than 57 lakh zinc tablets and 16 lakh ORS packets were freely distributed to all the children to protect them against diarrhoea.

Second Phase of Mission Indradhanush

The second Phase of Mission Indradhanush has been started from 7th October, 2015. The second, third and fourth rounds of this phase will start from 7th November, 7th December 2015 and 7th January 2016. 

The aim is to achieve full immunization in 352 districts which includes 279 mid priority districts, 33 districts from the North East states and 40 districts from phase one where huge number of missed out children were detected.

Gold standard tests

Gold standard method for estimating resting energy expenditure – indirect calorimetry

Gold standard investigation for diagnosis of Iron deficiency anemia – Estimation of serum Ferritin

Gold standard for proving that the life span of red cell is decreased ( useful in Hemolytic anemia) – Red cell survival study

Gold standard for evaluation of stem cell transplantation therapy – Hemopoietic stem cell transplantation

Gold standard technique for differentiating allograft rejection and reactivation of disease after heart transplantation – Endo-myocardial Biopsy

Gold standard investigation for diagnosis of DVT – Contrast Venography

Gold standard investigation for diagnosis of acute pharyngitis – Throat Culture

Gold standard investigation for diagnosis of pertussis – Culture of nasopharyngeal secretions

Gold standard investigation for diagnosis of Otitisexterna caused by P. aeruginosa – Technetium99 bone scan

Gold standard investigation for diagnosis of Acoustic Neuroma – Gadolinium MRI

Gold standard investigation for diagnosis of Shigella infection – Isolation and identification of pathogen from fecal material

Gold standard investigation for diagnosis of Tuberculous meningitis – Culture of CSF

Gold standard investigation for diagnosis of HSV Encephalitis – Brain biopsy (CSF PCR largely replaced brain biopsy in recent times)

Gold standard investigation for diagnosis of histoplasmosis – Fungal Culture

Gold standard investigation for diagnosis of hypertrophic cardiomypathy and atrialmyxoma – Echocardiogram

Gold standard investigation for imaging heart valves and valve motion abnormalities – 2D echocardiography

Gold standard investigation for assessment of Myocardial viability (Identification of ischemic or hibernating myocardium)– PET

Gold standard investigation for assessment of LV mass and volume – MRI

Gold standard method for evaluation of renal arteries and identification of renal artery lesions – Contrast arteriography

Gold standard method for evaluation of respiratory gas exchange – ABG

Gold standard investigation for assessment of albuminuria – 24 hr urine collection

Gold standard investigation for diagnosis of PNH (Paroxysmal Nocturnal Haemoglobinuria) – Flow cytometry

Gold standard investigation for diagnosis of ATTR and other AF mutations – DNA sequencing

Gold standard method for identifying and quantifying atherosclerosis in cerebral arteries – X-ray cerebral angiography

Gold standard investigation for evaluating anatomy of arterio-venous malformation – X-ray angiography

Gold standard for diagnosis and classification of ataxia – genotype

Gold standard investigation for diagnosis of of lung infection (Radiotherapy induced) in a cancer patient – open-lung biopsy

Gold standard medical treatment for symptomatic progressive pulmonary hypertension – Prostacyclin

Gold standard investigation for diagnosis of PIH – Serum Urea

Gold standard for assessment of visual impairment – Snellen's chart

Gold standard method of treatment of non-castrate metastatic disease – surgical orchidectomy

Gold standard method for bacterial stain analysis – Pulse-field gel electrophoresis

Gold standard method of treatment of DCIS – Mastectomy

Gold standard approach for resection of anterior and middle mediastinal masses – median or lateral thoracotomy

Gold standard method of treatment of Coarctation of aorta – Surgical repair

Gold standard method for evaluation of coronary artery disease – Cardiac Catheterization

Gold standard method for culture of V. cholerae o139 – Conventional culture method

Gold standard to determine cut-off titer of widal test for diagnosis of Typhoid fever – Nested PCR

Gold standard treatment of brucellosis in adults – IM Streptomycin + Doxycyclin

Gold standard investigation for diagnosis of of chronic arterial mesentric ischemia – Angiography

Gold standard method for treatment of chronic ulcerative colitis – Total proctocolostomy with end ileostomy

Gold standard method for evaluation of imaging modalities for liver tumors – Intraoperativeultrasonography

Gold standard investigation for diagnosis of common bile duct stones – Endoscopic cholangiography

Gold standard investigation for measurement of GFR – Inulin clearance

Gold standard for treatment of organ confined, muscle invasive, bladder cancer is – Radical cystoprostatectomy in men and anterior pelvic exenteration in woman

Gold standard for treatment of femoral shaft fractures – Reamed locked intramedullary nailing

Gold standard method in case of difficult intubation – Flexible fibreoptic intubation scope

Gold standard method for diagnosis and treatment of Ventilator Associated Pneumonia (VAP) – Broncho alveolar lavage

Gold standard treatment of hyperparathyroidism – Surgery

Gold standard investigation to differentiate follicular and papillary carcinoma of thyroid gland- Histology

Gold standard procedure for thymectomy – Trans cervical mediastinoscopy and surgery

Gold standard for treatment of adrenal tumors – Laparoscopic adrenalectomy

Gold standard investigation for diagnosis of breast cancer – Mammography

Gold standard method for staging of breast cancer – Axillary lymph node dissection

Gold standard for evaluation of a stable patient with suspected vascular injury – Angiography

Gold standard investigation for diagnosis of GERD – Ambulatory 24 hr PH monitoring

Gold standard method for treatment of GERD – LaparoccopicNissensfundoplication

Gold standard for evaluating cure rate in duodenal ulcer patients – Vagotomy

Gold standard finding for the diagnosis of GI perforation – Finding pneumoperitoneum

Gold standard for diagnosis of Zollinger-Ellison syndrome – Serum gastrin levels( Most patients have serum gastrin levels above 1000pg/mL)

Gold standard investigation for diagnosis of colonic mucosal disease – Colonoscopy

Gold standard investigation for diagnosis of steatorrhoea – Timed quantitative stool fat determination

Gold standard method for treatment of incontinence with an isolated sphincter defect – Overlapping sphincteroplasty

Gold standard investigation for diagnosis and method of management of Acute arterial occlusion – Laparotomy

Gold standard method for confirmation of mesentric arterial occlusion – Mesentric angiography

Gold standard investigation for diagnosis of celiac disease – Small intestine biopsy

Gold standard for identifying choledocholithiasis – ERCP

Gold standard method of treatment of Symptomatic cholelitiasis – Lap cholecystectomy

Gold standard method for diagnosis of Primary sclerosingcholangitis – ERCP

Gold standard investigation for diagnosis of Hepatitis C – HCV RNA assay

Gold standard test for diagnosis of intraluminal bile duct abnormalities – ERCP

Gold standard method for management of hydatid disease – Surgery

Gold standard for assessing degree of liver injury and fibrosis – Liver Biopsy

Gold standard method for management of blunt hepatic trauma – Non-operative management

Gold standard test for assessment of function of sphincter of oddi – Manometry

Gold standard investigation of diagnosis of Klatskin tumor – Cholangiography

Gold standard investigation for diagnosis of invasive amoebiasis – ELISA

Otosclerosis

The cochlear promontory may have a faint pink tinge reflecting the vascularity of the lesion, referred to as the Schwartz sign. Conductive hearing loss is usually secondary to impingement of abnormal bone on the stapes footplate. This involvement of the oval window forms the basis of the name fenestral otosclerosis. The most common location of involvement of otosclerosis is the bone just anterior to the oval window at a small cleft known as the fissula ante fenestram.
Also there is mounting evidence that measles virus is present within the otosclerotic foci, implicating an infectious etiology (this has also been noted in Paget’s Disease).
Otosclerosis is associated with osteogenesis imperfecta in 0.15 % of cases. This is known as Van der Hoeve syndrome or Adair - Dighton syndrome.
....### cochlear implants. ....
Inserted in scala tympani
Inserted via round window
*External device: Processor, Microphone ,Transmitter.
*Internal device :Receiver, stimulator.
Lowest age 1 yr

##### types of hemorrhage
primary - at the time of operation
reactionary - within 24 hours of surgery
secondary - 5th to 10th post operative day ..

The classification system for tympanograms commonly used today was developed by Liden (1969) and Jerger (1970). There are three main types of tympanograms: A, B, and C. Type A tympanograms look like a teepee, and indicate a normal middle ear system, free of fluid or physiological anomalies which would prevent the admittance of sound from the middle ear into the cochlea.
Type B tympanograms are a flat line, which is consistent with middle ear pathology, such as fluid or infection behind the ear drum. In some cases, these tympanograms are seen when there is a hole in the ear drum; the difference lies in the ear canal volume: a larger ear canal volume indicates a perforation in the ear drum.
Type C tympanograms are still shaped like a teepee, but are shifted negatively on the graph. This indicates negative pressure in the middle ear space, often consistent with sinus or allergy congestion, or the end-stages of a cold or ear infection.

Neurotransmitters

BRIEF REVIEW OF NEUROTRANSMITTERS

Acetylcholine (ACh)
1. Neurotransmitter at nerve-muscle connections for all voluntary muscles of the body
2. Also many of the involuntary (autonomic) nervous system synapses
3. Despite long history, the exact role of ACh in the brain unclear
4. Cholinergic neurons concentrated in the RAS and basal forebrain
5. Significant role in Alzheimer disease
6. Dementia in general associated with decreased ACh concentrations in amygdala, hippocampus, and temporal neocortex
7. Associated with erections in males
8. Muscarinic and nicotinic receptors
9. In the corpus striatum, ACh circuits are in equilibrium with dopamine neurons.

Norepinephrine (NE)
1. One of the catecholamine neurotransmitters
2. Transmitter of the sympathetic nerves of the autonomic nervous system, which mediate emergency respons
a. Acceleration of the heart
b. Dilatation of the bronchi
c. Elevation of blood pressure
3. Implicated in altering attention, perception, and mood
4. Key pathway: locus ceruleus in upper pons
5. Implicated in monoamine hypothesis of affective disorders:
a. Depletion of NE leads to depression
b. Excess of NE (and serotonin) leads to mania
c. Based on two observations:
1. Reserpine depletes NE and causes depression.
11. Antidepressant drugs block NE re-uptake, thus increasing the amount of NE available postsynaptically.
6. Receptors:
a. Alpha-I: sympathetic ( vasoconstriction)
b. Alpha-2: on cell bodies of presynaptic neurons, inhibit NE release
c. Beta-1: excitatory for heart, lungs, brain
d. Beta-2: excitatory for vasodilatation and bronchodilatation

Dopamine
1. The other catecholamine neurotransmitter
2. Synthesized from the amino acid tyrosine
3. D2 receptors most important
4. D1 and D5 stimulate G-protein and increase cAMP and excitation
5. D2, D3, and D 4 inhibit G-protein and decrease cAMP and excitation
6. Three pathways of known psychiatric importance:
a. Nigrostriatal pathway • Blockade leads to tremors, muscle rigidity, bradykinesia b. Meso-limbic-cortico pathway • Blockade leads to reduction of psychotic symptoms
c. Tuberoinfundibular system • Blockade leads to increases in prolactin (Dop = PIF)

Serotonin (5-hydroxytryptamine, 5-HT)
1. The transmitter of a discrete group of neurons that all have cell bodies located in the raphe nuclei of the brain stem
2. Changes in the activity of serotonin neurons are related to the actions of psychedelic drugs.
3. Involved in the therapeutic mechanism of action of antidepressant treatments (most are 5-HT re-uptake inhibitors; a few new ones are 5-HT agonists)
4. Has inhibitory influence; linked to impulse control
5. Low 5-HT =low impulse control
6. Has role in regulation of mood, sleep, sexual activity, aggression, anxiety, motor activity, cognitive function, appetite, circadian rhythms, neuroendocrine function, and body temperature

Glutamic Acid
1. One of the major amino acids in general metabolism and protein synthesis, also a neurotransmitter
2. Stimulates neurons to fire; principal excitatory neurotransmitter in the brain 3. The neurotransmitter of the major neuronal pathway that connects the cerebral cortex and the corpus striatum
4. Also the transmitter of the granule cells, which are the most numerous neurons in the cerebellum
5. Evidence that glutamic acid is the principal neurotransmitter of the vi-sual pathway
6. May have a role in producing schizophrenic symptoms
7. Reason for PCP symptoms (antagonist ofNMDA glutamate receptors)
8. Glutamate agonists produce seizures in animal studies

Enkephalins
1. Composed of two peptides, each containing five amino acids
2. Normally occurring substances that act on opiate receptors, mimicking the effects of opiates
3. Neurons are localized to areas of the brain that regulate functions influenced by opiate drugs.

Substance P
1. Peptide containing 11 amino acids
2. A major transmitter of sensory neurons that convey pain sensation from the periphery, especially the skin, into the spinal cord
3. Also found in numerous brain regions
4. Opiates relieve pain in part by blocking the release of substance P.
5. New class of antidepressant medications being tested to work on substance P

Gamma Amino-butyric Acid (GABA)
1. One of the amino-acid transmitters in the brain
2. Occurs almost exclusively in the brain
3. Reduces the firing of neurons; principle inhibitory neurotransmitter in the brain 4. The transmitter present at 25 to 40% of all synapses in the brain
5. Quantitatively, the predominant transmitter in the brain
6. Associated with anxiety, cannabis, benzodiazepines