Most Common Site of Primary Bone Tumors

Epiphyseal

- Chondroblastoma (before physeal closure)

- Osteoclastom/Giant cell tumor (after physeal closure in adults)

- Articular osteochondroma

Metaphyseal

- Chondrosarcoma

- Enchondroma

- Osteochondroma

- Osteoblastoma

- Bone cyst

- Osteosarcorna

- Osteoclastoma (in children)

- Osteomyelitis mostly starts in metaphysis

​Diaphyseal

- Round cell lesions: Ewing’s sarcoma/Multiple myeloma /Reticulum cell sarcoma

- Admantinoma

- Osteoid osteoma

Amphotericin B: Naegleria fowleri, Leishmania donovani

Metronidazole: Giardia lamblia, Trichomona vaginalis, Entamoeba hystolytica

Nitazoxanide: Cryptosporidium

Bendazoles or Pyrantel Pamoate: Enterobius vermicularis, Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus (ne M atodes)

Mebendazole: Toxocara canis

Albendazole: Strongyloides stercolaris, Toxocara canis, neurocysticercosis, Echinococcus granulosus.

Paziquantel: Taenia solium, Schistosoma, Diphylobotrium latum, Clonorchis (P latyhelminthes)

Pyrimethamine + Sulfadiazine: Toxoplasma gondii

Suramin: Trypanosma bruceii (blood borne)

Melarsoprol: Trypanosoma bruceii (CNS)

Nifurtimox or Benznidazole: Trypanosoma cruzi

Quinidine (IV): severe Plasmodium infx

Mefloquine or Atovaquone/Proguanil: Plasmodium resistant

Atovaquone + Azythromycin: Babesia

Diethylcarbamazine (DEC): Loa loa, Wucheria bancrofti

Ivermectin: Onchocerca volvulus, Strongyloides stercolaris

Sodium stibogluconate (Pentavalent Antimony): Leishmania donovani

Cloroquine: Plasmodium falciparum, Plasmodium malariae

Cloroquine + Primaquine: Plasmodium ovale, Plasmodium vivax

TYPES OF TRACHEOSTOMY TUBE

• A tracheostomy tube may be metallic or nonmetallic

Metallic Tracheostomy Tube

• Metallic tubes are formed from the alloy of silver, copper and phosphorus
• Example Jackson’s Tracheostomy tube.
• Has an inner and an outer tube.The inner tube is longer than the outer one so that secretions and crusts formed in it can be removed and the tube reinserted after cleaning without difficulty. However, they do not have a cuff and cannot produce an airtight seal.
• Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner cannula.
• Inner cannula should be removed and cleaned as and when indicated for the first 3 days. Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow a track to be formed when tube placement will be easy.

Nonmetallic Tracheostomy Tube

• Can be of cuffed or noncuffed variety, e.g. rubber and PVC tubes.

Cuffed Tracheostomy Tubes

• Pediatric tubes do not have a cuff.
• Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).
• The cuff should be deflated every 2 hours for 5 mins to present pressure damage to the trachea.

Uncuffed Tracheostomy Tubes

• It is suitable for a patient who has returned to the ward from a prolonged stay in intensive care and requires physiotherapy and suction via trachea.
• This type of tube is not suitable for patients who are unable to swallow due to incompetent laryngeal reflexes, and aspiration of oral or gastric con­tents is likely to occur.
• An uncuffed tube is advantageous in that it allows the patient to breathe around it in the event of the tube becoming blocked. Patients can also speak with an uncuffed tube.

Important

Nonmetallic Tracheostomy Tube - Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).

Metallic Tracheostomy Tube -Metallic tubes are formed from the alloy of silver, copper and phosphorus .

• Example Jackson’s Tracheostomy tube.
• Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner cannula.

a forcep is a metal device  that enables gentle rotation and/or traction of the fetal head during vaginal delivery

Types

Kielland: enables rotation and traction of the fetal head

Simpson: only enables traction of the fetal head

Barton: used for occiput transverse position of the fetal head

Piper: used to deliver the fetal head during breech delivery

Classification

Outlet: fetal head lies on the pelvic floor
Low: fetal head is below +2 station (not on the pelvic floor)
Mid: fetal head is below 0 station (not at +2 station)
High: fetal head is not engaged

Indications

Prolonged second stage of labor

Breech presentation

Nonreassuring fetal heart rate

To avoid/assist maternal pushing efforts

Prerequisites

Clinically adequate pelvic dimensions (see “Mechanics of childbirth”)

Full cervical dilation

Engagement of the fetal head

Knowledge of exact position and attitude of the fetal head

Emptied maternal bladder

No suspicion of fetal bleeding or bone mineralization disorders

Advantages
Scalp injuries are less common

Cannot undergo decompression and “pop off”

Complications

Maternal: obstetric lacerations (cervix, vagina, uterus)

Fetal: head or soft-tissue trauma (e.g., scalp lacerations, injured ears), facial nerve palsy

 

Thalassemia

Thalassemias are a heterogeneous group of hereditary blood disorders characterized by faulty globin chain synthesis resulting in defective hemoglobin, which can lead to anemia

Thalassemia provides partial resistance against malaria.

Beta thalassemia

Clinical features

Minor variant (heterozygous): unremarkable symptoms (low risk of hemolysis, rarely splenomegaly)

Major variant (homozygous) Severe hemolytic anemia, Hepatosplenomegaly ,Growth retardation ,Skeletal deformities (high forehead, prominent zygomatic bones, and maxilla)

Alpha thalassemia

most commonly seen in people of Asian and African descent

Clinical features

Silent carrier: asymptomatic

Alpha thalassemia trait: mild hemolytic anemia with normal RBC and RDW

Hemoglobin H disease

Jaundice and anemia at birth

Chronic hemolytic anemia which may require transfusions

Hb-Bart's hydrops fetalis syndrome (most severe variant of alpha thalassemia)

Intrauterine ascites and hydrops fetalis, severe hepatosplenomegaly, and often cardiac and skeletal anomalies

Incompatible with life (death in utero or shortly after birth)

Diagnostics

Microcytic hypochromic anemia

Blood smear: target cells , teardrop cells

Bone marrow biopsy: reactive hyperplasia

Confirmatory tests

Hb-electrophoresis Alpha thalassemia can usually only be detected if ≥ 3 alleles are defective.

DNA analysis: to test for alpha thalassemia minor and minima (< 3 alleles defective)

Skeletal deformities -high forehead, prominent zygomatic bones and maxilla can be seen on all imaging modalities.

X-ray: hair-on-end (“crew cut”) sign

Umbilical cord prolapse

acute, life-threatening emergency for the fetus, in which a part of the umbilical cord lies between the antecedent part of the fetus (mostly head) and the pelvic wall, causing rupture of membranes

Epidemiology: rare (0.5% births)

Etiology: often seen in presentation anomalies (e.g., breech presentation, transverse fetal position), multiple pregnancy, long umbilical cord, or abnormal fetal movement (polyhydramnios, premature birth)

Clinical features: -
- an abrupt change from a previously normal CTG to one with fetal bradycardia or recurrent,
- severe decelerations,
- occuring after the rupture of membranes

Diagnostics: vaginal palpation → thick, pulsating cord is palpable

Treatment: Trendelenburg position; fetus is pushed back into the uterus; immediate tocolysis using β2-mimetics (e.g., fenoterol) → emergency cesarean section

 

Constrictive Pericarditis

Etiology

- any cause of acute pericarditis may result in chronic pericarditis

Symptoms

- dyspnea, fatigue, palpitations
- abdominal pain

Signs

- general examination - mimics CHF (especially right-sided HF)
• ascites, hepatosplenomegaly, edema
- pulses: increased JVP, Kussmaul's sign (paradoxical increased in JVP with inspiration),
- Friedrich's sign (prominent “y” descent > “x” descent)
- pressures: BP normal to decreased, +/– pulsus paradoxus
- precordial examination: +/– pericardial knock (early diastolic sound)

Investigations

- 12 lead ECG: low voltage, flat T wave, +/– AF
- chest x-ray: pericardial calcification, effusions
- CT or MRI: pericardial thickening
- cardiac catheterization: equalization of RV and LV diastolic pressures, RVEDP > 1/3 of RV systolic pressure

Management

- medical: diuretics, salt restriction
- surgical: pericardiectomy

- Ankylosing spondylitis or AS, is a form of arthritis that primarily affects the spine, although other joints can become involved.
- It causes inflammation of the spinal joints (vertebrae) that can lead to severe, chronic pain and discomfort.
- Most people with AS have an antigen called HLA-B27
- Ankylosing spondylitis (AS) is a chronic, multisystem inflammatory disorder involving primarily the sacroiliac joints and the axial skeleton.

Key components of the patient history that suggest AS include the following:

• Insidious onset of low back pain - The most common symptom
• Onset of symptoms before age 40 years
• Presence of symptoms for more than 3 months
• Symptoms worse in the morning or with inactivity
• Improvement of symptoms with exercise

Complications

- AS can cause pain and inflammation in other parts of your body.
- Eyes. About 40% of people with AS have an eye problem called uveitis. It’s a painful inflammation that can blur your vision and make you sensitive to bright light.
- Heart valve. It’s not common, but AS can enlarge the aorta, the largest artery in your body. This can change the shape of the aortic valve, which can allow blood to leak back into your heart.
- Cancer. A large study found that people with AS are more likely to get certain types of cancers. They include bone and prostate cancers in men and colon cancer in women, as well as blood-related cancers in both sexes.

ENDOMETRIOSIS

The proliferation and functioning of endometrial tissue outside of the uterine cavity

Incidence: - 15-30% of all premenopausal women, -mean age at presentation: 25-30 years
 
Etiology - unknown

theories

- retrograde menstruation theory of Sampson
- Mullerian metaplasia theory of Meyer
- endometriosis results from the metaplastic transformation of peritoneal mesothelium under the influence of certain unidentified stimuli
- lymphatic spread theory of Halban
- surgical transplantation
- deficiency of immune surveillance

Predisposing Factors

- nulliparity
- age > 25 years
- family history
- obstructive anomalies of genital tract

Sites of Occurrence

ovaries  most common location, 60% of patients have ovarian involvement
broad ligament
peritoneal surface of the cul-de-sac (uterosacral ligaments)
rectosigmoid colon
appendix

Symptoms

there may be little correlation between the extent of disease and symptomatology

pelvic pain - due to swelling and bleeding of ectopic endometrium, unilateral if due to endometrioma

dysmenorrhea (secondary) - worsens with age, suprapubic and back pain often precede menstrual flow (24-48 hours) and continue throughout and after flow

infertility - 30-40% of patients with endometriosis will be infertile, 15-30% of those who are infertile will have endometriosis

dyspareunia  on deep penetration

premenstrual and postmenstrual spotting
bladder symptoms - frequency, dysuria, hematuria

bowel symptoms - direct and indirect involvement diarrhea, constipation, pain and hematochezia

Diagnosis

truly a surgical diagnosis

history - cyclic symptoms - pelvic pain, dysmenorrhea, dyschezia

physical examination

- tender nodularity of uterine ligaments and cul-de-sac
- fixed retroversion of uterus
- firm, fixed adnexal mass (endometrioma)

laparoscopy

- dark blue or brownish-black implants (mulberry spots) on the uterosacral ligaments, cul-de-sac, or anywhere in the pelvis
- chocolate cysts in the ovaries (endometrioma)
- powder-burn lesions
- early white lesions and blebs

Treatment

pseudopregnancy - cyclic estrogen-progesterone (OCP) or medroxyprogesterone (Provera)

pseudomenopause - danazol (Danocrine) = weak androgen, s/e:  weight gain, fluid retention, acne, or hirsutism, leuprolide (Lupron) = GnRH agonist (suppresses pituitary GnRH)

s/e: hot flashes, vaginal dryness, reduced libido, and osteoporosis with prolonged use .these can only be used short term because of osteoporotic potential

surgical

- laparoscopic resection and lasering of implants
- lysis of adhesions
- use of electrocautery
- unilateral salpingo-oophorectomy
- uterine suspension
- rarely total pelvic clean-out
- follow-up with 3 months of medical treatment

Medications can interfere with folate metabolism, including:

anticonvulsant medications (such as phenytoin, primidone, carbamazepine or valproate)
metformin (sometimes prescribed to control blood sugar in type 2 diabetes)
methotrexate, an anti-cancer drug also used to control inflammation associated with Crohn disease, ulcerative colitis and rheumatoid arthritis.
5-fluorouracil
Hydroxyurea
trimethoprim
sulfasalazine (used to control inflammation associated with Crohn disease, ulcerative colitis and rheumatoid arthritis)
triamterene (a diuretic)
birth control pills