Brain Tumours

The sulci may also be obliterated by expanding lesions within the
brain such as a tumour or an abscess. In addition to mechanical
compression of the sulci, associated swelling of the surrounding
gyri from oedema leads to the appearance of complete obliteration
of the sulci as shown in Figs.

EXTRA AXIAL AND INTRA AXIAL LESIONS
The type of lesion in Figs. 1.15 and 1.16 is called intra axial,
meaning it is inside the brain itself. However, a mass lesion that
arises in the coverings of the brain like a meningioma (tumour

FIGURE 1.13. In the brain CT scan above, the CSF pattern is more obvious
and I have named a few landmark structures for your ready reference (FL
= frontal lobe; TL = temporal lobe; FH = frontal horn of lateral ventricle;
SF = Sylvian fissure; QC = Quadrigeminal cistern; LV = lateral ventricle).


of meninges, Figs. 1.17 and 1.18), which will immediately squash
both gyri and sulci together is called an extra axial mass. The
schematic drawing (Fig. 1.17) is a general illustration of what
happens to the brain with an extra axial mass. Similarly a blood
clot on the surface of the brain or over the membranes of the
brain will also be an extra axial lesion. Can you identify the
abnormality in the CT scan in Fig. 1.17? ‘And do not forget the
right half of the CT scan is on the left hand side of the reader!’

BRAIN SWELLING

whenever the brain swells, it
means the gyri get larger and the sulci get smaller as illustrated
below:
As in Fig. 1.12, the sulci and gyri may not be obvious because
of either swelling or compactness as in most young people. However,
it is very important to appreciate that the whole brain surface
is made of sulci and gyri, which is easier to appreciate in
Figs. 1.11 and 1.13. ‘All the gyri and sulci of the brain are named.
Some of the CSF spaces are larger (big sulci) and more constant
(present in every scan) and easily identified; therefore they are
FIGURE 1.11. CT scan
showing widely spaced
CSF spaces. This and
the next figure also
serve to illustrate the
point that although
some CT scan images
appear simply as a
granular mass as in
Fig. 1.12, you should
bear in mind that it
always represents sulci
and gyri on the surface
of the brain as in this
figure.

used as the compass for navigating the maze of sulci on the surface
of the brain (Fig. 1.13). Can you name some of them?’
Occasionally the presence of air (dark spots in Fig. 1.14A) in
the sulci allows us to appreciate easily that the homogenouslooking
appearance of the CT scan (Fig. 1.14) actually consists
of sulci and gyri.

Clinical Procedures

Another group of skills are those which the intern will be expected to observe and perhaps
perform under supervision, but not necessarily demonstrate fully independent competence at
this stage of training. It is important that the principles of these procedures are observed and
understood and can be explained to patients. These skills include, among others:
• indirect laryngoscopy;
• lumbar puncture;
• use of a tonometer; and
• advanced local anaesthetic and field block including intravenous local block (Bier), and
epidural block commonly used in obstetrics.
A fourth group of skills include those which are not considered suitable for those at intern level,
but which may have been observed by individuals whilst medical students or interns. There is a
common misconception that such procedures need to be learnt at internship, when in reality the
procedures should preferably only be undertaken independently by individuals with already
developed specialist skills. Again, the principles of these procedures should be understood at
intern level, such that they can be explained to patients. These procedures include:
• cricothyroidotomy;
• insertion of a central venous line;
• insertion of an intercostal draintube;
• peritoneal dialysis/lavage; and
• haemodialysis/haemofiltration.
Missing from these lists are a number of tasks sometimes thought of as procedures, but which
in reality should be considered an essential part of the examination of the patient. These
include:
• ophthalmoscopy;
• measurement of blood pressure;
• otoscopy; and
• urinalysis.
Specialist and generic endoscopic skills
These are usually confined to performance by specialists in various disciplines and include:
• nasolaryngoscopy, bronchoscopy;
• upper gastrointestinal endoscopy – – oesophagoscopy, gastroscopy;
• lower gastrointestinal endoscopy — flexible sigmoidoscopy, colonoscopy; and
• arthroscopy, thoracoscopy, laparoscopy.
This section contains some examples of procedures which the intern is expected to be able to
perform competently and be able to explain to a patient.
The following table is an AMC composite checklist of ‘Clinical Procedural Skills’. Students are
expected by graduation to understand the principles of all of these, and to be able to explain
them clearly to a patient.
Competence levels expected as regards performance thus varies between those they should
be able to perform and interpret independently (A), perform under supervision and with
guidance (B), or observe and understand principles (C).

Blood transfusion consent for a 33-year-old pregnant woman with a severe APH at 7 months gestation

To assess the candidate’s ability to counsel appropriately a patient refusing a blood transfusion

on religious grounds.
EXAMINER INSTRUCTIONS
The examiner will have instructed the patient as follows:
You are Miriam, a 33-year-old Jehovah’s Witness. You are seven months pregnant and having a
life-threatening haemorrhage. You believe the baby is still alive, but do not know whether it will
survive.
Opening statement
‘I do not want a blood transfusion as I am a Jehovah’s Witness.’
The candidate should counsel you that a blood transfusion is necessary in order to avert a very
high likelihood of dying from blood loss for both you and your baby. DO NOT agree to this at any
point during the interview. Remain determined to refuse the transfusion.
Questions to ask unless already covered:
• ‘Can t you save me and the baby without a blood transfusion?’
• ‘Can t you deliver the baby now without transfusing me?’
After six minutes, the examiner should ask the candidate:
• ‘Summarise the legal and ethical issues in this situation.’
• ‘What will you do — how would you manage this situation?’
EXPECTATIONS OF CANDIDATE PERFORMANCE
The candidate should understand the ethical issues of autonomy and the patient’s right as an
adult of sound mind to self-determine her treatment.
However a patient’s right to be autonomous is restricted by the potential to damage a third
person.
If candidates are not able to counsel the mother in relation to the potential damage to the infant
and are unable to obtain consent for transfusion they could seek an emergency order from the
Court to commence the transfusion, although they are most unlikely to receive permission to do
so.
In Australia, the fetus has no ‘rights’ justifying treatment being forced on the mother against her
wishes, as until the baby is born it is most unlikely any Court would force any treatment on the
mother to improve the chances of fetal survival.
Once the baby is born, the possibility of transfusing the baby changes completely.

Leukemia: Causes, symptoms, and treatment

Leukemia is cancer of the blood or bone marrow (which produces blood cells). A person who has leukemia suffers from an abnormal production of blood cells, generally leukocytes (white blood cells).

People sometimes confuse leukemia and lymphoma. Leukemia is a cancer of the blood; lymphoma is cancer of the lymphatic system (lymph glands). The word Leukemia comes from the Greek leukos, which means “white”, and aima, which means “blood”.
The DNA of immature blood cells, mainly white cells, becomes damaged in some way. This abnormality causes the blood cells to grow and divide continuously. Healthy blood cells die after a while and are replaced by new cells, which are produced in the bone marrow.
The abnormal blood cells do not die when they should, and accumulate, occupying more space. As more cancer cells are produced, they impede the function and growth of healthy white blood cells by crowding out space in the blood. Essentially, the bad cells crowd out the good cells in the blood.
Contents of this article:
Leukemia symptoms
Risk factors
Leukemia types
Treatments
Fast facts on leukemia
Here are some key points about leukemia. More detail and supporting information is in the main article.
According to the Leukemia and Lymphoma Society, 60,140 people were expected to be diagnosed with leukemia in 2016.
There are about 54,270 new cases of leukemia in the United States each year.
Although leukemia is among the most common childhood cancers, it most often occurs in older adults.
Leukemia is slightly more common in men than women.
People with leukemia have many treatment options, and treatment for leukemia can often control the disease and its symptoms.

Leukemia symptoms
Blood clotting is poor – As immature white blood cells crowd out blood platelets, which are crucial for blood clotting, the patient may bruise or bleed easily and heal slowly – he may also develop petechiae (a small red to purple spot on the body, caused by a minor hemorrhage).
Affected immune system – The patient’s white blood cells, which are crucial for fighting off infection, may be suppressed or not working properly. The patient may experience frequent infections, or his immune system may attack other good body cells.
Anemia – As the shortage of good red blood cells grows the patient may suffer from anemia – this may lead to difficult or labored respiration (dyspnea) and pallor (skin has a pale color caused by illness).
Other symptoms – Patients may also experience nausea, fever, chills, night sweats, flu-like symptoms, weight loss, bone pain, and tiredness. If the liver or spleen becomes enlarged the patient may feel full and will eat less, resulting in weight loss.
Weight loss can also occur independent of hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen). Headache is more common among patients whose cancerous cells have invaded the CNS (central nervous system).
As all these symptoms could be due to other illnesses, a diagnosis of leukemia can only be confirmed after medical tests are carried out.

Leukemia risk factors
Some factors put certain people at higher risk of developing leukemia. The following are either known or suspected factors:
artificial ionizing radiation
viruses – HTLV-1 (human T-lymphotropic virus) and HIV (human immunodeficiency virus)
benzene and some petrochemicals
alkylating chemotherapy agents used in previous cancers
maternal fetal transmission (rare)
hair dyes
smoking
Genetic predisposition – some studies researching family history and looking at twins have indicated that some people have a higher risk of developing leukemia because of a single gene or multiple genes.
Down syndrome – people with Down syndrome have a significantly higher risk of developing leukemia, compared with people who do not have Down syndrome. Experts say that because of this, people with certain chromosomal abnormalities may have a higher risk.
Electromagnetic energy – studies indicate there is not enough evidence to show that ELF magnetic (not electric) fields that exist currently might cause leukemia. The IARC (International Agency for Research on Cancer) says that studies which indicate there is a risk tend to be biased and unreliable.
Leukemia and bone marrow function
The bone marrow is found inside of bones. The marrow in the large bones of adults produces blood cells. Approximately 4 percent of our total bodyweight consists of bone marrow.
Leukemia cells
There are two types of bone marrow:
Red marrow, made up mainly of myeloid tissue.
Yellow marrow, made up mostly of fat cells.
Red marrow can be found in the flat bones, such as the breast bone, skull, vertebrae, shoulder blades, hip bone, and ribs. Red marrow can also be found at the ends of long bones, such as the humerus and femur.
White blood cells (lymphocytes), red blood cells, and platelets are produced in the red marrow. Red blood cells carry oxygen, white blood cells fight diseases. Platelets are essential for blood clotting. Yellow marrow can be found in the inside of the middle section of long bones.
If a person loses a lot of blood the body can convert yellow marrow to red marrow in order to raise blood cell production.
White blood cells, red blood cells and platelets exist in plasma – blood plasma is the liquid component of blood, in which the blood cells are suspended.

Leukemia types
Experts divide leukemia into four large groups. These groups are classified as acute vs. chronic and lymphocytic vs. myelogenous

Chronic and acute leukemia
There are several stages of maturation in a white blood cell’s lifespan. Acute leukemia is a rapidly progressing disease that results in the accumulation of immature, useless cells in the marrow and blood. They are squeezed out of the bone marrow too early and are not functional. Chronic progresses more slowly and allows more mature, useful cells to be made. In other words, acute leukemia crowds out the good cells more quickly than chronic leukemia.
Lymphocytic and myelogenous leukemia
Leukemias are also subdivided into the type of affected blood cell. If the cancerous transformation occurs in the type of marrow that makes lymphocytes, the disease is called lymphocytic leukemia. A lymphocyte is a kind of white blood cell inside the vertebrae immune system. If the cancerous change occurs in the type of marrow cells that go on to produce red blood cells, other types of white cells, and platelets, the disease is called myelogenous leukemia.
To recap, there are two groups of two groups – four main types of leukemia, as you can see in the illustration below:
Diagram of the types of leukemia
Acute lymphocytic leukemia (ALL)
Also known as acute lymphoblastic leukemia – this is the most common type of leukemia among young children, although adults can get it as well, especially those over the age of 65. The 5-year survival rate is greater than 85 percent among children.
The following are subtypes of ALL: precursor B acute lymphoblastic leukemia, precursor T acute lymphoblastic leukemia, Burkitt’s leukemia, and acute biphenotypic leukemia.
Chronic lymphocytic leukemia (CLL)
This is most common among adults over 55, although younger adults can get it as well. It is the most common type of leukemia in adulthood. CLL hardly ever affects children. The majority of patients with CLL are men, over 60 percent. The 5 year survival rate of treated CLL patients is 82 percent. Experts say CLL is incurable. A more aggressive form of CLL is B-cell prolymphocytic leukemia.
Acute myelogenous leukemia (AML)
AML is more common among adults than children, and affects males significantly more often than females. Patients are treated with chemotherapy. In children diagnosed with AML, the 5-year survival rate is 60-70 percent, though the overall survival rate is 26.6 percent.
Under the WHO classification system, there are six main groups of AML: AML with recurrent genetic abnormalities, AML with myelodysplasia-related features, therapy-related AML and MDS, AML not otherwise specified, myeloid sarcoma, and myeloid proliferations related to Down Sydrome.

Chronic Myelogenous Leukemia (CML)
The vast majority of patients are adults. According to the National Cancer Institute, the 5-year survival rate is 65.1 percent. However, many people with CML have a gene mutation that responds to targeted cancer therapy, called Gleevec. Gleevec (imatinib) is commonly used to treat CML, as well as some other drugs. For those people whose cancer is susceptible to Gleevec, their survival rate can be as high as 90 percent. Chronic monocytic leukemia is a subtype of CML.

Leukemia treatments
As the various types of leukemias affect patients differently, their treatments depend on what type of leukemia they have. The type of treatment will also depend on the patient’s age and his state of health.
In order to get the most effective treatment the patient should get treatment at a center where doctors have experience and are well trained in treating leukemia patients. As treatment has improved, the aim is complete remission – that the cancer goes away completely for a minimum of five years after treatment.

Acute leukemia treatments
Treatment for patients with acute leukemias should start as soon as possible. The mainstay of treatment is still chemotherapy, which will be tailored to the type of cancer a patient has. Sometimes, chemotherapy may be given in three phases: induction, consolidation and maintenance. In some cases, a bone marow transplant may be warranted (allogeneic stem cell transplantation).
Chronic leukemia treatments
Chronic leukemia treatment is tailored to the type of cancer a person has and what phase it is in. Types of treatment include targeted therapy, interferons, chemotherapy, radiation therapy, surgery and stem cell transplant. Targeted therapy is different than chemotherapy, because it attacks a specific part of the cancer cell. Examples of this include Gleevec (imatinib mesylate) for CML, Sprycel (dasatinib), and Tarigna (nilotinib).
In some cases of CLL, treatment isn’t necessary in the early stages. Instead, an oncologist may opt for watchful waiting with frequent doctor’s visits.
A bone marrow transplant is the only current way of curing a patient with CML. The younger the patient is the more likely the transplant will be successful.
Leukemia prognosis and life expectancy
All leukemia patients, regardless of what type they have or had, will need to be checked regularly by their doctors after the cancer has gone (in remission). They will undergo exams and blood tests. The doctors will occasionally test their bone marrow. As time passes and the patient continues to remain free of leukemia the doctor may decide to lengthen the intervals between tests.

Acting Up Against Ebola

As AIDS activists begin to engage with the ebola outbreak, we need to get our message right. I think we should target dumb quarantines, not all quarantines. Especially, we should target dumb quarantines motivated by politics.

For example, Kaci Hickox, the MSF nurse who was quarantined at Newark Airport and then in Maine, seems to have been selected for quarantine attention because she had a temperature measured once as 101. But later, her temperature measurement became normal and stayed normal. Unless ebola has a quiescent phase — most unlikely — that meant that the original measurement was not due to ebola. It should then have been irrelevant to her status. But Maine’s governor has a difficult re-election race next week.

If there are more U.S. cases, the cost of a policy of quarantining everybody who cares for an ebola patient also needs to be considered. It would mean that doctors and nurses would be in permanent quarantine until they stopped caring for those patients. All sorts of problems would result.

So far, the most horrible example of dumb quarantine is Louisiana telling medical people who have recently been fighting ebola in West Africa not to attend the meeting of the American Society of Tropical Medicine and Hygiene, November 2-6 in New Orleans. This meeting is supposed to be a forum for sharing experiences and improving strategies for fighting the disease.

I can’t imagine any situation where it would make sense to quarantine people who have no symptoms, no fever, no detectable virus, and no other sign of ebola infection, and who are willing to follow CDC and other medical recommendations. But conceivably, that might change.

Ebola activism is not a direct continuation of AIDS activism. The situations are very different. For example, stigma is a major problem in both cases, but the stigma is different.

Keeping an open mind even on quarantine will help reassure the public that we are always putting their interests first.

Treatment for Hair fall

Referred to as ‘crowning glory’, tresses are a direct expression of an individual’s personality and style. Excessive hair loss can be a troublesome problem, often causing worry and affecting self-esteem, especially for women. However, if diagnosed right, you can control hair fall with certain home remedies that are natural and effective in saving your locks.

Causes of hair loss

1. Nutritional deficiencies

It could be possible that essential nutrients may be missing from your diet such as iron, copper, zinc and proteins. Deficiency of vitamin D is another cause of hair loss. In order to avoid this, make sure to get out and soak up some sun.

2. Hormonal Imbalance

After the age of 30, women can experience hormonal imbalance which can cause hair loss. This is usually caused by excessive dihydrotestosterone (DHT) conversion. Even though estrogen is the main hormone that women produce, testosterone and other androgens such as DHEA also occur in the female body. As women reach a certain age, they may begin to convert these androgens to DHT.

3. Thyroid issues

If the thyroid gland, which is at the front of the neck, produces excessive or an insufficient amount of the thyroid hormone, then the hair growth cycle may change. However, if you do have a thyroid issue, you will notice other symptoms along with hair loss such as weight gain or loss, sensitivity to cold or heat, and changes in heart-rate.

4. Polycystic ovary syndrome (PCOS)

Women with polycystic ovary syndrome (PCOS) have a hormonal imbalance which creates higher levels of androgens than normal. This often causes hair to grow on the face and body, while hair on the head grows thinner. PCOS can also lead to ovulation problems, acne, and weight gain.

5. Birth Control Pills

Birth control pills can cause hair loss. The hormones in the pill that suppress ovulation can cause hair to thin, especially in women with a family history of hair loss. Sometimes hair loss can occur when you stop taking the pill. Other drugs associated with hair loss are blood thinners and medicines that treat high blood pressure, heart disease, arthritis, and depression.

6. Stress

Extreme stress can cause sudden hair loss which could last for several months. Minimizing stress through exercise, meditation yoga and massages will reduce your chances of experiencing hair loss.

7. Hair styling products

Over-treated hair can lead to hair loss due to the toxic chemicals found in dyes and styling products. Similarly, almost all shampoos contain Sodium lauryl sulfate (SLS) which has a toxic effect on your immune system and has been proven to corrode hair follicles and impede hair growth. It is advisable to stick to natural shampoos and dyes.

8. Medical Conditions

– Telogen effluvium

general shedding from all over the head. We typically lose some 100 hairs a day but sometimes shedding accelerates due to stress, illness, medication or hormones. Hair generally grows back within six months.

– Androgenetic alopecia

in women, hair generally thins in the top, frontal area, just behind the hair line, but stays thick at the back. An enzyme causes conversion of the male sex hormone testosterone to another hormone, dihydrotestosterone (DHT), causing the hair follicles to produce thinner hair until they stop.

– Alopecia areata

an autoimmune disease that affects up to 2% of the population. It causes round patches of hair loss and can lead to total baldness. In many cases, the hair regrows.

– Ageing

As we age, the rate at which our hair grows tends to slows down. Hair strands get smaller and have less pigment, and hair becomes thinner, finer, and grey. In order to keep your hair healthy, eat whole foods which help to keep your body youthful, as well as your hair. If you have premature grey hair, you can find here natural supplements that can help you.

– Genetics

Hair loss that is genetic is known as androgenetic alopecia and is known to be the most common cause of hair loss. The gene can be inherited from either your mother’s or father’s side of the family, though you’re more likely to have it if both of your parents had hair loss.

Tips for controlling hair fall

1. Shampoo

It is extremely important to understand your scalp type and choose the right shampoo. Also, you need to wash your hair depending upon your scalp. For instance, over washing hair with dry scalp can lead to hair fall, or not washing oily locks thrice a week can lead to the same.

Further, make sure the shampoo is not loaded with chemicals including sulfate, paraben and silicone that can make your tresses brittle and hence, prone to breakage.

2. Conditioner

A good conditioner can work wonders for your locks. It contains amino acids that help to repair damaged hair, and also helps to keep them smooth.

3. Diet and Exercise

You need to feed your hair all the right nutrients particularly plenty of protein and iron. However, along with eating a balanced diet ensure you are exercising side by side. Yoga and meditation are effective in reducing hair fall.

4. Chemical Treatments

Undergoing rigorous hair treatments like straightening, perming and colouring are definitely not kind to your tresses. Further avoid using blow dryers, curling rods, especially on wet hair as they actually boil the water in your hair shaft and make them brittle.

If you really need to use a blow dry, then keep it on the lowest heat setting. If using other products that heat your hair, start with a fortifying leave-in conditioner and finish with a protective spray.

5. Oiling

Oiling improves blood circulation and nourishes the roots. Make sure to massage your tresses once a week with oil that suits your scalp. Cover it with a shower cap and wash it off with a mild shampoo after two hours.

6. Too many styling products

Using too many chemically laden products on your hair could prove harmful in the long run. It’s best to give them a break and try natural home-made recipes instead.