Prevention of hypoglycemia and hypoglycemic emergencies

Hypoglycemic attack has always been considered as a medical emergency, if it is left untreated for sometime can lead to permanent brain damage due to poor supply of glucose to brain, this damage is generally irreversible. Thus a slight alertness can save a person and can decrease the mrorbidity and mortality from hypoglycemia. Emergency management of acute hypoglycemic attack has been mentioned here at Emergency management of hypoglycemic attack.

Hypoglycemia is preventable to some extent, there are certain dietary modification and drug supplements which can prevent this. Hypoglycemia can occur as reactive or fasting as in case of insulinoma etc. Prevention in both the conditions are briefed below.

Prevention of reactive hypoglycemia

Reactive hypoglycemia can be prevented by simple modification of diet and some drugs which act to delay absorption of glucose leading to supplement glucose to blood.

Prevention of hypoglycemia by diet

A simple diatary manipulation and modification can prevent reactive hypoglycemia. A high protein diet is adviced because amino acid is a antitrigger factor and stimulate insulin release to a lesser extent than glucose. Thus a decreased intake of sugar containing foods, more protein diet and restricted calories are helpful to prevent hypoglycemia.

Prevention of hypoglycemia by drugs

There are certain drugs used in different conditions to prevent hypoglycemia. These are-
Anticholinergic drugs are used in prevention of hypoglycemia as they inhibit vgal action and delay gastric emptying in patients with accelerated glucose absorption.

Mild use of tranquilizers like meprobamate, lonazepam or alprazolam and avoidance of caffiene and cigarette smoking in anxious and hyperkinetic patient may be beneficial in preventing them from hypoglycemia.

Phenformin hydrochloride alleviate hypoglycemia in diabetes by inhibiting intestinal glucose absorption which in turninhibit insulin release.

Though not thoroughly evaluated but there are certain insulin inhibitors which has been used in prevention and treatment of hypoglycemia, these are diazoxides, phenytoin and propranolol (inderal).

In patients associated with early onset diabetes, the oral hypoglycemics sulfonylurea has been beneficial in preventing hypoglycemia in them because they restore sensitivity of beta cells to any kind of physiological stimulus.

Prevention of fasting hypoglycemia

Fasting hypoglycemia can occur in certain conditions like insulinoma and tumors of pancreas where there is excess insulin. Prevention of hypoglycemia can be done in these cases by

Surgery for prevention of hypoglycemia

In tumors like insulinomas it is recommended a surgical resection of functioning islet cell tumor in order to prevent hypoglycemia.

In some non resectable tumors of pancreas streptozocin is used. This streptozocin selectively destroys pancreatic tissues. However following this patient require life long insulin therapy.

These are some of the methods to prevent hypoglycemia in the conditions like tumors or as a complication of diabetes. A little consciousness and alertness can prevent this deadly complication.

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Emergency management of hypoglycemia

Hypoglycemia is an abnormal depletion of glucose from uor blood and lead to a complex of symptoms as the nerves gets deprived of glucose. The symptoms of hypoglycemia generally becomes evident when blood glucose level falls below 40 mg percent. Inaccurate insulin dosing or overdose of oral hypoglycemic drugs may lead to hypoglycemia which is considered as the most important complication of diabetes.

Hypoglycemic attack is always considered as a medical emergency and immediate intervention is required to prevent from permanent brain damage due to inadequate supply of glucose to the brain

Treatment of hypoglycemia

The treatment of hypoglycemic attack is done by two ways by replacing or reinfusing glucose and other by certain drugs to counter the emergency situation.

Glucose replacement in hypoglycemic attack

If the patient is conscious glucose or glucose containing liquid should immeditely be given, sugar cubes can do the same if one is at home and hospital is a bit far away. If the patient is unable to take glucose supplement orally then 50 cc of 50% glucose in infused intravenous and this gives a dramatic improvement. Patient should be educated to take frequent small feeds and glucose.

Drugs used in treatment of hypoglycemic attack

During the hypoglycemic attack some drugs are used to activate internal formation of glucose and counter the adverse effect of hypoglycemia.

0.5 cc of 1:1000 adrenaline is given subcutaneously to stimulate hepatic gluconeogenesis and counteracting hypoglycemia.

100 mg of hydrocortisone hemisuccinate or 4mg of dexamethasone is given intravenously.

Sometimes in acute situation glucagon is given 1 to 2 mg to raise blood sugar. Glucagon is just reverse to insulin in action. But as this drug is too expensive so not used routinely.

If there is cerebral edema then mannitol and lasix or frusemide is used to reduce them.

There are some method by which hypoglycemia can be prevented. This may be either by slight manipulation in diet or certain drugs. Complete detail of prevention of hypoglycemia is given here at Prevention of hypoglycemia and hypoglycemic emergencies.

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Chest pain mimicking angina pectoris

Not all chest pains are anginal or heart attack. There are several disease in which chest pain is a prominent symptom and can be considered as differential diagnosis of angina pectoris. These chest pain mimicking angina pectoris and heart attack can be of cardiac origin even but usually non coronary. There are several other causes or diseases where chest pain occurs mimicking angian pectoris. These are-

Non coronary heart disease having chest pain

The cardiac or heart disease in which chest pain is a symptoms and can be confused with angina pectoris are-

Cardiomyopathy

In cardiomyopathy chest pain is more prolonged and not constricting. There are gallop rhythm present in pulse and having a systolic murmer of papillry muscle dysfunction.

Mitral valve prolapse

Chest pain in mitral valve prolapse is more or less like anginal pain but usually prolonged and icreased in anxiety and stress. Fever may be associated sometimes and a mid systolic click is heard on auscultation with stethoscope. ECG can diferentiate anginal pain with pain in mitral vaive prolapse.

Musculoskeletal cause of chest pain

Though in the era of electrocardiogram muscular cause of pain chest can easily be distinguished but in clinic at first instance there are some musculoskeletal disorders which can be confusing and mimick angina pectoris. These are

Costochondritis or Tietze's disease

A local pain and tenderness at sternal region or left side of chest may or may not be associated with swelling at the site can be confused with pain of angina, ECG can be a distinguishing factor which is normal in chostocondtitis or Tietze's disease.

Pain in herpes zoster

In herpes zoster at left side of chest in pre eruptive phase can cause cruciating pain and may mimick angina. Diagnosis is confirmed once eruption occurs. Before eruption the pain should be checked carefully which is generally in the distribution of nerve roots.

Cervical spondylitis

In cervical spondylitis the pain in chest may be radiating from neck. There is associated paraesthesia, ECG is normal and X Ray spine may show the features of spondylitis.

Pulmonary Cause of chest pain

There are some pulmonary diseases which causes intense pain in chest and be quiet confusing until a proper diagnosis is made, these diseases are

Pneumonia

Left sided pneumonia is most often confused with anginal pain as it may increase on insppiration but is not related to exertion. However there may be constitutional symptoms associated with it like fever.

Pneumothorax

Air in the left pleura or left sided pneumothorax causes intense pain and there may be respiratory distress. Breath sound is decresed and trachea is shifted in pneumothorax which can be the distinguishing feature. ECG may be normal.

Gastrointestinal cause of pain chest

There may be pain in the chest mimicking angina pectoris in some gastrointestinal disease mentioned below.

Hiatus hernia

There is heart burn and feeling of indigestion. This mimick nocturnal angina. Pain may aggravate by meal or change in posture. ECG is normal and stress test and barium studies can distinguish it from anginal pain.

Achalasia cardia

The pain in achalasia cardia is squeezing in nature in substernal area which may radiate to jaw or arm. Pain may precipitae by food. Associated dusphagia for liquids more than solid is the characteristic of achalasia cardia. Barium studies shows spasm.

Peptic ulcer

Again here there is heart burn due to acid reflux and is not associated to exertion. Pain is of longer duration and is related with food intake.

Gall stones

Gall stones lead to cholecystitis and there is pain in epigastrium and sometimes in chest confusing anginal pain. Nausea and vomitting is associated feature. Ultrasonography can distinguish as it may detect the stone and lesion. ECG is normal.

Splenic flexure syndrome

Splenic flexure is a part of colon and distension at that part may mimick anginal pain. Here too pain is not related to exertion or efforts. Pain in splenic flexure syndrome often subsides on passing stool or flatus.

Neuropsychiatric causes of chest pain

There may be chest pain in extreme anxiety state and this pain is stabbing in nature, there is no relation of pain with esxertion or effort, but there amy be palpitation and this is the most confusing stage with angianal pain as there may be perspiration and sweating indicative of an heart attack. Urgent ECG is required which is usually normal.

Thus a pain chest is not always a heart attack or angina pectoris but a careful examination is necessary and most of the other causes can be distinguish by ECG and the nature of pain.

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Rotator cuff injury -The most common injury of sports person

The Television channels were occupied with the injury and surgery of Shahrukh Khan, most of the news channels and internet websites presented it in their own way. Actually what was the real problem, simply a shoulder injury? No is the answer. He suffered from one of the most painful tear called rotator cuff tear or rotator cuff injury.

Rotator cuff

The shoulder joint is most unstable joint and liable to get dislocated quite often. It is surrounded by rotator cuff. The rotator cuff is a set of four muscles which toil together to afford the shoulder joint an effective stability while rotation of the shoulder joint. The rotator cuff muscles are namely supraspinatus, infraspinatus, Teres minor and subscapularis.

Cause of rotator cuff injury

The involvement of shoulder joint is on the extreme especially in games like Cricket, baseball, swimming etc. Overuse of the joint plus laxity of joint together leads to overstressed muscles leading to injury. There may be a tear of the tendon or internal bleed; sometimes an inflammation can occur leading to intense pain while moving the hand. Chronic injury is caused by exposure to small amount of stress regularly like traveling in bus and tram standing and holding pipes for support.

Symptoms of rotator cuff injury

The symptoms of rotator cuff injury include a feeling of tear and rigorous pain in the shoulder joint which limits the movement of the shoulder joint. The pain may radiate to the arms and even forearms. There may be muscle spasm and sometimes even an internal bleed in the muscles which resolves once the bleeding stops by internal coagulation mechanism. In case of severe tear the abduction movement is restricted and person cannot lift his arm without any help or support.

Types of rotator cuff tear

The rotator cuff tear or injury may be of three types depending upon its onset and cause as acute, chronic and rotatorcuff injury due to inflammation.

Acute injury of rotator cuff

Acute injury can occur due to fall, sudden stretching while bowling or any forceful movement, lifting of a baby with forearm etc. The pain in acute injury in intense at the time of onset which usually get resolved gradually if there is no dislocation of shoulder joint.

Chronic tear of rotator cuff

This is the injury what filmstar Shahrukh Khan suffered from, a chronic tear of rotator cuff. This is the most common type of tear and usually occur in person above 40 years of age. There is mild to moderate pain which worsen gradually, most often it may awake the patient from sleep due to pain. Gradually the movement starts affecting and lifing of shoulder without assistance becomes difficult.

Inflammation of rotator cuff

The inflammation of rotator cuff is due to some injury at a particular area of in any muscle forming the cuff as mentioned above. It usually occur in middle ages person. There is tenderness at the site which increases on movement of arm above shoulder. This may ofter lead to chronic tear if not intervened early.

Diagnosis of rotator cuff injury depends on several tests which is used to assess the extent and cause of injury.

Treatment is usually symptomatic initially and later a surgical intervention may be required especially in chronic tear.

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Care of a fracture at the site of an accident

I must start the article with a message that it is better to be late than never, so accidents are avoidable if we are careful.

Now if at all accidents occurs there are some important care to be taken not only by a doctor but even by a general person as these care can reduce the complication to a great extent and you can gain the pleasure to save a human life.

There may be two types of fractures in an accident one is closed one where the bones are not visible externally and other is open fracture where the wound is such that bones are visible by naked eye.

Care at the site of accident in closed fracture

As mentioned above emergency care begins at the site of the accident and most important is to splint them where they lie.
There are many advantage of splinting as it may prevent movement of fracture and person can get a relief from pain.

Splinting may prevent further damage to skin, soft tissues and neurovascular bundle of the injured extremity. Even the bleeding may be prevented to some extent in there is open injury.

The most important advantage of splinting is that it may prevent some dangerous complications like fat embolism and hypovolemic shock which may be life threatening.

Last but not the least splinting makes the transportation and carrying the victim in easier way.

How to splint a fractures person at accident site

For splinting you may not require the proper wooden splint as it may not be available at the accident site. Splinting can be done by any available object which should be hard enough to immobilize the injured extremity. It may be a folded news paper, a magazine, a rigid cardboard, a pillow, an umberella a bamboo stick or any wooden plank. These may be used as a splint and any long piece of cloth can be used for tying the splint to the fractured limb.

One should not forget to remove any ring or bangles or any ornament in the injured extremity before splinting.

Care at the site of accident in open wound and open fracture

At the site of accident when there is an open wound and person is bleeding one should take the following measures.

The first and foremost important thing is to stop bleeding and this should be stopped by applying a firm pressure using a clean piece of cloth. Some times it may be necessary to use a tight circular bandage proximal to the wound to stop bleeding.

If the wound is very dirty , it should be washed with clean tap water and should be covered with a clean piece of cloth like handkerchief.

The fracture should be splinted as mentioned above.

Many times a piece of bone which is detached from the body may be lying out of the wound. It is important to note that it should be never left and should always be taken to the hospital with the patient keeping it in a clean piece of cloth as it may be most of the time useful in reconstruction of the fracture.

Thus a general consciusness and a bit application of mind with patience can save a persons life from the accident or may prevent them from becoming disable.

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Angina Pectoris : An alarming sign of heart attack

Angina pectoris is the substernal pain or heaviness, which radiates to both arms, jaw, teeth, epigastrum or occipital region of the head. The term angina pectoris was given by Haberdon in 1769 and he described first the typical angina pectoris.

The variation of the typical pain of angina can be the gas in the substernal region or in the areas of radiation without substernal pain.

Apart from pain and heaviness there may be breathlessness or fatigue due to low cardiac output.

Types of Angina Pectoris

Angina pectoris is generally of five types depending upon the nature of pain, mode of releif and associated symptoms. These types are-

Stable Angina

In stable angina chest pain and discomfort occuring with physical exertion and releived by rest and nitrates. In stable angina the pain also aggravates by straining at stool, sexual intercourse, emotional upsets, high altitude, smoking and cold weather.

Nocturnal angina

In this type of angina, chest pain or heaviness occurs in the middle of the nightand is due to the left ventricular failure. This pain gets more aggravated by dreams because it releases catecholamines in our body. A full urinary bladder or hypoglcemia at night are also precipitating factor for nocturnal angina.

Unstable angina

Unstable angina in real term is an alarming signal of heart attack and also called preinfarction angina as 20% of the patients with unstable angina develop myocardial infarction or heart attack within 4 to 6 months. The anginal pain in unstable angina have certain features as mentioned below-
* Angina which occurs recently that is within 2 months.
* If the chest pain or anginal pain occurs at rest.
* Anginal pain following myocardial infarction or heart attack.
* An stable angina in whom symptoms are more severe in intensity, frequency
and duration.

Prinzmetal angina

Prinzmetal angina is due to the spasm in the coronary artery which reduces the blood supply to the heart causuing pain. This may be induced by smoking or hyperventilation. The ECG finding shows an elevation in ST segment as in myocardial infarction though coronary arteries are normal in angiography. In about half of the cases there is associated coronary artery obstructive disease. The pain inprizmetal angina aggrevates by beta blockers like propranolol (Inderal) and thus is contraindicated while nifedipine (nicardia) and nitrates relieves the pain.

Post infarction angina

Some patients with heart attack or myocardial infarction develop angina within 2 days to 2 months following attack. These patients usually have multiple vessel diseas and residual myocardial ischemia.
Angiography in these patient should be at earliest and promp treatment is needed.

New York Heart Association (NYHA) classification of angina

New York Heart Association (NYHA) classified angina according to the functional basis into four classes. I,II,III and IV.

I. Patients with heart diseases but without resulting limitations of physical activity. Ordinary and light physical activity does not cause undue fatigue, palpitation, breathlessness and anginal pain.

II. Patient with heart disease resulting in slight limitation of physical activity. These patients are comfortable at rest while ordinary physical activity results in fatigue, dyspnea, palpitation and anginal pain.

III. Patient with heart diseases resulting in marked limitation of physical activity. These patients are comfortable at rest while even less than ordinary physical activity results in fatigue, dyspnea, palpitation and anginal pain.

IV. Patient with heart diseases resulting in inability to carry any physical activity without any discomfort. They may show symptoms of cardiac insufficiency and the anginal syndrome like pain, breathlessness and palpitations may even be present at rest. Any physical activity increases the intensity of discomfort.

Angina pectoris hence is an alarming feature and need prompt care and treatment. Most of the untreated angina pain had turned into severe myocardial infarction, thus it is necessary to control before it starts.

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Fever : Types of fever and its advantage and disadvantages

Fever or pyrexia means means an increase of more than 1 degree centigrade or any rise above the maximal normal temperature. The body temperature is the temperature of the viscera or the tissues of the body. A maintainence between the heat gain and heat loss which is regulated by hypothalmus keeps the body temperature normal.

How to measure body temperature

The body temperature is best recorded by a mercury thermometer which should be kept in the mentioned position for a minute. Usually the position which people prefer is axilla to record temperature. However in summer days or when there is lot of perspiration, oral temperature is taken.

In special circumstances like in Cholera rectal temperature is taken which is usually high whereas skin temperature may be subnormal.

The normal body temperature varies from 36 degree celcius to 37.5 degree celcius. There is a diurnal variation of 1 degree celcius and lowest temperature is seen at 2-4 AM while highest in afternoon.

Types of Fever

A human beings when suffer with fever, can show many characteristics some of fevers are present continuosly or some follow on and off. Fevers are thus of six types and the type depends on the cause of the fever.

Continuous fever

In continuous fever the temperature remains above normal throughout the day and does not fluctualte more than 1 degree centigrade in 24 hours. This type of fever may be present in urinary tract infections, typhoid, brucellosis, infective endocarditis, lobar pneumonia, Typhus fever etc.

Intermittent fever

In intermittent fever temperature is seen only for some hours in a day and comes back to normal for rest of the hours. If this spike of up and normal occurs every day it is quotidian, if every alternate day like fever today and normal tomorrow and again fever day after tomorrow, then it is called tertian and if this occur after every third day then it is quartan intermittent fever. This type of fever is seen in malaria, kala azar, pyemia, septicemia etc.

Remittent fever

In remittent fever temperature is above normal throughout the day and fluctualtion is more than 1 degree celcius. This type of fever is mostly seen in our clinics. Example are in typhoid, infective endocarditis etc.

Hepatic or septic fever

In this type the fluctuation of temperature between peak and nadir is very high and usually more than 5 degree celcius. It may be present in some septicemia.

Pel Ebstein fever

In Pel Ebstein type of fever there is alteration of recurrent bouts of fever and afebrile period. It may take 3-4 days for fever to rise, remains high for few days and remits in 3-4 days with an afebrile period of 7-10 days and agian starts regaining fever. This type of fever is seen in infectious mononucleosis.

Low grade fever

Low grade fever as the name suggest the temperature doesnt exceed 37.8 degree centigrade and remains throughout the day with rise in evening. Many times this is ignored by patients as may not indicate any disease, but this type of fever is present in tuberculosis.

Advantages and disadvantages of fever

Fevers as the general view is, are not always harmful. In some diseases it is beneficial like in neurosyphilis, chronic arthritis and some widespread cancers. In fact fever is induced in these cases by injection of milk protein and BCG vaccine.

Fever is associated with release of endogenous pyrogens, which activates the T- cells and thus enhance the host defence mechanism.

Disadvantages of fever is wellknown that it may cause hypercatabolism leading to nitrogen wastage and weight loss and weakness. Due to sweating it may lead to electrolyte imbalance. They may be convulsion and brain damage in case of high fever. Circulatory overload, arrythmia can occur in fever leading to untoward effects.

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Progesterone on pill or Mini pill - An ideal contraception for lactating mother

During the lactation period a mother whatever take are generally directly or indirectly affect the baby.
Though breast feeding if is continuous and sustained itself prevents from further pregnancy but cannot be considered as absolutely safe.

Mode of contraceptions in lactating mother

Other methods of contraceptions like barrier method or intrauterine contraceptive devices can be used but not ideal in lactating mother because while lactating the baby is too small and one wants a contraception measure which have least failure rate.

Condoms or other barrier methods are though coming up with spermicidal jelly and failure rate has decreased, still there is a chance of pregnancy as they may break or leak. The spermicidal jelly may not be 100 percent cidal for sperms and can cause pregnancy.

Intrauterine contraceptive device is though a much safer mode than barrier method of contraception but as during lactating period, there is irregularity in menstruation thus not considered as a good choice of contraception in lactating or breast feeding women. Another important point which is against the use of intrauterine contaceptive device (IUCD) in lactating mother is that it is contraindicated for 6 weeks if the delivery of the child is by caeserean section. Thus intrauterine contraceptive device also doesnt find any place as ideal method.

Oral contraceptive pills in lactating mother

The oral contraceptive pills like Ovral or Novelon or Mala N or Mala D constitutes estrogen and progesterone. Though it is considered as an ideal choice of contraception for unmarried or newly married women, but has an adverse effect on lactating or breast feeding women because the lactation is affected due to its estrogen content. There is reduction in milk production and also alter the quality of the milk by reducing protein and fat content of the mother's milk. Estrogen having significant amount of steroid may affect the baby also. Thus oral pills which are in general use is also not suitable for breast feeding or lactating mother.

The most effective and ideal contraception in lactating women or breast feeders is Mini pills.

Mini pills or Progesterone only pills for lactating women

Mini pills or progesterone only pills as the name suggest is devoid of estrogen and even progesterone in also in very low quantity. The progesterone may be in form of levonorgesterol 75microgram, or norethisterone 350 microgram or desogestrel 75 microgram or lynesterol 500 microgram or norgestreel 30 microgram.

How minipills or lactating pills works

Mini pills or lactating pills or progesterone pills thickens cervical mucus in side the cervix thus prevents sperm from penetrating it, so fertilization is prevented. It also makes endometrium atrophic which prevents blastocyst to get attached if in case sperm penetrates and fertilize the ovum. In 2 percent cases it also prevents ovulation.

Dose and schedule of mini pills or lactating pills

Mini pills starts from the first day of the menstrual cycle in contrast to other other contraceptive pills which are usually started from 5th day of menstrual cycle. There after mini pills should be taken continuously without a break of a single day even when the pack is finished. Mini pills ideally should be taken everyday at same time of the day.

Advantages and disadvantages of lactating pills

Mini pills have no side effects which is due to estrogens like weight gain, thromboembolism etc. It can be prescribed in lactating mother thus also called lactation pills. As it is taken continuously without break so there is no on and off regime. It plays a protective role in endometrial cancer and pelvic inflammatory diseases (PID). In contrast to combined oral pills it can be safely given to patients having hypertension, diabetes, history of thromboembolism, fibroid, epilepsy and smoking.

Disadvantages of mini pills is that it may aggravate acne, it can cause breakthrough bleeding or sometimes amenorrhoea. It may cause small ovarian cyst which seldom requires any surgery or any treatment.

Thus mini pills is the ideal oral contraceptive pills for a women who is breast feeder and want to be safe from other issues immediately.

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Natural methods of contraception - Avoid pregnancy naturally

Conception is the art on conceiving or becoming pregnant, where as contraception is prevention of becoming pregnant and giving child birth.

Evolution of Contraception

The Arabian merchants in the middle East, as early as in 1900 used to travel across the deserts with loads of materials on their camel's back to different places for trading. In the course of their journey, if the camels became pregnant, the merchants were unable to complete their mission within the stipulated time. It was posing a serious problem to their business.
The Arabian merchants started controlling conception in the camel by introducing a small round stone in each horn of the camel's uterus. This method was quite effective as a birth control procedure. Truly speaking that was the evolution of Intra uterine contraceptive device. Over the years it has undergone several modifications in size and shapes as well as in their constituting material.

Types of contraception

There are various modes by which pregnancy can be prevented right from barrier method to hormonal pills. The contraceptives are mainly of three types one is temporary in which one can have pregnancy when the mode of contraception is stopped and other is permanent when one cannot become pregnant one adopting this. The third category which is not very effective is natural contraception.

Here is the variety of contraceptive devices and procedures of all the three category mentioned above.

Natural contraception

Natural contraception is one where contraception is attained on the basis of physiology of human beings. These include-

Rhythm method of contraception

This is the only method of contraception approved by Roman Catholic church. This is based on identifying the fertile period and abstaining from sexual intercourse during that period. The first unsafe day is noted by substracting 20 days from the length of the shortest cycle and last unsafe day by deducting 10days from the longest cycle. In general ways counting the first menstrual day as day 1. The unsafe period is from day 7 to day 21.
During menstrual period it is almost safe period.

Coitus interuptus method of contraception

It is the oldest and thought to be most widely accepted mode of contraception. In this method the male organ is withdrawn at the time of ejaculation. A sufficient level of self control is required in this method.

Breast feeding as a contraceptive measure

A prolonged and sustained breast feeding provide natural protection from pregnancy. The risk of pregnancy who is fully breast feeding and not having menstruation is about 2%. However there is high failure rate so an extra precaution is required either by barrier method or intrauterine contraceptive devices.

Advantages and disadvantages of natural contraception

The advantages of natural contraception is that is requires no cost, there is absolutely no side effects and no external appliances is required. Normal physiology is not hampered at all.
Disadvantages of natural contraception are that in rhythm method the calculation of safe period is never absolutely correct. One have to abstain from sexual act during certain period. Women having irregular period as may be during breast feeding the rhythm method is not applicable. Incoitus interruptus extreme self control is required. Men and women both may suffer from depression or anxiety neurosis. There is more failure rate of contraception and chances of pregnancy is more as there may be sperms in precoital secretions.
The biggest disadvantage of rhythm method is a higher rate of ectopic pregnancy or congenital abnormality of the fetus because there is chance of the union of the ageing sperm and ovum.

Natural method of contraception is now a days not considered as as an ideal method of family planning and most of the doctors suggests different modes to adopt as per the condition like oral pills in newly married, intrauterine device after first child birth, barrier method in case of any chance of sexually transmitted diseases etc.

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Emergency Contraception : Avoid pregnancy from unprotected sex

Emergency contraception means the method to prevent pregnancy after the coitus or sexual act. It is generally used in case of rapes or any form of unprotected sex. Unprotected sex here doesn't mean protection from sexually transmitted diseases but actually means sex without using any contrceptive devices.

Emergency Contraception

A new dimension to the concept of contraception in our current day practice is emergency contraception. After unprotected sex, emergency oral contraception can prevent pregnancy It mainly stops ovulation that is release of ovum from the ovaries, but perhaps also works in other ways. However it does not disrupts any existing pregnancy.

Efficacy of emergency contraception

It has been calculated that the pregnancy rate after one act of unprotected intercourse in the second or third week of the menstrual cycle is 8%. The incidence comes down to 2% if the lady takes emergency contraception within 72 hours of the sexual act.

Indication or Use of Emergency Contraception

Any women can use emergency contraception, provided she is not already pregnant. Some situations are highlighted below-

* Sex which took place without contraceptive protection, and the women does not desire to become pregnant.
* A broken condom during the sexual act.
* An itrauterine device like copper T has come out of the place.
* A woman has missed 2 or more oral contraceptive pills, which she is taking regualrly as contraceptive measure.
* Women had sex against her will, or have been forced to have sex for example rape.

Formulations of Emergency contraception

Earlier 2 tablets of standard oral contraceptive pills containing 50 micro grams of ethinyl estradiol and 0.5 mg of Levonorgestrol for example Ovral were given and a repeat dose of the same 2 tablets were given after 12 hours. Some patients developed severe nausea and vomitting as side effects.

Currently emergency contraceptive pills containing Levonorgestrol 0.75 mg have come to the limelight. These pills are given as a single dose tablet as early as possible after the unprotected intercourse and a repeat dose of the same tablet is given after 12 hours. The advantage of the Levonorgestrol pills over the conventional oral contraceptive pills as an emergency contraception is its better tolerability, lesser dose and fewer side effects.

Instruction to the user of emergency contraceptive pills

First of all this should be clear that emergency contraceptive pills do not prevent sexually transmitted diseases, and it cannot disrupt an already existing pregnancy.

An emergency contraception does not guarantee 100% protection, therefore the user must visit her doctor if her next period is unusually light as it may be a possibility of pregnancy.

If the next period is doesn't start within a month a doctor should be seen as it may be a possiblity of pregnancy.

If there is an unusual pain in abdomen. Immediately consult your doctor as it may be possibility of ectopic pregnancy.

Since emergency contraception cannot protect sexually transmitted diseases, therefore it is also advisable that the user should visit her doctor if she gets the symptoms of STD like unusual vaginal discharge, painful urination or burning.
Lastly it must be understood that emergency contraception is not as effective as the regular methods of contraception, therefore it should not be used regularly as a method of family planning.

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Cochlear Implant Surgery : Ideal treatment of deafness

There has been several risk factors for congenital deafness. Deafness in a new born has been very difficult to detect leading to late intervention causing defect in speech. Normal signs of hearing has always been suggested to be checked and for one year there are several characteristics features to diagnose normal hearing. In fact a proper screening is equally necessary for necessary action in proper time so that the speech defect should be minimized. The various mode of screening is detailed at Screening of congenital deafness.

Candidate for cochlear implant surgery

The introduction of hearing aid devices in the 1950s made many a 'deaf person' a 'hard of hearing' one. The splitting up of schools for the deaf into school for hearing impaired children and truely deaf children dates from that time.

The last two decades have seen a phenomenal growth in the technology and application of cochlear implants. Many otologists are now operating and result in both post lingual and pre lingual patients are very encouraging.

Patients with a completely afunctional cochlea but still a functional auditory nerve which is sensitive to stimulation are ideal candidates for nuclear implants. There are many otologists in India who are capable of performing this operation. Proper and meticulous evaluation of the patient pre-operatively, including tests to evaluate residual hearing likr Brain stem evoked response potential or BERA test, usefulness of hearing aid and suitability of the patient from medical, surgical, psychological and support point of view is crucialto the success of the implant. Otherwise, unsuitable patient implanted by even the most skilful surgeon is doomed to failure.

Preoperative test for cochlear implant surgery

The anatomy of the mastoid bone and more so of cochlea is studied preoperatively by CT scan and MRI, to rule out any malformation like ossified cochlea, single cavity cochlea, absent cochlear or absent auditory nerve, in which the operation is very diffcult or contraindicated. Other tests include all routine test which is designed before performing any operation.

How cochlear implant works

Multichannel implants of 22 channel are universally accepted. These eletrodes are connected with a small induction coil. This coil is implanted in the mastoid. On his body, the patient wears a so called processor, which processes sound from outside in such a way that optimal use is made of the low dynamics of the auditory nerves. Via another coil the magnet on the outside of the mastoid, this processor is connected with the implant. In this way it is possible to convert sounds into a signal to which the auditory nerve reacts.

It is still not understanding of speech, but the new information ie sound and rhythm which is of great value to the previously deaf person is lip reading and in controlling his own voice.

Speech therapy after cochlear implant

Once the cochlear implant surgery is successfuly done and the implant is in place, one should begin the most important part of the program, namely the mapping and subsequently the training with a competant and well trained speech therapist, it requires great patience and dedication on the part of the speech therapist in cae of pre lingual children. Parental support and active involvement is a key factor, and must be encouraged. It si doomed to be a failure , if a team and the requisite facilities for the purpose is not set up before starting a cochlear implant surgery.

Scope of cochlear implant in India

In our country, cost factor is the most important problem which does not allow the needy or ideal patient to undergo such surgery frequently, multichannel cochlear implant cost several lakhs, and seem beyond the reach of average Indian patients.
One is always hoping for the reduction in prices as the manufacturers recover their research and development costs and increase the volume of their sales, but such a hope is still very distant. So let us wait for the making of an indigenous cochlear implant.

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Smile Pinky - An oscar award for all cleft lip children

Its a known fact that the movie Slumdog millionaire got 8 oscars including that of best music for A.R. Rehman and made our Country pride, but we should not forget the documentary movie Smile Pinky which bagged best documentary film award. As here I am mentioning because its a role of a doctor and a role of a patient on which the film is based. The disease by which Pinky suffered is called cleft lip.

The movie smile Pinky

"Smile Pinky" is a 39 minutes documentary film made by made by Megan Mylan who is an American filmmaker. He made this for Smile Train, an international organisation that does free surgeries for cleft-lip patients all over the world.

The movie is based on a small girl who looks beautiful but has cleft lip. Her family contains five person and reside in a villge. This cleft lip makes her aloof and she is often teased by her friends leading to a suppressed Pinky without having normal childhood fun. The term smile is used as the patient with cleft lip is unable to smile or laugh with full expression of joy.

What is cleft lip

There are several children who are like Pinky suffering from cleft lip and cleft palate all over the world. In majority of cases Cleft lip results from abnormal development of the medial nasal and maxillary processes at the time that they bulge down wards in front of and below the nasal pit and when their surfaces should touch, the epithelia over them fuse and then break down. In minor degrees of cleft lip the dificiency appears on mainly of tisues of medial nasal process. Cleft lip also leads to dislocation of tongue thus interfereing in speech , dentition and sometimes hearing is also impaired.

Is cleft lip treatable

Those who have seen the documentary movie Smile pinky must be surprised by seeing the change in look of small baby Pinky before and after surgery. Plastic surgeons are able to operate and close the defect with minimal scar and the person looks as good as normal.
The ideal time to repair cleft lip is at 10 weaks after birth. Later the defect will be closed, more will be the scar mark and more difficult to attain full recovery.

Smile Train is an international organisation that does free surgeries for cleft-lip patients all over the world.

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Schizophrenia A major functional psychosis

Schizophrenia is a major functional psychosis and is an illness which is considered by general people as madness. It was Bleuler who gave the name schizophrenia in 1911.
In patient with schizophrenia the insight of the patient is absent and the decesion making becomes poor. The person becomes detached from the sorroundings and whatever he says does not mean any thing to the nearby persons.

The level of consciousness remains intact and even there is no change in the memory and intelligence of the schizophrenic person.

The schizophrenic patients may suffer from delusion that is false belief on a thing which doen not exist or with invalid reference like believing a snake on seeing a rope etc. There may be hallucinations, disorganised speech, poverty of speech termed as alogia etc.

Types of schizophrenia

There are three types of classification of schizophrenia Diagnostic and Statistical Manual of Mental Disorders DSM-III-TR), Crow classification and ICD-9 classification.

DSM III R classification of schizophrenia

In this classification schizophrenia is mainly divided into five major types namely
Diasorganized or heberphrenic schizophrenia

In heberphrenic schizophrenia the person is verbally incoherent, there is mainly involvement of thoughts and may have moods and emotions does not match the situation. The person appears childish in behaviour. Hallucinations are usually absent.

Catatonic schizophrenia

In catatonic schizophrenia the person is extremely withdrawn, becomes negative and social withdrawl is present thus the person becomes isolated. There is marked psychomotor disturbance with muscle excitement which presents as rigidity with waxy flexibility at times. Person sometimes becomes stuporuos. Grimacing and echolalia is present which is characteristic of catatonic schizophrenia.

Paranoid schizophrenia

In paranoid schizophrenia delusion is the most prominent feature, hallucination is present. Person becomes suspicious with persecuity ideation that is delusion of persecution is present. Person always feels suspicion on every act going on in his sorroundings.

Residual schizophrenia

In rsidual schizophrenia the common characteristics of the disease is not present like halluciantion or delusion or any type of verbal incohorence or disorganised behaviour. There is simply lack of interest in day to day activitywith decreased motivation and interest.

Undifferentiated schizophrenia

Undifferentiated schizophrenia is one which doesnt fall in any of the above types and having something different and unusual symptoms or presentation. There is not a clear set of features to keep them in any of the above types is kept in undifferentiated type of schizophrenia.

Crow classification of schizophrenia

According to Crow classification schizophrenia is divide into two types.
1. Type 1 schizophrenia in which the positive symptoms of schizophrenia predominates which appear to reflect an excess or distortion of normal functions like hallucination, paranoid ideation etc.

2. Type 2 schizophrenia in which negative symptoms predominates which is difficult to evaluate like social withdrawl or persecutory delusions etc.

ICD-9 Clasification of scizophrenia

In ICD-9 classification of schizophrenia there are mainly of four types that is
1. Simple schizophrenia
2. Catatonic schizophrenia
3. Heberphrenic schizophrenia
4. Paranoid schizophrenia

Simple schizophrenia

Simple schizophrenia in contrast to its name is very diffcult to diagnose, hallucinations are absent and there is gradual detoriation of personality. In DSM-III R classification it is not considered as a subtype of schizophrenia, rather it is considered as schizotypal personality disorder.

It is important to note that 50 percent of patients of schizophrenia have attempted suicide and 10 percent succeeded sometimes in 20 years of follow up. Thus it is very much necessary to know your patient and the way to treat and deal them.

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Diagnosis and assessment of Peripheral Arterial Disease

One in five of the population aged between 65 to 75 years in UK have a clinical evidence of peripheral arterial disease although only a quarter of them have symptoms. The most common symptom is muscle pain with exercise is intermittent claudication.

Diagnosis and assessment of of Peripheral Vascular Disease

A diagnosis of intermittent claudication can usually be made on the basis of the history with a specificity of 91% and sensitivity of 99% as based on Edinburg claudication questionnaire.

Clinical examination reveals weak or absent pulses with local sign of ischemia in severe cases. The legs may turn white on cold exposure.

The diagnosis is confirmed by vascular doppler or duplex ultrasonography. The invasive investigation of angiography is reserved for a small minorityof patients in whom invasive intervention is contemplated.

Non invasive procedures like ultrafast CT scan and MRI are also confirmatory, but are expensive and should not be used routinely to diagnose peripheral arterial diseases.

Differential diagnosis of Peripheral arterial disease

While diagnosing peripheral arterial claudicatio, it should be differentiated from the the venous and neurogenic claudication. Differentiation can be done on the basis of four characteristics as mentioned below-

1. Quality of pain - In arterial claudication the pain is mainly like a cramp, while in venous claudication pain is bursting. In neurogenic claudication the pain is just like an electric shock.

2. Pain is relieved by - In arterial claudication pain is relived by standing still, in venous claudication by elevation of leg. In neurogenic claudication pain is relieved by sitting down or bending forward.

3. Location of pain - Ina rterial claudication the main is mainly located to muscle group mainly of buttocks, thighs and calf while in venous claudication pain occurs in whole leg. In neurogenic claudication pain is poorly lacalised and can affect the whole leg.

4. Leg affected - In arterial and venous claudication usually one leg is affected while in neurogenic claudication both the legs are usually affected.

These are some assessment of peripheral arterial disease. BEST medical treatment is mainly preferred and in some conditions it should be referred for surgical intervention.

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Diagnosis and treatment of patient with fever and joint pain

Fever and joint pain can be dealt according to their cause which has been discussed here Fever with joint pain. Diagnosis depends on proper history of the patient which includes signs and symptoms, clinical examination and required investigations.

Clinical history of patient with fever and joint pain

A proper history regarding the onset and duration of the disease, number of joints involved, temporal pattern of joint involvement, symmetry of joint involvement, degree of disability, associated systemic symptoms apart from fever, past history of joint pain or any chronic illness etc is taken.

Fever with joint pain may be acute ie present for last few days only or chronic. Joint pain may be monoarticular involving one joint, oligoarticular involving 2-4 joints or polyarticular involving 5 or more joints.

Bacterial infection of the joint commonly produces acute and mono or oligoarticular arthritis. Tuberculosis and some fungal infections produce chronic monoarticular arthritis.

With a migratory pattern of joint involvement, inflammation persists only for few days in each joint for example in acute rheumatic fever or disseminated gonnococcal infections. With an additive or simultaneous pattern, inflammation persists in involved joints as new ones become affected as in reactive arthritis. With an intermittent pattern, episodic involvement occurs, with intervening periods free of joint symptoms for example Gout and Lyme arthritis.

Joint pain with fever may be symmetric as seen in rheumatoid arthritis and SLE or may be asymmetric as seen in septic arthritis, reactive arthritis or Lyme arthritis.
Important associated history of systemic symptoms like conjunctivitis, urethritis and diarrhea may be present in reactive arthritis, rash and photosensitivity may be present in SLE and tophi may be seen in gout. These associated symptoms may help to find out the cause of joint pain.
History of drug intake should always be obtained to determine drug induced joint pain.

Examination of patient with fever and joint pain

During examination we should look for vitals, whether the patient is toxic which may be in bacterial arthritis with sepsis, presence of rash which can be present I viral arthritis, SLE and even rheumatoid arthritis. Lymphadenopathy of sub occipital region may be seen in Rubella infection.

Individual system examination is very essential to determine the cause of joint pain. Musculoskeletal system examination is very essential to determine the cause of joint pain. Musculoskeletal system examination is very much essential to confirm and review the the conclusion from the history taken.

Detailed joint examination is the key to formulate a diagnosis. A patient having fever, sick looking with RED FLAG signs in the joint indicates septic arthritis or gout. Other system examinations also help us to arrive at a diagnosis like presence of a cardiac murmur in acute rheumatic fever and infective endocarditis, ocular findings, skin rashes in SLE, rheumatoid arthritis and reactive arthritis and pulmonary findings in tuberculosis.

Investigations in patients with fever and joint pain

An acute bacterial infection rapidly destroys articular cartilage and damages the joint, all inflamed joints must be evaluated without delay to exclude noninfectious process and determine appropriate antimicrobial therapy. Apart from routine blood examinations, joint aspiration for examination of synovial fluid is very essential to arrive at a diagnosis. Synovial fluid cell ranging 25,000 to 250,000 per uL with more than 90% neutrophils are characteristics of acute bacterial infection of the joint. Gout, rheumatoid and other non inflammatory arthritis are usually associated with less than 50,000 cells per uL. In mycobacterial and fungal infections cell counts are usually less than 30,000 per uL with 50-70% neutrophil and remainder lymphocytes. Definitive diagnosis is based on staining and culture of the synovial fluid.

Raised ESR and CRP (c reactive protein) establish an inflammatory joint disease. Other specific tests, which help to arrive at a specific diagnosis, are
1. Serum rheumatoid factor (RA factor ) and anti CCP (cyclic citrullinated peptide) antibody for rheumatoid arthritis.
2. Antinuclear factor and DsDNA ( double stranded DNA) for SLE.
3. Specific viral antibodies for viral arthritis.
4. In suspected rheumatic fever ASO titre, throat swab, echocardiography and ECG should be done to establish diagnosis.

Arthroscopy and synovial biopsy help to diagnosis of some undiagnosed cases by these measures.

Treatment of patient with fever and joint pain

For all patients of joint pain rest to the joint is very essential. Non-steroidal anti inflammatory drugs are used to reduce joint pain. Antibiotics are given for bacterial infection of the joint, steroid for SLE and rheumatic fever. Intra articular steroid injection is good method of treatment in selected cases of mono and oligoarticular arthritis. Physiotherapy is very essential once the fever and pain subsides.

Early diagnosis and proper treatment is the key to success in preventing joint damage, hence medical consultation is to be done at earliest sign of joint affection with fever.

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Causes of Fever with joint pain

Fever is the common manifestation of many diseases, and so is the joint pain. When these two symptoms occur together many diseases can be short listed.
There are two terms used to refer joint pain – one is arthralgia, which means joint pain and the other term is arthritis which means inflammation of the joint associated with arthralgia.

Causes of fever with joint pain

When a patient presents with fever and arthritis or arthralgia, the first and foremost important cause comes in clinical practice is of infective origin. Other important causes include autoimmune diseases. There are some drugs which lead to joint pain as there side effects. The details of the causes are described below.

Infections causing fever with joint pain

Infective causes of fever with joint pain include viral infection, bacterial infection and fungal infection. In our clinical practice viral arthritis is probably the commonest form of infective arthritis followed by bacterial or septic arthritis. About 50% of women having rubella infection also called German measles have arthritis with joint pain. The pain is usually in the small joints.
Arthropods born viral infections like Japanese encephalitis, yellow fever, West Nile fever causes fever with joint pain. One of the recent observation is the Chickungunya infection which has been epidemic recently. The joints involved in arthropod born viral infection are usually the larger joints like elbow, hip, knee joints.
Other causes of viral arthritis include mumps, infectious mononucleosis also called glandular fever, Parvo virus 19, Hepatitis B and HIV infection.

Bacterial causes of arthritis are staphylococcus, streptococcus, gram negative bacilli Neisseria gonorrhoea causing sexually transmitted disease called gonorrhoea, Lyme disease. Tuberculosis of the joints is one of the important causes of chronic febrile arthritis in low socioeconomic populations.

Some fungal infections are also a cause for fever with joint pain. These fungi include Candida, Cryptococci etc.

Fever with joint pain in autoimmune diseases

Fever with joint pain is also a manifestation of systemic autoimmune diseases. In India post streptococcal rheumatic fever is one of the leading causes of fever with arthritis. Autoimmune disease like systemic lupus erythematosus (SLE) may also manifest with fever with joint pain. Other causes in this group are rheumatoid arthritis patients may be RA factor positive or negative, Still,s disease, inflammatory bowel disease which include Ulcerative colitis and Crohn’s disease, reactive arthritis which may be associated with urethritis and conjunctivitis and called Reiter’s disease and other vasculitidis.
Acute attack of gout may have fever with joint pain. Even infective endocarditis may manifest as fever with joint pain along with other cardiac symptoms.

Drugs causing fever with joint pain

Some drugs also cause joint pain and if these drugs are administered during an episode of fever. These drugs include quinolones an antibiotic usually used in Typhoid fever and other Gram positive infections. Cefadroxil and cefixime the third generation cephalosporin, clindamycin a macrolide clopidogrel used as an antiplatelet agent in prevention of myocardial infarction and lamuvudin an anti retroviral drug.

Thus a patient with fever and joint pain can be dealt accordingly as per the cause. It is necessary to diagnose the proper cause to ensure proper treatment. For diagnosis and treatment of patient kindly see Diagnosis and treatment of patient with fever and joint pain.

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Screening of a child to detect congenital and early onset deafness

Congenital deafness and early onset conductive or sensorineural deafness is a difficult task to recognise in an infant as there are only few signs and mostly ignored by parents.
First of all the risk factors causing congenital and early onset deafness should be recognised and should be prevented. There are several signs of normal hearing of a child upto one year and parents should be vigilant about this. The check list of these signs can be seen here General signs of normal hearing of an infant

Screening have a great role in early detection and needful intervention to prevent permanent deafness and specch defects.

Screening for hearing loss at eight month

Screening at the age of eight months is very important as the goal is to detect Congenital deafness and early onset sensorineural and conductive deafness specially due to secretory otitis media so that management may be initiated and implemented during the phase of language acquisition of the child.

Screening for hearing loss upto three years

Screening for hearing loss after 8 month to three years should be done for at least two times, one at the age of around sixteen months. At this age if there is no recognizible words by then, a prompt investigation is urgently needed.

Second at the age of three years screening for hearing loss is important to detect middle ear dysfunction, early onset and mild mid frequency cochlear deafness and to assess language acquisition.

Screening for hearing loss at the age of seven years

Screening at the age of seven years is necessary to detect middle ear dysfunction, unilateral deafness and acquired and progressive deafness so that proper remedial measures, which includes educational and medical action can be initiated.

Thus when there is a strong suspicion that the baby is congenitally deaf or is suffering from early onset deafness, he should be thoroughly investigated. Various tests ilke Brainstem Evoked Response Potential test (BERA), Visual Reinforcement Audiometry, Electrcochleography etc. must be undertaken for confirmation of clinical diagnosis.
With the advancement of "Hearing Aids" and with the scope of "Cochlear Implant" operation, the affected child may grow up studying in a normal school with active cooperation of parents, doctors and teachers rather than growing up in a special school and learning 'Sign Language'.

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General signs of normal hearing of an infant

If you will go through this post Congenital hearing defect and speech defects you can see the several risk factors for congenital deafness and speech impairment. It is sometimes difficult to check whether your child can hear or not, and if not checked early may lead to speech impairment in the future. Here I am enumerating some quick checklist of general signs of normal hearing in first one year of life. This checklist will ensure whether you child can hear or not and if not a quick intervention can be done in time to prevent future problems.

Signs of hearing after birth

The baby blinks or open his eyes widely to a sudden loud sound such as clapping of hands, slamming of doors etc. There may also be a movement of the whole body with spine stiffened and legs and arm extended and fingers and toes fanned out.

Signs of hearing by age of one month

By the age of one month the child will pause and listen to prolonged sounds like the sound of a vacuum cleaner, siron or bells.

Signs of hearing by age of four months

The baby smiles or keep quiet to the sound of your voice even when he/she cannot see you. He/She may turn his head or eyes towards you if you come up from behind or speak to him from the side.

One should note that cries, grunts and other vocalization produced within six months is no guide to the absence of deafness as it may occur both in normal and the deaf child.

Signs of hearing by age of seven months

At seven month of age your baby should turn immddiately to your voice across the room or to very quiet noises made on each side if he/she is not busy with other things.

Signs of hearing by age of nine months

At the age of nine months your child should listen carefully to familiar voice which he/she hear everyday and search for very quiet sound made out of sight. He should also show pleasure in bubbling loudly and tunefully.

Signs of hearing by age of twelve months

At the age of one year or twelve months your child should show some response to his name and to other familiar words.He may also respond when you say common words like "NO" "BYE BYE" etc, even when he cannot see any accompanying gesture while a normal child say a small number of intelligble word with meaning.

The deaf child loses the reflexive utterances of early months, fail to develop babble and become silent.

Thus if you would be careful and vigilant about the signs of normal hearing in your child you can prevent your child from being deaf and dumb.
There should be screening at certain ages for detecting any abnormalities in hearing. The details of screening is given here Screening of a child to detect deafness and speech defect.

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Congenital deafness and permanent speech defect

Many times in hospital a mother comes with a complain saying that she feels her child is not responding to her properly. The baby may in fact suffering from congenital or early onset deafness.

Normal development of speech and language is impaired due to congenital deafness, while sensorineurl deafness may result in a permanent speech defect. Conductive deafness results in delayed rather than deviant speech. Early detection and interventions helps a lot in minimizing the effects of both the conductive and sensorineural deafness upon speech development.

Risk factors for congenital and early onset sensorineural deafness

The risk factors for congenital and early onset sensorineural deafness are due to several reasons enumerated below-

Intrauterine causes for congenital deafness

* The intrauterine risk factors which can cause congenital deafness are environmental hazards such as strong chemicals, noise pollution etc.
Diabetes during pregnancy which can causes several cardiac disease, sacral agenesis and congenital deafness.
Toxemia of pregnancy,
Ototoxic drugs which include aminoglycosides like Kanamycin, amikacin and neomycin Teratogenic chemicals like thalidomides etc.
Genetic causes.

Infection during pregnancy which can lead to congenital deafness

The infection which van lead to congenital and early onset sensorineural deafness includes rubella, cytomegalovirus, measles, Chicken pox, Herpes, Toxoplasma, Syphilis etc. These risk factors can be taken care of if these infections are detected early.

Perinatal complications which may lead to congenital deafness

The perinatal complications like low birht weight less than 1500 gms, hyperbilirubinemia, hypoglycemia, frusemide drugs, Incubator noise, ototoxic drugs like aminoglycosides, Apgar score less than 5 at 1 minute and less than 7 at 5 minutes. Those neonate requiring mechanical ventilation for more than 4 days. Out of these risk factors the role of incubator noise is still doubtful.

Neonatal infections which can cause early onset deafness

There are few neonatal infections which may lead to deafness like meningitis, encephalitis and septicemia.

Out of the above listed risk factors most of them are avoidable and preventable. A simple care can make your child healthy and free from such incidence of congenital and early onset deafness with impaired speech.
When ever you plan for a baby a preconceptional counselling is required which can be a solution of millions of problems.

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Preconceptional counselling and care - A care before pregnancy

Pregnancy is the most valuable gift of nature to woman. A couple planning to have a baby goes through several doubts, fear and curiosity regarding it. The objective of preconceptional counselling is to ensure that a woman enters pregnancy with an optimal state of health which would be safe both to herself and the fetus.

Need of counselling before pregnancy

A woman once become pregnant usually visit obstetrician regularly as adviced, then there is a question that why they require preconceptional care and counselling. There is a strong reason behind this. Actually the organogenesis of the fetus that is formation of organs of the baby completes by first trimester and by the time a pregnant woman comes to doctor for first antenatal visit, it is often too late to advice many things about the adverse factors which have already begun to exert their effects. Virtually preconceptional counselling is a part of prevention and is time to identify the risk factors and to provide care to minimize those risk factors which may be a potential hazard in the pregnancy outcome.

Risk assessment and education at preconceptional visits

If a lady wants to be pregnant there are certain things which should be assessed at preconceptional visits and should be educated accordingly. These are-

Idetification of high risk factors for pregnancy
For identification of high risk factors a detailed interview should be taken evaluating medical, obstetric, family and personal history. The basic health level should be seen including level of hemoglobin and blood pressure. Rubella and hepatitis immunization should be taken by woman desirable to become pregnant if not immunized earlier. The fear should be removed by counselling, if the woman takes any drugs, it should be verified and educated accordingly. They should be urged to stop smolking if they are smokers as smoking is very much hazardous for the woman as well as fetus and may even lead to fetal death.

The lady who want to become pregnant should start taking folic acid 5 mg per day 4 weeks prior to conception and should take upto at least 12 weeks of pregnancy. This reduces the incidences of neural tube defect and many other congenital diseases.

Counselling for patient with bad pregnancy history

A well and convincing counselling is required with a lady having previous history of abortion or unwanted fetal loss. Importance of prenatal diagnosis of chromosomal abnormalities should be discussed. Sometimes there are managable genetic diseases by eliminating the causes. Thus a couple with recurrent abortion or fetal loss should be investigated and counselled properly.

Limitations of preconceptional counselling

The most unfortunate part is the lack of public awareness and couple start visiting the treating doctor only after being pregnant.
Many a times pregnancies are unplanned so there remains no scope for preconceptional counselling.

In brief a preonceptional counselling and care may lead to an uneventful pregnancy with a healthy baby and health of the mother too remains optimum after delivery to take proper care of her child.
All queries are welcomed here...

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Balloon Sinuplasty - A recent advancement in treating chronic sinus infection

There are many medical and surgical treatment of chronic sinusitis. FESS technique has evolved the use of endoscopic tools.

Now there is an evolution in endoscopic sinus surgery with the balloon sinuplasty technology. The balloon sinuplast uses a small catheter and balloon to quickly open and expand blocked sinus.

Steps to use balloon sinuplast device

To gain initial sinus access, the sinus guided catheter is introduced into the target sinus under endoscopeic visualisation. A flexible sinus guideware is introduced through the sinus guide catheter and gently advanced into the target sinus under fluroscpic guidance.
The sinus balloon catheter tracks smoothly over the sinus guideware and position across the blocked ostium. Using fluroscopy, the position of the sinus balloon catheter is confirmed. It is gradually inflated to gently restructure the blocked ostium.
The balloon sinuplasty system or catheter is removed leaving the ostium open and allowing the return of normal sinus drainage and function. There is little or no disruption to mucosal lining.

Benefits of using Balloon Sinuplasty technology

There are several benefits of using balloon sinuplasty technology over other surgery for chronic sinusitis. These are

Balloon sinuplasty is safe and effective

While use of any surfgical instrument involves some risk, clinical studies have indicated the balloon sinuplasty system to be safe and effective in relieving symptoms of sinisitis.

Balloon sinuplasty is minimally invasive

The balloon sinuplasty technology uses small, soft, flexible devices that enter entirely through the nostrils. These devices gently open blockes sinus and in many cases without tissue or bone removal thus there is no or minimal invasion.

Balloon sinuplasty reduces bleeding

In many instances no tissue or bones are removed while using balloon sinuplasty technology, there is reduced bleeding associated with the procedure. As a result, the need for uncomfortable nasal packing may not be required.

Balloon sinuplasty improves recovery time

While recovery time varies from patient to patient, but in most instances with treatment using balloon sinuplasty patient can return to normal activities within 24 hours.

Balloon sinuplasty does not limit treatment options

Balloon sinuplasty is an endoscopic tool and may be used with other medical therapies or sinus surgery techniques. It does not limit treatment options if you have progressive disease requiring other treatments too.

Thus with this recent advanvcement we can get rid of chronic sinusitis which is a disturbing ailment with a blood less surgery.

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Medical and surgical treatment of chronic sinus infection

Sinus problems or sinusitis affects millions of people each year, making it one of the most common health problem. It is a very stubborn problem and difficult to treat upto the satisfaction level of a patient.
Two approaches have emerged for treating the patients of chroninc sinusitis.
1. Medical therapies
2. Surgical interventions

Medical therapy for chronic sinusitis

Medical therapies have advanced from basic remedies to an array of specialized drugs and sophisticated delivery methods. These treatments are often effective in reducing sinusitis symptoms. The treatment includes normal course of antibiotics with steam inhalation and some decongestants. However for many patients, these medications are inadequate and surgery may be the next step in finding relief.

Surgical treatment of chronic sinusitis

As in other medical fields sinus surgery has eveolved from open to less invasive surgical techniques. As recently as the 1970,s sinus surgery required extensive removal of tissues and mucosa. It was hypothesized that the diseased mucosa was the primary cause of the condition leading to chronic sinus infection and should be removed.

FESS surgery for chronic sinusitis

With the advent of FESS in 1980,s surgery took an evolutionary leap forward with the eleimination of open surgery, the introduction of endoscopic tools, and the discovery that blocked sinus ostia may be the primary cause of or culprit of the chronic sinusitis.

This FESS procedure pioneered the use of endoscopes and surgical instrument allowing sinus surgery through nostrils. During this time it was discovered that blocked sinus passage ways disrupts normal mucociliary flow and were the main culprit of the disease chronic sinusitis.

FESS technique not only changed the procedure of surgery but also defined the goals of sinus surgery that :

1. Clear blocked sinuses, restoring normal sinus drainage and function.
2. Preserve normal anatomy and mucosal tissues.

More recent advances took place in the treatment of sinus surgery and a new, minimally invasive technology for treating chronic sinus infection is now available called balloon sinuplasty.

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Frequently asked questions about pregnancy

Pregnancy is the most cherishable gift given by God to females and being pregnant is a major change in life. A pregnant female specially when one becomes first time pregnant go through many kind of suggestions from each and every one, still they end up with lots of doubts. Every one wants to have an uneventful pregnancy with a healthy baby. There are several questions which we come through in our clinic from a pregnant woman. These questions with a suitable and admissible answer is given below-

How much weight gain should occur in pregnancy

A normal weight gain during the entire duration of 9 month of singleton pregnancy should be around 11 to 14 kilograms (25 to 30 pounds). The weight gain is distributed as 1-2 Kg in first trimester and 5-6 kgs in second and third trimester. The weight should be checked regularly.

Importance of checking weight in pregnancy

Simple weight checking is of limited use and can only give you an idea of overweight or underweight but periodic weight checking is necessary to detect abnormalities.

Rapid weight gain that is more than 0.5 kg in a week or more than 2 kg in a month in later half may be an indication of pre-eclampsia and you should immidiately consult your obtetrician.
Stationary or falling weight is an indication of intrauterine growth retardation or intrauterine fetal death and consult your obstretician immediately.

What should one eat in pregnancy

What is eaten feeds the baby too, so it is wise to choose healthy food and to skip the junk. A pregnant woman needs 300 extra calories each day. The pregnancy diet ideally should be light, nutritious, easily digestible and rich in protein, minerals and vitamins.
Always add the following things in your diet if you are pregnant.

* Three to four servings of milk or dairy products.
* Five to ten servings of vegetables and fruits.
* Five to twelve servings of bread, cereals, rice or pasta.
* Two to three servings of meat, fish, poultry,dried beans, eggs or nuts.
* At least 6 to 8 glasses of liquids.
* Limit your intake of caffiene to two cups of coffee or 6 glasses of soda.

Can one take medicines in pregnancy

Folic acid, Iron and Calcium is necessary supplementation in pregnancy. For other medicines one should always consult a doctor and should never use any over the counter drugs. Medicines are categrized as A, B and C category depending upon its safety in pregnancy. Some are absolute safe, some absolutely contraindicated and some should be taken with precautions. So consult your doctor for your ailment and take only prescribed drugs.

Can one perform exercise during pregnancy

Unless there is any problem in pregnancy one can do the exercises what they did before being pregnant. Doing exercise will make active and feel better. Walking and swimming are great choices. Yoga is a better alternative. Exercise make an easier delivery and less painful labor. One can even start doing exercise slowly if she was not doing before being pregnant. Avoid strenuous exercise that can injure you and your baby.
Yoga which are not contraindicated in pregnancy is the best option apart from walking.

Can one perform sex during pregnancy

In a normal course of pregnancy sex is never contraindicated, but it is better to avoid in early pregnancy when fetus is immature and not fully attached to uterus and it last trimester when there is risk of damage due to weight.

If you have any other doubt or question you are welcomed here.

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Treatment and Prevention of back pain

The common types of back pain which we often suffer are preventable. A list of these common back pain can be seen by going through the link given. Common back Pains.

Here I will mention some common treatment with emphasis on the mode of prevention of these back pains.

Treatment of back pains

Most of the patients having common back pain get relieved by simple treatment. These treatments include-
A cold pack such as a bag of ice may be helpful in acute conditions. In chronic cases hot compression may be helpful.
Simple analgesics like Paracetamol, Ibuprofen or Diclofenac may be helpful and is present at over the counter at any pharmacy in most of the countries.
A short period of bed rest is helpful but too much rest actually may aggravate the condition. Rest is usually recommended in tarumatic causes of back pain.
If the simple measures fail to relieve pain then one should go for
Physiotherapy and chiropractor.

Prevention of back pain

As we see that back pain are mostly due to the postural effect and bending and twisting, prevention is aminly based on improving postures. The way to improve posture is mentioned below-

Improve posture to prevent backache

Stand upright with head facing forward, back straight and avoid slouching. Being still at one posture for a long time particularly on low soft armchairs is an important cause of aching and stiffness of back, thus avoid it.

While sitting at the desk in your office or work place ensure that you can sit upright with a support on the back. For this choose desk of sufficient height which gives sufficient leg space so that you can sit upright while working and should not have to bend.

Way to lift object from floor to prevent backache

While picking any object from floor use kinetic method of lifting. Once it will be come into practice you may not face problems like backache. There are three steps-

Step I
The right way to lift is to place your feet apart at right angles to each other and with the front foot pointing in the direction to whcih the object is to be picked. This posture puts you in stable position and prevents from twisting your back during the process of lifting and then moving off.

Step II
Crouch down bending your hips and knees but keeping your back straight. Your whole spine may be inclined forward but it is important to avoid bending your back. In this position your knees are well apart and the object is positioned between them and kept close to your body. You can geta good firm grip and lifting is done using the leg muscles and not the back.

Step III
Once you are in upright position you should carry the load close to your body without twisting your back, put it down carefully using the same procedure.

The main reason of back pain is bending, twisting and lifting heavy weight specially during travel and tour. By following the above process we can prevent the ill effects of these and can be free from the most common ailment of the body.

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Some common back pains

Backache is a common illness specially in industrial set up. It is an unpleasant and awkward but not desperately serious problem in majority but not all cases as is generally caused by some kind of mechanical stress or damage within the back which gets better fairly quickly if taken care of.

Back pain - A growing problem
Back pain is a remarkably common problem seen in day to day life. At any time some 30 to 40 percent of the population have backache and between 80 to 90 percent experience it at sometimes in their life.
In our out door in orthopedic department 30 to 40 percent of patients attend with backache which not only hamper the work of their company but also disturb them physically as well as psychologically. Female patients are more in number which perform house hold work as well as in offices.

Common cause of backaches

Here I am enumerating some common back problems seen usually in day to day life with their consequences.

Non specific back pain

Many person who have trouble with their backs, experience brief episodes of pain from which they recover fully. This type of pain mainly diagnosed as lumbosacral or sacroiliac strain is caused due to strains of ligaments and tendon or soft tissues due to work and stress.

Slip disc or burst disc

When the spine is stressed by bending , twisting or lifting, the disc some times burst or slips from its place and a jelly like central nucleus is squeezed out through a split in the outer annulus. This jelly like substance presses the nerve running next to disc causing severe pain in the back that spread down the legs and some times even down to foot. There may be tingling and numbness in legs and foot. Pian in slip disc is very severe and a bed rest is suggested.

Sciatica

As the heavy weight and bending forces are mainly experienced in the lower part of lumbar spine, the nerve most often suffer is the 5th lumbar nerve root and 1st sacral nerve root. Pain arising due to damage of these nerve root is called sciatica. Pain is limited to low back and becomes severe in bending or stretching.
Mild yoga is helpful in back pain due to sciatica.

Wear and tear spondylosis

Due to the daily activities, weight bearing, bending and twisting the spines undergo wear and tear and due to this there is formation of osteophytes. These osteophytes compresses the adjacent nerves causing pain. The cervical region and lumbar region are most vulnerable and sometimes it becomes such an extensive that patient may feel unpleasant tingling and numbness to hand and feet and other associated area. Some neck exercise and back exercise is strongly recommended.

Lumbago
Lumbago is one of the most common problem and present as recurrent spells of acute back pain which may spread to buttocks or one of the thigh. Back becomes stiff and tenderness is present. Improvement of posture is helpful for preventing lumbago.

Backache due to nerve problems

The nerves gets easily squashed within the vertebral canal and as they emerges from the sides of the vertebral column they are more prone to get damaged due to damaged disc or joints or vertebrae. This results in tingling and sensation of the associated area.

Coccydenia

This is a pain associated at the tail of the spine or the coccyx. This is often due to prolonged sitting on hard surface. For prevention on should sit on soft cushion which may not be too thick.

These are some of the causes of back pains and can be preventable by using simple measures and consciousness.

Go through the link for treatment and prevention of back pain.

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Common discomfort in pregnancy and their remedy

The nine month of pregnancy is a full of new adventurous going inside a female both physically and mentally. The normal routine completely changes and a female may face lots of discomfort. Visiting a gynaecologist every time with every problem sometimes is not easy as it lead to physical, mental as well as monetary harassment.
Therefore I am briefing some common discomfort during pregnancy and their remedies.

Morning sickness during pregnancy
Nausea or vomitting may strike anytime during the day or night during pregnancy and usually occurs in the first three months. It is more striking in the first pregnancy.

Try eating small meals and frequent meals, avoid greasy and oily foods. Keep crackers by your bedside to eat before getting up. Other tips include eating cold foods and to avoid food having more fragrance after being cooked.

If morning sickness lasts past the three months of pregnancy or is enough to cause loose weight or dehydration consult your doctor.

On a positive note, women withlots of motion sickness rarely miscarry.

Feeling of tiredness during pregnancy
Tiredness may be due to anemia. Though iron and calcium supplements are already given as a part of antenatal care but if one feels excessive tiredness, doctor should be consulted and get your protien level and hemoglobin checked. Take enough rest in this case. Take a daytime nap if possible.

Leg cramps in pregnancy
The demand of calcium increses by two fold in our body thus a calcium tablets are given to all pregnant females. Leg cramps also occurs due to weight gain and changes in blood flow.
For remedy take calcium supplement as prescribed. Gently stretch the calf of your leg by pointing your toes upward, towards your knees.

Constipation during pregnancy
Constipation is the most irritating and uncomfortable events during pregnancy. The abdomen enlarges and constipation adds discomfort.
For remedy drink plenty of fluids. Eat foot with lots of fibres such as prunes and bran cereal. Take fruits instead of fruit juices. Never take laxatives without consulting your doctors. Stool softeners are though safe.

Increased frequency of urination
During pregnancy frequency of urination is more and increases as your baby grows up in the womb. This can't be helped and is a normal phenomenon as the baby grows he or she puts pressure on the bladder leading to increased urination.
In case of any burning sensation in urination a doctors advice is required as it may be urinary tract infection.

Change in mood during pregnancy
During pregnancy the hormones are on a roller coaster ride for nine months. This frequent change in hormones plus the life going through a big change with the feeling of being a mother leads to frequent mood change.
The remedy is to get yourself engaged in some light work. Do some meditation and yoga but avoid Bhastrika pranayama.

Changes in skin during pregnancy
Stretch marks appear as a red lines on your skin specially abdomen. It itches a lot and leads to frequent touch by hand which should be avoided.
Moisturiser and smoothening lotions can be applied to keep the skin moist and reduce itching. Stretch marks can't be really prevented but often fades after birth if not touched frequently.

Heart burn during pregnancy
Acidity and heart burn is often felt during pregnancy and to avoid this take small and frequent meals. Dont take antacid or any other medicine without consulting your doctor. Sucralfate are considered safer. Avoid spicy and greasy food. Don't lie down immediately after eating.

Infection during pregnancy
If you or your partner has genital herpes, consult your doctor. The risk of passing herpes to your baby is small and usually occurs at the time of delivery.If you do bot have herpes but your partner have, avoid sex till your partner gets cured. Use a condom during sex while you are pregnant.

Stuffy nose in pregnancy
This stuffy nose is related to changes in the levels of female hormone estrogen. Some times a nose bleed may also occur.
Avoid decongestants.

Edema in pregnancy
Fluid retention or edema in pregnancy can be normal to dangerous. Consult your doctor if edema is excess and increasing. Regularly check your blood pressure.
Remedy for mild edema includes resting legs on upward position generally by keeping pillows below the leg. Lie on the left side while sleeping so blood flows from your legs to the heart in better way. Never use diuretics (water pills).

Consultation of doctor during pregnancy

The doctor should always be consulted if the following symptoms is felt apart from normal antenatal visits.

* If any blood or fluid comes out of vagina.
* Sudden or extreme swelling of your face or fingers.
* Headache and that is severe and don't go away.
* Nausea and vomitting if severe or persist beyond three months.
* Dizziness
* Dim or blurred vision
* Pain and cramps in the abdomen.
* Fever or chills.
* A decrease in frequency of movement of baby.
* Less urination or burning sensation during urination.

So, follow these advices and have an uneventful pregnancy and a healthy baby.

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Pen Injectors - The modern insulin delivery device

A successful anti diabetic treatment involve mainly a quality of life issues that a patient faces in every day management of this deadly disease called diabetes. The worry will always comes in mind is a feeling of discomfort in self injection or hypoglycemia or even of gaining or excessive loosing weight.

Insulin is generally administered in syringes and it requires the accuracy of insulin dosage drawn from the vial without making it un hygenic. It is also tedius and inconvenient to carry specially to those who travel and is in daily active job.

Pen injectors for delivery of insulin

Now a days for injecting insulin there are modern pen injector devices which has alleviated many problems and inconvenience in insulin administration. By this pen injectors it is not only safe and easy to deliver insulin but is also a safe means of carrying around the injection equipments. a comparative study reveals that pen injectors not only safely deliver insulin but the dosing is more accurate and provides a psychological advantage to the patients too.

These insulin injection devices have easy to read dial, large buttons for injection and there is an audible clicks for units injected. The needles are thin and fine causing no or minimal pain in comparison to syringes used to deliver insulin from vials. Pen injectors are easy to handle and a patient having any visual problem or paralysis or other short of motor dysfunction can self administer insulin with ease. Research revealed that most of the patients prefer this pen device against the traditional insulin syringes for delivering insulin.

Advantage of Insulin pen device over traditional insulin syringes

There are numerous advantage and in fact this pen device are gaining popularity and may obselete the traditional insulin syringes in coming days.

* It is more convenient mode of insulin delivery and much more discreet that insulin syringes.

* The dosing with insulin pen device is more accurate.

* The needles of Pen device is so fine that pain is minimal thus making easier compliance with insulin regimen.

* Though it is simpler for all but for specific patients like older adults, pregnant females, children and adoloscents who are always in physical activity, this pen device is more simpler.

* The insulin pen injectors have improved social acceptibility specially at gatherings like in school, work place or any short of social gathering as you dont have to find a place and prepare for injection.

* There is disposable and reusable options in insulin pen devices which makes more flexible to use.

* Last but not the least it increases the quality of life as there is no more psychological discomfort and fear of inconvenience to administer, or fear of inaccurate dosing leading to hypoglycemia etc.

Thus the jist is that the insulin Pen device has made the treatment easy by bettering the compliance of the patients. It had almost abolished the fear of insulin therapy from the mind of diabetics.

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A cure to ageing skin

Skin is the main indicator for ageing and if we take care of it we can fool the nature and can delay ageing process. There are 10 most important quick fixes to fool the nature and a cure to ageing skin.
Out of 10 quick fixes five are vitamins which play a major role for skin care and has been mentioned at Vitamin for prevention of skin from ageing.
Ohter five important things which play a vital role in cure to ageing skin are-

Role of protein for skin

The main and primary component of skin is protein. Keratin, melanin all are protienaceous material. A rich protein diet is always helpful to maintain skin texture and delay ageing. But the source of nourishment should be selective. Soya, pulses, tofu, are good options. Apart from those, lean meats like fish, chicken is also a good choice. Low fat milk and egg white can also be a good and rich source of protein helpful for skin. Fish is the best protein among these as it also contains essential fatty acids and omega fatty acids.

Role of selenium for skin

This is an anti oxidant mineralwhich reduces the risk to sun burn. Selenium also minimise the damaging effect of ultra voilet light. A research at Texas Tech University at Lubbock revealed that low blood level of selenium increases the risk of skin cancer. Thus selenium becomes a very important part for skin care. Rich sources are wheat germ, tuna, sesame seed and whole grains. In fact whole grains is most important diet to remove skin imperfections.

Role of Zinc for skin

Zinc is a trace mineral and helps in maintaining collagen and elastin fibres. These fibres provide firmness to skin thus preventing from sagging and wrinkles. Collagen has also a great role in healing wounds and zinc links amino acids together which is required for the formation of collagen. Thus zinc also plays a vital role in a cure to ageing skin.

Role of water for skin

Water acts as a cleanser and detoxifier of our system. It hydrates our skin and prevents from drying and scaling. According to Mayo clinic 8-10 glasses of water intake per day is recommended. Though some studies contradict excess intake of water still 8 glasses is always recommended. Water flushes down the toxins and makes the skin to glow.

Role of yoga and exercise for skin

Yoga and exercise improves blood circulation and keeps the skin firm and wrinkle free. Daily schedule of 45 minutes exercise works wonder for skin. Brisk walking, treadmill breathe or play makes your skin to glow. Yoga like Kapalbhati pranayama and Anulom Vilom pranayama is miracle for skin disorders.

Thus these steps and diet should be strictly followed and try to remain young by your mind, body as well as your skin.

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Vitamins for prevention of skin from ageing

If you are 40 years of age certainly after 10 years you will be of 50, this is inevitable but what is evitable is not to look like being aged. There are some methods by which you can delay your ageing by looks, by skin texture and by energy level but obviously not by birthday counts.
Ageing is a natural process and none of us are above the nature but there are some methods by which we can somewhat fool the mother nature. Some of them are mentioned at A cure to ageing skin.
Most important changes in ageing is of the skin texture and there are some vitamins by which we can make our skin that will age very very late by natures hit. The role of those vitamins are mentioned below :

Role of Vitamin A for skin

It is a fat soluble vitamin and its role for night blindness and other eye disorders are well known. Apart from that it is essential for maintaining and healing epithelial tissues. The best source is egg yolk, non fat milk and colored fruits and vegetables.
Eating fruits rich in vitamin A will give your skin the inner glow and radiance.

Role of beta carotene for skin

Best sources of beta carotene are colored fruits and vegetables like tomatoes, carrots, water melons etc. Colored fruits and vegetables are also rich in lycopene which is beneficial for skin. According to reasearch done by Germans 30 mg of beta carotene which is equivalent to 1 and 1/2 cup of cooked carrots can help to reduce redness due to sun burn. When combined with Vitamin E it reduces skin sensitivity.

Role of Vitamin B for skin

Vitamin B converts calories into energy required for skin metabolism. This helps activating enzymes that maintain normal skin function, like maintaining the oil glands which lubricates the skin and keeps it smooth and moist. Deficiency of Vitamin B makes the skin dry and scaly. Sources for vitamin B are fish, red meat, bananas, whole grains peanuts and eggs.

Role of Vitamin C for skin

Vitamin C helps in maintaining collagen which is the underlying supporting structure of skin. Sun exposure and even stress drain vitamin C form the skin making it vulnerable to damage from the environment or nature hit. Therefore more than extra vitamin C is required in summer and tropical areas. Rich sources are citrus fruits like Indian gooseberry, lemon, tomatoes, green peas etc.
Regular intake of Vitamin C helps the skin to look fresh and smooth.

Role of Vitamin E for skin

Vitamin E is an anti oxidant which helps in slowing the ageing process of skin cells by reducing the production of collagen , which is an enzyme and helps to break down the collagen. Breakdown of collagen is the cause of sagging of skin and wrinkles thus if collagenase is reduced wrinkles can be delayed. Like Vitamin C sun exposure also deplete Vitamin E making skin vulnerable to damage. Thus extra vitamin E is required. Best sources of Vitamin E are salmon, almonds, lean meat, olive and sesame oils, legumes and green leafy vegetables.

Thus the above mentioned vitamins play a vital role in skin protection and can prevent or delay ageing. Select your diet accordingly and see if you can fool the mother nature for quite some time.

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Exercises for Vertigo and Dizziness

Many a times vertigo or dizziness occurs in person without any major organic diseases. In those cases which is the majority the feeling of giddiness or rotation of space is due an imbalance in the co-ordination mechanism of the body. Ottorhinolaryngologists prescribe certain drugs which help in alleviating the symptoms of vertigo or dizziness.

Though the doctors advice would, of course be the best in conditions of vertigo or dizziness and the ottorhinolaryngologists(ENT specialists) suggests something more than mere medicines.

Apart from medicines prescribes doctors specially ENT specialists suggests to carry out certain exercises which is of great help in adapting to the attacks of giddiness, dizziness or vertigo. These exercises are :-

Exercise for vertigo, giddiness or dizziness at bed

While on bed you can perform some exercise which is helpful in adapting the condition of dizziness or vertigo, these are specially the exercises of eyes and head.

Eye exercises for dizziness or vertigo

1. Looking up and down- Without moving the head move your eyes up and down. The movement should be restricted to eyeballs only.

2. Look alternatively left and right- Similarly like looking up and down, move your eyeballs to look left and right alternatively.

3. Convergence exercises- Converge your eyeballs by trying to look at the tip of your nose.

Head exercises for dizziness and vertigo

1. Bend your head alternately forward and backward, the movements should be through neck region.

2. Turn your head alternatively left and right and here too movements should be through neck region.

Exercise for vertigo, giddiness or dizziness in sitting position

While sitting you can perform following exercises for vertigo or dizziness.

1. Shrugging and rotating of shoulders- Both the shoulders should be shrugged up and rotated alternatively or even at the same time as per convenience.

2. Bend forward to pick objects-Sitting on a bench or chair put the object on the floor and then pick it up by bending forward.

3. Sitting on a table or chair without arms turn your head and trunk alternatively to left and right.

Exercise for vertigo, giddiness or dizziness in standing position

The exercises done while standing are as follows:-

1. Sit on the chair and stand frequently. Do this initially with open eyes and then close your eyes and do the same. This will help in adapting coordination and help to curb vertigo.

2. Take a small ping pong ball and throw from one hand to other making an arc. Move your eyes according to the movement of ball. Start slowly and gradually do it faster.

3. Take the ping pong ball and similarly throw it from one hand to other hand under the knee.

Exercise for vertigo, giddiness or dizziness while walking

The exercises for vertigo can be done while walking in the garden or park. These exercises are :-

1. Throw the ball above and catch it while walking around.

2. Walk up and down a flight of stairs.

3. When you are in house walk around in the room with eyes open and closed.

4. Play the games in the park which involves movements like bending, stretching and aiming with the ball.

Cautions while doing exercise for vertigo, giddiness or dizziness

While doing above mentioned exercises always take the following things into considerations.

1. Do not perform these exercises while you have a vertigo or dizziness attack.

2. Never take any medication of your own, as there are some medicines which may slow down the adaptation process gained by above exercises.

3. Always consult your doctor before taking any medicine which are not prescribed by your treating doctor.

And above all always consult your doctor before performing these exercises.

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