WHICH JOINT HAS LEAST CHANCE OF RECURRENT DISLOCATION?

1. HIP
2. SHOULDER
3. ANKLE
4. PATELLA

ANS. ANKLE JOINT ankle joint has least chance of recurrent dislocation
b\c of mechanical efficiency in joint. considerable force required to dislocate it and normally a\w with fractures

Dislocation of the ankle without associated fracture or wound is an extremely rare injury. [1] Fahey and Murphy [2] classified tibio-talar dislocations into anterior, posterior, medial, lateral, superior or combinations of these basic displacements. Most of these are either open and/or with an associated fracture of the tibia, fibula or the talus itself. Of these the posterior-medial dislocation has been described most often in the literature. [1],[2],[3],[4],[5] Most authors have described this injury in young adult males. Falls, road traffic accidents and sports have been described as the most frequent causes of these injuries. Forced inversion or eversion with axial loading in a maximally planter-flexed foot is thought to be the cause of this injury. The patho-Anatomy of this injury has been dependent on findings during surgical repairs and has not been described accurately. We are reporting a case of closed posterior dislocation of the ankle without fracture in an 18-year-old male patient following road traffic accident. The most probable mechanism is forced forward displacement of the tibia leaving the talus behind. The patho-Anatomy as evident from the magnetic resonance finding is also being described. The injury is being described not only for its rarity but also to discuss its unique patho-mechanics, mechanism of trauma and its prevention.


Case History Top


An 18-year-old, 6 feet 4 inch tall male weighing 90 kg presented with pain, swelling and deformity one hour after a road traffic accident. The patient was on a bike when he was hit from behind over the right leg just above the ankle by another fast-moving vehicle where the large heel-breast of his shoes got stuck in the footrest and the leg was pushed anteriorly with great force resulting in a closed posterior dislocation of the talus from the ankle mortise. Physical examination revealed a deformed ankle with foot posteriorly displaced. There was no open injury. Swelling was present. The dorsalis-pedis and posterior tibial pulsations were normal. There was no hypoaesthesia, hyperlaxity or associated injuries.

Plain anterior-posterior and lateral radiograph of the right ankle demonstrated a posterior dislocation of the ankle without any fracture or widening of the tibio-fibular syndesmosis [Figure 1]. Patient was treated by leg elevation, above knee slab application and analgesics followed by closed reduction under general anesthesia and application of an above knee cast. Post reduction magnetic resonance imaging [Figure 2] demonstrated a torn anterior talo-fibular ligament and medial collateral ligament. A fibrous talo-calcaneal coalition was also found. He was advised surgical repair of the ligaments which he refused following which he was advised not to bear weight for six weeks. On follow-up at two years although he had painless normal range of ankle motion with full weight bearing and squatting, the x-ray of the ankle revealed osteophytes, calcification of the collateral ligaments beneath the malleoli with mild subluxation of the ankle joint [Figure 3].


Discussion Top


Dislocation of the ankle requires considerable force because of the mechanical efficiency of the mortise and the strength of the associated ligaments. [3] Since ligaments are stronger than the malleoli, most ankle dislocations are associated with fractures. Wilson et al. , reviewed the literature prior to 1939 and found 16 cases of ankle dislocation without fracture. [1] More recently Soyer et al. , (1994) found 73 cases in the relevant literature. [4] About 50% of ankle dislocations are usually open. However, in our case there was no open injury. An increased participation in outdoor activities is probably the cause of the higher incidence of this injury in young males. Our patient was also an 18-year-old, strong, adult male. Unlike ankle sprains, which predominantly occur in sportsmen, ankle dislocation is caused mainly by road traffic accidents, particularly motorcycle accidents. Sports trauma is the second most common cause.

The exact patho-mechanics of this injury has not been described accurately. Most authors suggest the cause as a combination of inversion along with axial loading while the foot is maximally plantar-flexed. This hypothesis is supported by experimental work done by Fernandez [5] on cadavers. The ligaments, which he found to be injured in this type of injury, were the anterior talofibular and calcaneofibular ligament. He also postulated that once the ankle is dislocated without fracture, the tendon of calcaneus pulls it posteriorly. Most authors have supported this postulate. However, Wroble et al. , were of the opinion that dislocations of the talus occur because of extrusion of the talus anteriorly or posteriorly when force is applied in a plantar-flexed foot. [6] In our case, the patient was wearing large shoes resting on the footrest well supported on it by the high heel-breast of the shoe. Being hit from behind above the ankle the patient's foot being plantar-flexed at this time got stuck at the footrest due to the high heel-breast, resulting in the tibia being forcefully pushed anteriorly, leaving behind the talus and the foot [Figure 4]. The associated talocalcaneal bar prevented an associated subtalar dislocation.

Since the injury occurs due to inversion, the structures that are primarily torn are the anterior talofibular, the calcaneofibular and posterior talofibular respectively. The deltoid ligament is usually spared. However, in our case since the mechanism of injury was not inversion with axial loading but a forward extrusion of the tibia leaving the talocalcaneal complex with the foot behind, we expected both medial and lateral collateral ligament injuries. Our clinical suspicion was confirmed by MRI report, which documents complete tear of the anterior talofibular and medial collateral ligament. Interestingly, our patient had a talocalcaneal coalition. This may have predisposed the patient to have an ankle dislocation rather than a subtalar dislocation when he was hit from behind. Tarsal coalition as a predisposing cause of ankle dislocation without fracture has not been previously described in the literature.

We are reporting this case for its unique mechanism of injury, MRI findings and outcome. We recommend that for racing bikes the footwear should not have a heel with a high breast-line; preferably, they should have a flat sole which will not permit the heel getting stuck in an accident, bringing about this type of grave injury.


References Top

1. Wilson MJ, Michele AA, Jacobson EW. Ankle dislocations without fracture. J Bone Joint Surg 1939;21:198-204. Back to cited text no. 1
2. Fahey JJ, Murphy JL. Dislocations and fractures of the talus. Surg Clin North Am 1965;45:79-102. Back to cited text no. 2
3. Uyar M, Tan A, Is¸ler M, Cetinus E. Closed posterior dislocation of the tibiotalar joint without fracturein a basketball player. Br J Sports Med 2004;38:342-3. Back to cited text no. 3
4. Soyer DA, Nestor BJ, Friedman SJ. Closed posteromedial dislocation of the tibiotalar joint without fracture or diastasis: A case report. Foot Ankle Int 1994;15:622-4. Back to cited text no. 4
5. Fernandes TJ. The mechanism of talo-tibial dislocation without fracture. J Bone Joint Surg Br 1976;58:364-5. Back to cited text no. 5
6. Wroble R, Napola J, Malvitz T. Ankle dislocation without fracture. Foot Ankle 1988;9:64-74. Back to cited text no. 6

1. Proteus –ans. triple phosphate renal stone
2. Appetite stimulant a/e – melanocyte stimulating hormone, melanocyte corticotropic releasing hormone, neuropeptide Y
3. non invasive diarrhoea a/e – shigella, b.cereus, salmonella, y.enterocolitica
ans b.cereus
4. motorcyclist frc
ans ring fractre
5. Probability – 6/25, 3/5, 2/5
ans 3/5
6. IDEAS – disability
7. Hernia – loop/end colostomy, loop/end ileostomy
ans end iliostomy
8. Anatomical snuff box – radial a
9. Foreign body sensation in the eye, arthritis –reactive
10. Immediately after eating dyspneoa, cyanosis – c1 def
11. Lupus anticoagulant – increase in aPTT only, abortion in pregnant females, can occur without other signs of lupus
12. Milkman # - pseudo#
13. Punched out lesion in skull – nxt dx to b done is ca level
14. Least polar – methyl, carboxyl, amino, phosphate
ans methyl
15. Nerve entrapment all except – femoral
16. Mammography less sensitive in young women – more glandular
17. Medulla blood supply all except – bulbar
18. Trochlear n – ipsilateral sup oblique, longest intracranial n, dorsal n, outside annulus of zinn
alll apr to b true bt it shd b annulus ........
19. Vasomotor centre of medulla – only baroreceptor not chemoreceptor
20. Chronic low back pain – pain management, exercise, remove the etiology
ans expt exercise
21. Pauci immune glomerulonephritis – microangiopathic
22. Coombs positive anaemia – sle
23. juxta foveal telangiectasia a/e – variant of coats, macular telangiectasia, ........
24. diabetic retinopathy treatment a/e – seal the tear, remove peripheral retinal layers, vitrectomy, photocoagulation
all are true
25. narrow angle glaucoma avoid – duloxetine, citalopram, fluphenazine,
26. valproate causes all of these n rest 1 left was da ans – weight gain, alopecia, liver damage
27. uveal effusion a/e – myopia, abnormal scleral structure, scleritis, cilio-choroid can get separated
28. nitrosamine – hypotension and bradycardia
29. paravertebral block can go to a/e – epidural space, subarachnoid space, paravertebral space, intercostals space
30. neuroblastoma – most common extracranial solid tumour in children, >50% come with mets, lung mets common, invove aorta and branches at early stage.
31. monetary fund given to – schizophrenia or mentel retardation ? help out
32. normal curve –mean=median
33. frequency distribution – histogram
34. involvement of sweat gland and hair follicles – lichen scrofulosum
35. all are direct cutaneous disease except – reiter’s disease
36. scarring alopecia – lichen planus
37. adrenal adenoma a/e – hypoechoic on non contrast ct, contrast appears early and washes out late, regular border ? help out
38. casper dictum – time since dth
39. stellate wound – contact wound
40. pedestrian with multiple abrasions – tert impact. or secondary
41. para 3+0,CIN 3 in one quadrant on pap smear, what is the management – hysterectomy
42. thyroid papillary ca 2cm – near total with rnd
43. follicular adenoma vs carcinoma – hurthle cell, increased mitosis, vascular invasion ? help
44. sertoli cells – spermatogenesis
45. obstructive azoospermia – fsh and lh nrml
46. smoking assoc with a/e – ca larynx
47. latest WHO scale of disability – ideas
48. SEPS – veins
49. commonest organ to be injured in bomb blast – lung
50. causes pf hypercoagulability a/e – paraproteinemia
51. features of pnh a/e – DVT rathr occr superficial
52. thromboembolism assoc with a/e – pnh
53. cannot be defined in operational terms –objective
54. cannot be defined in operational terms –objective
55. leptospirosis a/e – treatment of choice iv penicillin g, 10-15% mortality, rat urine
56. all true except – tetanus dust droplets
57. all true – hypochlorite virucidal, glutaraldehyde sporicidal, phenol require organic material
58. all true except – zinc def pulmonary problems
59. precocious puberty boy 5years with pubic hair, bp 120/90 – 17 a hydroxylase
60. positive urinary anion gap a/e– diarrhoea
61. water sample estimation a/e – clostridium recent contamination
62. nutritional survey a/e – 1 to 4 year mortality
63. q fever vector – aerosol
64. crude birth rate a/e – still born excl
65. imci includes all – malaria, resp infections, diarrhoea
66. trauma patient with gcs score 15, bp 100/80 next step – iv fluid with blood for cross matching
67. ductal carcinoma in situ investigation – mammography
68. calcification of post spinal ligament a/e – begins from thoracic level
69. neural tube closes from – cervical or cephalic/ help me
70. chronic renal failure patient with hyperkalemia immediate treatment glucose with insulin
71. after starvation which site will have less glucose receptor –adipose tissue
72. lipoprotein lipase a/e – adipocytes, myocytes, does not need CII as cofactor
73. child bites his fingers – hgprtase def
74. after cutting with restriction enzymes segments joined by – dna ligase
75. colon carcinoma a/e – mismatch repair
76. comet tail artefact – adenomyomatosis
77. aedes mosquito a/e - constant bite
78. dengue hmgic fever a/e – reinfection with diff serotype
79. hiv maximum transmission – homosexual
80. hiv enters – cd4
81. GIST which is increased max – cd 117
82. pancreatic transplant with bladder catheter – urine amylase, blood amylase, blood glucose
83. 29 yrs with diabetes, no ketonuria, father does not have DM ,ans dm1
84. RCC a/e – cushings
85. angiotensin a/e – vasodilatation
86. renal Physiology a/e – dct is always hypoosmotic
87. reversible ischaemia – thallium
88. maltese cross – blastomycosis, penicillium, candida
89. deep perineal pouch a/e – bulbourethral gland, urethral sphincter, root of penis
90. pelvic diaphragm a/e - colles fascia
91. aortic aneurysm rupture – posterior
92. m.c. site of subclavian artery constriction – 1st part
93. arteriovenous shunt a/e – not under the control of ANS
94. pseudomonas - ?
95. mifepristone used in – ectopic pregnancy
96. lactating female best contraceptive – barrier method
97. laproscopic sterilisation not done in – heart disease, hiatus hernia ............... neeed help
[snip]. incontinenti pigmenti a/e – 100% ophthalmic problems
99. neurofibromatosis a/e – autosomal recessive
100. trotters triad – seizures
101. tuberous sclerosis triad a/e– rhabdomyosarcoma
102. the following species of borrelia cause relapsing fever except – ????
103. pancreatic carcinoma a/e – 75% associated with p53 mutatn
104. gold standard test to diagnose insulinoma is 72 hrs fasting glucose
105. a 9 year old girl posted for tonsillectomy, massive haemorrhage with prolonged aPTT and normal PT – factor 9 def
106. simple random sampling – everyone has equal chance of being picked
107. incidence rate can be calculated from – prospective studies
108. all are analytical studies except – field trials
109. baby clinic a/e – bafter normal delivery breast feed within 4 hrs
110. target strategy in aids a/e – treatment of STD
111. chemoprophylaxis done for all except – cholera
112. vaccine with highest efficacy –tetanus
113. the following vaccine when contaminated causes toxic shock syndrome – measles vaccine
114. the following contractions of esophagus are stationary – primary, secondary, tertiary, quarternary ?? help
115. late expanding phase of population – birth rate stationary death rate falling, birth rate lower than death rate, falling death rates with low birth rate
116. fish odour from vaginal discharge – gardenella vaginalis
117. all the following are composite muscles except – flexor digitorum sup
118. the following joint has least chances for recurrent dislocation – ankle
119. hemochromatosis a/e – phlebotomy is not useful, common in females, complete penetrance. ?/???
120. a young female had following lab values mcv 70, hb 10 mg%, serum iron 60, serum ferritin 100, the diagnosis is – iron deficiency anaemia
121. facilitated diffusion is – requires carrier
122. oxygen demand of heart – increases in a constant proportion with heart rate
123. pulsatile large liver is seen in – tricuspid regurgitation
124. systolic thrill in left 2nd or 3rd intercostal space is seen in a/e – pulmonry stenosis
125. a down syndrome patient is posted for surgery, the necessary pre-op investigation to be done is – usg
126. zenkers diverticulum true statement is – barium xray lateral view
127. all are the uses of lithium except – major depression,
128. a female child was brought with complaint of generalised swelling of her body. She was passing fatty cast in her urine. No haematuria. The true statement is – no IgG or C3 deposition seen on renal biopsy
129. von hippel landau syndrome consists of a/e – gastric cancer
130. finnish type of nephrotic syndrome is due to mutation in – nephrin
131. renal polycystic disease in children all are true except – autosomal dominant
132. splicing is brought about by – sn RNA
133. superior middle alveolar artery is a branch of – palatine br of maxiilary
134. splenic artery gives all the following branches except – rt gastro epiploic
135. chemotherapy is given to all the following cancers except – (various stages of different cancers were in the options) t2 n1 mo ......
136. triple assessment of breast dis includes – history, clinical examination, obsrv
137. necrotising fasciitis a/e – due to group b haemolytic streptococcus, debridement is mandatory, involves trunk and lower limbs
138. the following cephalosporin doesn’t need dose modifications depending on gfr values – cefoperazone
139. tacrolimus side effect – nephrotoxicity
140. hand foot and mouth syndrome – capecitabin
141. amifostine – skin
142. small cell lung cancer true statement – it is chemosensitive
143. ifosphamide is – an alkylating agent
144. liquefactive necrosis is seen in – gangrene
145. reduces bone resorption and increases bone formation – strontium
146. the nephrotoxicity of cisplatin is increased by a/e – rifampicin
147. treatment of severe falciparum malaria – quinine or artesunate ??
148. hepatitis C true statement is – most common with liver transplantation
149. parvo virus B 19 false statement is – can cross the placenta in only <10% case
150. all cause traumatic asphyxia except – accidental strangulation.
151. true statement of RDA - RDA is dietry.............
152. restless leg syndrome seen in – chronic renal disease,
153. cyanosis does not occur in anaemia because – certain amount of reduced hb has to be present
154. 2,3 disphosphoglycerate not increased in - inosine, hypoxanthine
155. hb dissociation curve is sigmoid because – binding of oxygen to one molecule of hb increases the affinity of other oxygen molecules
156. modafinil used in – narcolp
157. best non surgical treatment of stress incontinence – electrical stimulation
158. carpal tunnel syndrome caused by a/e acromegalyor diabetes
159. a lady with temporal field defects, galactorrhoea, most common cause – pituitary macroadenoma
160. sleep controlled by – hypothalamus
161. juvenile arthritis all are present except – rheumatoid nodules
162. bleomycin – reduces type 2 pneumocyte
163. hepatomegaly is caused by all except – hepatocyte porphyria
164. cancer larynx – HPV 6 ..............
165. limb defects with scarring of skin in new born – varicella virus
166. mitomycin C used in – strg webr
167. cell cycle specific antineoplastic drug – vinblastine
168. treatment of osteosarcoma are a/e – high dose methotrexate,…. ?? help with rest options
169. in subclinical folic acid deficiency the following drug will bring about vitamin B 12 deficiency
170. the following drug can be given safe in pregnancy - propylthiouracil
171. rapid correction of hyperglycemia using insulin alone will result in – hypokalemia
172. icd 10 includes all except – lack of exercise, alcoholism, poisoning, unhealthy food. ??
173. cheif cells are found in – neck, pit, fundus ?
174. risk factor 4 GB Ca a/e – stones
175. motorcyclist's fructure means – ring #
176. spastic paraplegia caused by all except – motor neuron disease, vit B 12 def ..................
177. all are true about eaton lambert syndrome except – positive tensilon test.
178. pain sensitive structures – dural venous sinus,choroid n may b falx too.
179. icd….
180. cystic fibrosis all are true except – defect in calcium channel
181. girl with abnormal sweat chloride test, next diagnostic test – transnasal potential difference
182. Rheumatoid factor will give false negative tests with – coombs test….
183. abrasions can be confused with – eczema or ant bite ?
184. newborn with hydrocephalous – toxoplasmosis
185. Disease which permanently alters finger print – leprosy
186. vaginal delivery allowed in all except - monochorionic monoamniotic twins
187. dysgerminoma marker – LDH
188. Rate of mineralisation of newly formed osteoid – fluro.........
189. sympathectomy done in all except – anhidrosis
190. intermittent claudication the pain is on takn last step
191. severe chronic limb ischaemia true is – rest pain
192. best graft for surgery below inguinal is – sapheous
193. superior gluteal nerve supplies all except – gluteus maximus
194. carotid artery emboli and CRVO are differentiated by – raised retinal artery pressure
195. intrinsic factor secreted by - parietal cells
196. priviliged converstaion is between – doctor notified dis
197. myodesis is c/i in ischemia
198. which factor is specifically a part of intrinsic clotting pathway – 9
199. Seen in acute inflammation classically – vasodilatation with leakage
200. 45 year old male had a chest pain. he died after 4 days. on postmortem intramural coagulation was found. this is – neutrophils
201. mammography can detect all except – adenosis
202. Athletes pubalgia is...hamstrings
203. SIRS includes all except thrombocytopenia
204. substance not fermented in human intestines – cellulose
205. Hb S differs in – stability
206. all are true regarding Hb S – glutamine replaced by valine, heterozygotes are protected against malaria,
207. Standing to sitting change in - increased venous return to heart
208. Actyl Co A can't directly form – Glucose
209. Dengue Hemorrhagic fever - Second Infection with different strain of virus the second time
210. 100 KD on SDS-PAGE, then second trial s-s
2x(20KD + 30KD)
211. Wilm's Tumor - National Wilm tumor staging system orthe b option?
212. Action potential starts in the initial segment of axon because – more ion channels
213. regulatory mechanisms by all except – g coupld
214. regarding lac operon, CAP is – positive regulator
215. E157:O7 culture -
216. not a cause of primary amenorrhoea - Sheehan
217. Chlamydia infection of the eyes, true statement a/e – mostly asymptomoatic
218. Salmonella non typhi -
219. edema – C 1 esterase deficiency
220. hyperaldosteronism a/e – metabolic acidosis
221. HepB infected neonate - both Vaccine and Immunoglobin
222. Hashimoto's thyroiditis true a/e – follicular destruction, increase in lymphocytes ..............
223. Diastolic pressure - Aorta elasticity
224. IMG –
225. Joint aspiration in acute gout shows - monosodium urate crystals
226. GIST most common marker – CD 117
227. all drugs can be given to a mother who is on 35th week of gestation except – methotrexate
228. neonate change seen – tacycardia
229. heat rupture – rbc rupture
230. won't be present in right heart failure - increased PCWP
231. - joule burn
232. parotid pathway all – auticulotemporal nerve.,ottic ,lesser petrosal all supply
233. sodium bicarbonate given to local Anaesthesia – quick and longer action
234. which prevents colon cancer – high fibre diet, selenium, antioxidants
235. Entero Virus won't cause haemorrhagic fever
236. meningitis leads to through – vestibular aqueduct
237. cardiac disease predictor – Lp a
238. Benign HTN - hyaline aterioscelerosis
239. micro RNA –
240. temporal arteritis all – can cause sudden blindness, elderly, females more than males
241. most common muscle to be congenitally absent – pectoralis major
242. popliteal artery not easy to palpate because – it is not superficial, and no bony structure to palpate
243. LHD increased in – retinoblastoma, galactosemia, glaucoma
244. intestinal absorption test – xylulose
245. lambda phage ans c
246. mc cause of superficial thrombophlebitis -i.v. line
247. pseudoclaudication - cauda equina syndrome
248. stellate ganglion block causes all except – bradycardia
249. lymphoid tissue seen in – sub mucosa
250. visual cycle – opsin combines with retinol
251. high tibial osteotomy for what ?
252. vocal cord sulci- vocal abuse
253. paneth cell – has more zinc
254. pulmonary artery pruning seen in ?
255. surgical staging of ovarian ca all done except – peritoneal wasing, peritoneal biopsy, mesenteric biopsy, palpation of organs ...
256. spongy urethra drainage into which node – deep inguinal
257. In which condition is d onset of condition to death the lowest – obstructed labou
258. About mesial temporal lobe epilepsy
259. angiogenesis requires a/e – il 8
260. weight of average Indian man – 60 kgs
261. synovial fluid characteristics –
262. functions of T helper cells are all except – cytotoxic
263. DMPA - 0.3% failure rate
264. tamoxifen side effect a/e ca. in opp brst
265. eclampsia –
266. fatty content in breast is found in a/e – galactocele
267. ageing –
268. thoracic outlet syndrome diagnosed by – clinical examination
269. apoptosis which cell organelle responsible – mitochondria
270. psammoma bodies seen in a/e – follicular cancer thyroid
271. the most bactericidal among the following – O2- metabolite
272. karyotyping used for – chromosomal abnormalities
273. central chemoreceptors are sensitive to – low O2
274. blood flow is increased during exercise due to – active metabolites produced

Laryngeal pseudosulcus as a predictor of laryngopharyngeal reflux.

OBJECTIVES/HYPOTHESIS: Laryngeal pseudosulcus is an accurate prognostic indicator of laryngopharyngeal reflux (LPR) disease. STUDY DESIGN: Prospective study of 20 consecutive patients with laryngeal pseudosulcus. Pseudosulcus is infraglottic laryngeal edema that is thought to be secondary to LPR. All patients were evaluated with dual-channel pH probe 24-hour monitoring to evaluate for the presence of laryngopharyngeal reflux. METHODS: Twenty patients identified with laryngeal pseudosulcus on routine physical examination were included in the study. Each patient underwent a 24-hour dual-channel pH probe. The data were analyzed and compared with previously published normative data. The data included the total number of reflux episodes and the percentage of time the pH dropped below 4 at the proximal probe. RESULTS: Eighteen of the 20 patients with laryngeal pseudosulcus were found to have LPR. The mean number of reflux episodes at the proximal probe was 29.4 (range, 3-82). The mean percentage of time the pH dropped below 4 was 1.15%. In the upright position the mean value was 1.59% and in the supine position it was 0.19%. This gives pseudosulcus a positive predictive value for LPR of 90%. CONCLUSION: This study shows laryngeal pseudosulcus to be an accurate predictor of laryngopharyngeal reflux disease.


low back pain a/e...bed rest for 3 months

Bed rest is usually appropriate for acute LBP and sciatica. Two days of bed rest is more effective than 7 days, resulting in less time lost from work. Prolonged bed rest can lead to progressive inactivity and avoidance, which reinforces abnormal illness behaviors. Such inactivity can also have deleterious physiologic effects, leading to shortened muscles and other soft tissues, joint hypomobility, reduced muscle strength, reduced cardiopulmonary endurance, and loss of mineral content from bone. For these reasons, bed rest is usually not recommended as a treatment for chronic LBP.

question was most sensitive investigation for ductal carcinoma in situ.....answer between pet and mri...
according to this journal reference published by AIIMS its mri

18F-FDG PET in Detecting Primary Breast Cancer
Rakesh Kumar and Neena Lal
All India Institute of Medical Sciences, New Delhi, India

Abass Alavi

Hospital of the University of Pennsylvania Philadelphia, Pennsylvania

TO THE EDITOR:We read the article by Moy et al. (1) with great interest. This is one of the few studies that have investigated the role of PET/MRI in evaluating primary breast cancer. Several investigators have assessed the role of 18F-FDG PET in the comprehensive detection of primary breast cancer and found encouraging results (2,3). The initial PET studies were done on smaller numbers of patients and with larger primary breast tumors. However, recent studies on small breast tumors have demonstrated a relatively lower diagnostic accuracy for PET. Because of the limitations of PET alone, the most popular area of research in recent years has been the role of combined PET and CT or MRI. The combination of PET with CT or MRI provides the best of 2 modalities; that is, PET reveals the functional status while CT or MRI reveals structural details in the same sitting. We want to emphasize that, in breast cancer imaging, PET alone and PET fusion with CT or MRI have a significant false-negative rate that must be considered before they are used as a screening modality and the patient potentially subjected to expensive and time-consuming tests.

Fusion of a functional imaging modality such as PET, which has high specificity, with a structural modality such as MRI, which has high sensitivity, should give us results with both high sensitivity and high specificity. Stadnik et al. (3) compared MRI and 18F-FDG PET in staging breast cancer and imaging axillary lymph nodes in 10 patients and found the sensitivity and specificity to be 100% and 80%, respectively, for MRI and 80% and 100%, respectively, for PET (3). The combination of MRI and 18F-FDG PET achieved 100% sensitivity and specificity. Thus, they concluded that the combined method had the potential to identify which patients should undergo axillary dissection versus which should undergo sentinel node lymphadenectomy. In contrast, Moy et al. (1) noted a sensitivity and specificity of 92% and 52%, respectively, for MRI alone and 63% and 95%, respectively, for PET/MRI. The high specificity of PET/MRI can help define the subset of patients that surely should undergo tissue diagnosis of the suggestive lesions. However, because of the high false-negativity of PET/MRI, there would still be an additional subset of patients who require histologic examination of the lesion to rule out cancer. In the study of Moy et al., ductal carcinoma in situ consistently showed lower 18F-FDG uptake (standardized uptake value [SUV] < 2), except in one patient (patient 21). It is interesting to note that patient 17, with a 9-cm ductal carcinoma in situ, had an SUV of 0.4 whereas patient 21, with a 2-cm ductal carcinoma in situ, had an SUV of 3.2. All invasive ductal carcinoma lesions with poor differentiation had SUVs of less than 2.5. A patient with moderately differentiated invasive ductal carcinoma and invasive lobular carcinoma, and other patients with smaller tumors ranging from 0.9 to 1.1 cm, had SUVs of less than 2.5. These results concur with already published data showing a higher tendency toward false-negativity for lesions from carcinoma in situ and for low-grade, well-differentiated, or lobular carcinomas.

Several studies have reported excellent sensitivity and specificity for PET in breast cancer (2,4). However, data on the detection of smaller lesions using PET are limited. In our study on 111 patients with suspected breast cancer (5), 18F-FDG PET alone had a sensitivity of 48%, a specificity of 97%, a positive predictive value of [snip]%, a negative predictive value of 40%, and an accuracy of 61%. In that study, we found a sensitivity of only 23% (7/30) for primary breast cancer lesions that were 10 mm or smaller. This finding has 2 potential explanations. One is that lower SUVs are greatly affected by partial-volume effects in smaller tumors because the counts are spread over a larger area. Another is that smaller lesions have lower SUVs because metabolic activity may increase with tumor growth. In one study, correction for partial-volume effect improved sensitivity from 75% to 92% while decreasing specificity from 100% to 97% (6). In our study, we did not find the significant correlation between tumor type and false-negative PET results that was found by other investigators (5,7). Another study found that invasive ductal carcinomas had significantly higher 18F-FDG uptake than did lobular carcinomas (SUV, 3.7 ± 2.2 vs. 2.1 ± 1.4, P = 0.003); thus, lobular cancers might be another factor leading to false-negative reports. The lower SUVs in lobular cancers might be explained by a lower tumor cell density and by diffuse surrounding tissue infiltration. A significantly positive correlation was found with the pattern of microscopic tumor growth (nodular vs. diffuse); thus, diffuse tumors might also be missed, causing false-negative results (7).

In conclusion, the clinical application of PET/MRI as an initial screening test may prove limited by the significant number of false-negative results. More randomized controlled studies using PET/CT or PET/MRI on patients with smaller breast lesions are required to establish the exact role of combined functional and structural modalities in this type of cancer.

Anterior perforated substance

Scheme of rhinencephalon. (Anterior perforated substance labeled at bottom left.)

Base of brain. (Anterior perforated substance labeled at center.)
Latin substantia perforata anterior
Gray's subject #189 827
NeuroNames hier-264
The anterior perforated substance is an irregularly quadrilateral area in front of the optic tract and behind the olfactory trigone, from which it is separated by the fissure prima; medially and in front it is continuous with the subcallosal gyrus; laterally it is bounded by the lateral stria of the olfactory tract and is continued into the uncus.

Its gray substance is confluent above with that of the corpus striatum, and is perforated anteriorly by numerous small bloodvessels.


Additional images
Human brainstem anterior view


Atlas of Anatomy at UMich n1a8p1 - "Interpeduncular fossa" (#6)
Anterior+perforated+substance at eMedicine Dictionary
Photo at umdnj.edu
This article was originally based on an entry from a public domain edition of Gray's Anatomy . As such, some of the information contained herein may be outdated. Please edit the article if this is the case, and feel free to remove this notice when it is no longer relevant.

This neuroscience article is a stub. You can help Wikipedia by expanding it.

v • d • eBrain: telencephalon (cerebrum · cerebral cortex · cerebral hemispheres)

Primary four
surface lobes Frontal lobe Precentral gyrus (Primary motor cortex, 4)
Superior frontal gyrus/Frontal eye fields (6, 8, 9) · Middle frontal gyrus (46) · Inferior frontal gyrus/Broca's area (44-Pars opercularis, 45-Pars triangularis)

Orbitofrontal cortex (10, 11, 12, 47)

Prefrontal cortex · Premotor cortex

Precentral sulcus · Superior frontal sulcus · Inferior frontal sulcus · Olfactory sulcus

Parietal lobe Somatosensory cortex (Primary (1 · 2 · 3 · 43) · Secondary (5)) · Precuneus (7m) · Parietal operculum
Parietal lobules (Superior (7l) · Inferior (40)) · Angular gyrus (39)

Intraparietal sulcus · Marginal sulcus

Occipital lobe Primary visual cortex (17) · (Cuneus · Lingual gyrus · Lateral occipital gyrus (18, 19))
Calcarine fissure

Temporal lobe Primary auditory cortex (41, 42) · Superior temporal gyrus (38, 22/Wernicke's area) · Middle temporal gyrus (21) · Inferior temporal gyrus (20)
Fusiform gyrus (37) Medial temporal lobe (Amygdala · Parahippocampal gyrus (27 · 28 · 34 · 35 · 36)

Interlobar sulci/fissures lateral: Central (frontal+parietal) · Lateral (frontal+parietal+temporal) · Parietoöccipital
medial: Medial longitudinal · Cingulate (frontal+cingulate) · Collateral (temporal+occipital)


Cingulate cortex/gyrus Subgenual area (25) · Anterior cingulate (24, 32, 33) · Posterior cingulate (23, 31) · Retrosplenial cortex (26, 29, 30)
Callosal sulcus

White matter tracts Commissural fibers · Association fibers
Internal capsule (Anterior limb · Genu · Posterior limb) · Corona radiata · External capsule · Lamina terminalis · Extreme capsule · Semioval center

Olfactory tract · Terminal stria · Diagonal band of Broca

Other Insular cortex

gray: Olfactory bulb · Anterior olfactory nucleus · Basal optic nucleus of Meynert · Substantia innominata · Anterior perforated substance

Corpus striatum - Limbic lobe

Some categorizations are approximations, and some Brodmann areas span gyri.


The Pathology of two cases of pulmonary damage due to bleomycin is described. The drug damages the alveolar walls. A sequence of pathological changes could be traced commencing with oedema, intra-alveolar fibrin and haemorrhage, followed by type II pneumocyte hyperplasia associated with bronchial epithelial squamous metaplasia. This led to intra-alveolar and alveolar wall collagen formation producing diffuse interstitial fibrosis with microcyst formation associated with cuboidalization of the epithelium. These changes are similar to those seen in experimental bleomycin damage in mice, where it has been shown that the changes are the result of vascular damage and type I pneumocyte necrosis. It is inferred that human diffuse alveolar damage develops in the same way.

endothelial damage or type 1 pneumocyte??? need better reference

in t/t of ALL all r done except
a. hydration
b. allopurinol
c. immediate chemotherapy
d.?

Discovered in nematodes in 1993, microRNAs (miRNAs) are non-coding RNAs that are related to small interfering RNAs (siRNAs), the small RNAs that guide RNA interference (RNAi). miRNAs sculpt gene expression profiles during plant and animal development. In fact, miRNAs may regulate as many as one-third of human genes. miRNAs are found only in plants and animals, and in the viruses that infect them. miRNAs function very much like siRNAs, but these two types of small RNAs can be distinguished by their distinct pathways for maturation and by the logic by which they regulate gene expression.

c/i of laparoscopic ligation a/e
a. heart ds.
b. hb<8g%
c. obesity
d. diapragmatic hernia

Abstract: The authors evaluated the combination of etoposide/cyclophosphamide (VP/CY) as initial, presurgical therapy for patients with osteosarcoma and found an 88% response rate for the primary tumor and any metastases. After definitive, limb-salvage surgery and adjuvant chemotherapy with etoposide, cyclophosphamide, cisplatin, and doxorubicin, patients without metastases at diagnosis whose cases were followed for a median of 2 years from diagnosis achieved a relapse-free survival (RFS) probability of 78% +/- 9%. This result is equivalent to the best adjuvant chemotherapy results reported to date. Patients without metastases at diagnosis had significantly better RFS probability (78% +/- 9%) than those with metastases at diagnosis (0%). Transient, severe myelosuppression has been the only major toxicity of the VP/CY courses. No irreversible organ damage or toxic deaths have been seen in patients enrolled in this study. The authors conclude that the combination of VP/CY is effective treatment for osteosarcoma, and when combined with cisplatin/doxorubicin (CIS/DOX), is as effective as any previously reported chemotherapy for osteosarcoma.
Review References: None
Notes: None
Language: English
Publication Type: Journal-Article
Keywords: Antineoplastic Agents, Combined therapeutic use : Bone Neoplasms drug therapy : Cisplatin administration and dosage : Cyclophosphamide administration and dosage : Doxorubicin administration and dosage : Etoposide administration and dosage : Osteosarcoma drug therapy

parvo virus all are true except-
ans-placental transmission less than 10%.
ref 17th edn harrisons page 1116.risk of transplacental fetal infection is 30%.
other options were-infects erythroid progenitor cells and infection is acquired byrespiratory infection,dont rem the third option,..

question on drug contraindicated in narrow angle glaucoma-

ans-Duloxetine can make narrow-angle glaucoma worse. If your glaucoma is under control, your healthcare provider should monitor your glaucoma to make sure it is not getting worse. If your glaucoma is not under control, you should not take duloxetine.

for ref-do google search for duloxetine in glaucoma,manyarticles are given..

India PG Exam is Very Tough. Those Student Pass it which have Excellent knowledge about Medical Tests.

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Its gray actuality is allied aloft with that of the bulk striatum, and is perforated afore by abundant baby bloodvessels.