Thursday, February 25, 2010

"Crabbit Old Woman"

What do you see, what do you see?
Are you thinking, when you look at me-
A crabbit old woman, not very wise,
Uncertain of habit, with far-away eyes,
Who dribbles her food and makes no reply
When you say in a loud voice,
I do wish you'd try.
Who seems not to notice the things that you do
And forever is loosing a stocking or shoe.
Who, unresisting or not; lets you do as you will
With bathing and feeding the long day is fill.

Is that what you're thinking,
Is that what you see?
Then open your eyes,
nurse, you're looking at me.
I'll tell you who I am as I sit here so still!
As I rise at your bidding, as I eat at your will.

I'm a small child of 10 with a father and mother,
Brothers and sisters, who loved one another-
A young girl of 16 with wings on her feet,
Dreaming that soon now a lover she'll meet,
A bride soon at 20- my heart gives a leap,
Remembering the vows that I promised to keep.
At 25 now I have young of my own
Who need me to build a secure happy home;
A woman of 30, my young now grow fast,
Bound to each other with ties that should last;
At 40, my young sons have grown and are gone,
But my man's beside me to see I don't mourn;
At 50 once more babies play around my knee,
Again we know children, my loved one and me.

Dark days are upon me, my husband is dead,
I look at the future, I shudder with dread,
For my young are all rearing young of their own.
And I think of the years and the love that I've known;
I'm an old woman now and nature is cruel-
Tis her jest to make old age look like a fool.
The body is crumbled, grace and vigor depart,
There is now a stone where I once had a heart,

But inside this old carcass, a young girl still dwells,
And now and again my battered heart swells,
I remember the joy, I remember the pain,
And I'm loving and living life over again.
I think of the years all too few- gone too fast.
And accept the stark fact that nothing can last-
So open your eyes, nurse, open and see,
Not a crabbit old woman, look closer-
See Me.

(The following poem was among the possessions of an aged lady who died in the geriatric ward of a hospital.)

A Nurse's reply "To the Crabbit Old Woman"

What do we see, you ask, what do we see?
Yes, we are thinking when looking at thee!
We may seem to be hard when we hurry and fuss,
But there's many of you, and too few of us.

We would like far more time to sit by you and talk,
To bath you and feed you and help you to walk.
To hear of your lives and the things you have done;
Your childhood, your husband, your daughter, your son.

But time is against us, there's too much to do -Patients too many, and nurses too few.

We grieve when we see you so sad and alone,
With nobody near you, no friends of your own.
We feel all your pain, and know of your fear
That nobody cares now your end is so near.
But nurses are people with feelings as well,
And when we're together you'll often hear tell
Of the dearest old Gran in the very end bed,
And the lovely old Dad, and the things that he said,
We speak with compassion and love, and feel sad
When we think of your lives and the joy that you've had,
When the time has arrived for you to depart,
You leave us behind with an ache in our heart.
When you sleep the long sleep, no more worry or care,

There are other old people, and we must be there.
So please understand if we hurry and fuss -
There are many of you, And so few of us.

The origin of HIV and AIDS

For over twenty years it has been a cause of countless arguments, with everything from a promiscuous flight attendant to a suspect vaccine program being blamed. What is the truth?

The first recognized cases of AIDS occurred in the USA in the early 1980s. A number of gay men in New York and California suddenly began to develop rare opportunistic infections and cancers that seemed stubbornly resistant to any treatment. At this time, AIDS did not yet have a name, but it quickly became obvious that all the men were suffering from a common syndrome.

What type of virus is HIV?

HIV is a lentivirus which attacks the immune system. The name 'lentivirus' literally means 'slow virus' because they takes heck of a long time to manifest as a disease. They have been found in a number of different animals, including cats, sheep, horses and cattle. But the most interesting lentivirus in terms of its relation to HIV is the Simian Immunodeficiency Virus (SIV).

So did HIV come from Chimps?

It is now generally accepted that HIV is a descendant of a SIV because certain strains of SIVs bear a very close resemblance to HIV-1 and HIV-2.

HIV-2 for example corresponds to SIVsm, a strain of the SIV found in the sooty mangabey (White-collared monkey)-indigenous to western Africa. Other closest counterpart of HIV that had been identified was SIVcpz-found in chimpanzees.

Scientists now believe that chimpanzees were the source of HIV-1, and that the virus had at some point crossed species from chimps to humans. It was then concluded that all three 'groups' of HIV-1 - namely Group M, N and O came from the SIV found in this particular Chimp (P. t. troglodytes), and that each group represented a separate crossover 'event' from chimps to humans.

How could HIV have crossed species?

It has been known for a long time that certain viruses can pass between species. As animals ourselves, we are just as susceptible. There are various theories about how this 'zoonosis' took place, and how SIV became HIV in humans:

The 'Hunter' Theory

In this scenario, SIVcpz was transferred to humans as a result of chimps being killed and eaten or their blood getting into cuts or wounds on the hunter. Initially the body would have fought off SIV, with time it adapted itself within human host and became HIV-1. The fact that there were several different early strains of HIV, each with a slightly different genetic make-up, would support this theory as every time it passed from a chimpanzee to a man, it would have developed in a slightly different way within his body, and thus produced a slightly different strain.

The Oral Polio Vaccine (OPV) theory

Some other rather controversial theories have contended that HIV was transferred iatrogenically. One particularly well-publicized idea is that polio vaccines played a role in the transfer.

An oral polio vaccine called “Chat” was tested on about a million people in the Belgian Congo, Ruanda and Urundi in the late 1950s. This theory suggests that “chat” was grown in kidney cells taken from infected chimps. This would have resulted in the contamination of the vaccine with chimp's SIV, and a large number of people subsequently becoming infected with HIV-1.

People have contested saying that local chimps were not infected with a strain of SIVcpz that is closely linked to HIV. Furthermore, the oral administration of the vaccine would seem insufficient to cause infection in most people as virus needs to get directly into the bloodstream to cause infection.

Later, Wistar Institute in Philadelphia (one of the original manufacturers of the Chat vaccine) announced the vaccine was analyzed and no trace had been found of either HIV or chimpanzee SIV.

The Contaminated Needle Theory

Even though the use of disposable plastic syringes became common around the world in 1950s, some parts of Africa might not have done so. It is therefore likely that one single syringe would have been used to inject multiple patients without any sterilization in between. This would rapidly have transferred any viral particles from one person to another, allowing virus to mutate and replicate.

The Colonialism Theory

During the colonial rule Africans were forced into labour camps with poor sanitation, scare food supply and physical demands were extreme. Prostitution was widespread and workers would have been treated with poor health ethics including non sterile needles. These factors alone would have been sufficient to create poor health in anyone, so SIV could easily have infiltrated the labour force and taken advantage of their weakened immune systems to become HIV.

The Conspiracy Theory

A a significant number of African Americans believe HIV was manufactured as part of a biological warfare program, designed to wipe out large numbers of black and homosexual people. Many say this was done under the auspices of the US federal 'Special Cancer Virus Program' (SCVP), possibly with the help of the CIA. Spread through smallpox inoculation programme, or to gay men through Hepatitis B vaccine trials.


Saturday, February 20, 2010

Neurocutaneous syndromes- always a big worry.

Neurofibromatosis (mostly familial)

T1: requires 2 of following for the dx
1)6 or more Café-au-lait spots (>5mm in pre, >15mm in post puberty
2)Axillary/inguinal freckling
3)2 or more Lish nodules (may need Slit lamp)
4)2 or more Neurofibroma ( 1 plexiform neurofibroma)
5)A distinctive osseous lesion (phenoid dysplasia, or cortical thinning of long bones)
6)Optic gliomas
7)A first-degree relative with NF-1
Assoc: Scoliosis, kyphosis, pseudoarthrosis, Gliomas, Mental retardation, seizures, neurofibrosarcoma, hypertension

T2: 10% of all NF,diagnosis needs 1 of…

1)Bilateral acoustic neuromas
2)First deg relative with NF-2 and either unilateral acoustic neuroma or any two of the following: neurofibroma, meningioma, glioma, schwannoma, or juvenile posterior subcapsular lenticular opacities.
Assoc: CNS tumours

Tuberous Sclerosis (Autosomal Dominant)

1)infantile spasms (hypsarrhythmic EEG pattern)
2)Ash leaf spots/ Amelanotic Navi (Wood ultraviolet lamp)
3)Adenoma sebacium (rare b4 2yr)
4)Shagreen paches
5)Subungual or gingival fibroma
6)Café-au-lait spots
7)retinal pharcoma
Assoc: Mental Retradation, developmental delay, palpable kidney (PCKD), epilepsy, cardiac rhabdomyomata, calcified tubers in the periventricular area (CT)

Mc_Cune Albright Syndrome (non familial)

Aka Polyostotic fibrous dysplasia. Features are…
1)Precauceous puberty (3-4yr, f>m)
2)Café-au-lait spots
3)Fractures/skeletal asymmetry
4)Assoc: Multiple endocrinopathy ( adrenal hyperplasia, thyroid, parathyroid and Growth Hormone abnormalities)

Sturge-Weber Syndrome (sporadic)

Features are…
1)Port wine stain at maxillary/ophthalmic division of trigeminal nerve
2)Ipsilateral: Oxophthamos, colobomata, glaucoma, buphthalmos.
3)Contralateral hemiparesis
4)Homonymous hemianopia
5)Taleniectasia of conjunctiva
6)Dark red fundus (retinal detachment)
Assoc: Epilepsy, mental retardation, cranial calcification (CT)

Von Hippel-Lindau Disease (Autosomal Dominant)

Features include:
1)Cerebellar hemangioblastomas (increase ICP)
2)Retinal angiomata (vision is unaffected until retinal detachment occurs)
3)Hemangioblastoma of the spinal cord (abnormalities of proprioception and disturbances of gait and bladder dysfunction)
4)CT scan typically shows a cystic cerebellar lesion.
5)Cystic lesions of the kidneys, pancreas, liver, and epididymis as well as pheochromocytoma, ranal carcinoma.

Child with Fever and Rash- a confusing condition?

Fever plus rash is a common combination seen in children. Often comes in out breaks. Most of the time diagnosis is made on clinical grounds and treated accordingly. Therefore it is important to know the differentials for a child with this problem.


I=7-10d, fever, coryza, cough, conjunctivitis, catarrh, Koplik’s spot.
Rash: 4th day, behind the ear to face and trunk (red, maculopapular)
Cplx: pneumonia, Otitis media, Encephalitis
Ix: raise in measles antibody titre, Immunoflourescence of Nasopharyngeal aspirate
Tx: symptomatic fluid and PCM, no antibiotics unless complicated


I= 10-21d, URTI, catarrh, cervical/suboccipital lymphadenopathy
Rash: erythematous, mainly on trunk
Cplx: Arthralgia, encephalitis (rare in childhood)
Ix: virus culture from stool/nose, rubella antibody titre

Mumps (no rash)

I=4-28d, parotitis (other glands rarely involved)
Cplx: meningitis, pancreatitis, orchitis
Ix: virus isolation from saliva, lymphocytosis, rise of Mumps antibody titre

Varicella (chicken pox)

I=10-21d, fever, rash (itchy): evolves from papules to vesicles, pulstures and scabes
Cplx: conjunctival lesion, encephalitis
Ix: electron microscopy of fluid from vesicles and virus culture, monoclonal antibody

Scarlet fever

I= 1-7d, (URTI) tonsillitis, rash (diffuse, erythematous, mainly on trunk 24-48hr after onset, papular, erythematous on trunk and limbs-looks red, face spared, blances, 3-4 d later rash fade with desquamation on hands, feet.)
Cplx: otitis media, Rh fever, Acute Nephritis
Ix: Throat swab for grp A haemolytic streptococcus, raised ASOT
Tx: penicillin V (250 mg/dose bid–tid PO) for 10 days, or benzathine penicillin G (600,000 IU for ≤60 lb, 1.2 million IU for >60 lb, IM) for compliance. Erythromycin (erythromycin estolate 20–40 mg/kg/24 hr divided bid–qid PO, or erythromycin ethylsuccinate 40 mg/kg/ 24 hr divided bid–qid PO) for 10 days

Other Differential Diagnoses to be considered:

Kawasaki disease (fever, rash, red swollen moth/hand/foot)

Meningococcemia (N. Meningitidis)

Roseola infentum (herpes 6&7)

Erythema infectiosum (parvo virus)

Dengue fever (fever, rash, bleeding, joint pain)

Hand foot mouth disease (coxsacie A)

Ricketsial diseases: Rocky Mountain spotted fever, Mediterranean spotted fever (eschar), scrub typhus (eschar) Dx by immunohistologic demonstration of rickettsiae on skin biopsy. Dec plt and wbc

I(incubation peiod), Ix (investigations), Tx (treatment), Dx (diagnosis) Cplx (complications)