On the chest radiograph, constrictive pericarditis may be suggested by the presence of pericardial calcification. The calcium may be quite thin and linear and appear as “eggshell calcification” around the margins of the heart (Figure 1 A and B). Care must be taken to differentiate this pattern from the calcifications within the myocardium in old infarcts. The etiology of the pericardial calcifications in constriction is speculative, but it is seen mainly after viral and uremic pericarditis. A second type of pericardial calcification is a shaggy, thick, and amorphous deposition, which historically was rather specific for tuberculosis (Figure 2 A and B). The calcium is particularly obvious in regions of the heart in which normal fat is found, namely in the atrioventricular grooves. Calcium in the atrioventricular region may indent the heart focally, producing “extrinsic” tricuspid and mitral stenoses. However, a calcified pericardium does not necessarily imply that constriction exists.
During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation. It is important to keep in mind that a good estimate of VT versus SVT can be made based on the clinical vignette:
Morphological criteria (if the above criteria are inconclusive)
Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusion: SVT with RBBB
Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. AV dissociation is present. Conclusion: VT
HAPPY Learning :-)
GOOD LUCK !!!
It creeps up on you, sometimes—knowing that you’ve changed. You didn’t realize, you still don’t know, how it happened. And the scary thing is that this change was a fundamental part of you. It was all of who you thought you were. It was your destination and your journey. But you lost it. Now, you feel distant from God, Who was at one point your only purpose.
The loss of a connection to God is the scariest thing that can happen to a person. You can remember what it felt like to go to sleep remembering God and to wake up thinking of Him. He was your Best Friend. You remember how you molded your character to be something that He loves. You remember when every cell of your body was energized, ready to work hard for His sake. And most of all, you remember the tranquility. You didn’t worry. You knew al-Wakeel (the Trustee) would take care of you.
But right now, you’re in such a different place. You don’t even recognize yourself anymore. You want to be in that place you were before so much, and you want to know how you didn’t even notice the gradual fall. Can you even go back?
Ask the one who was trapped in the belly of a whale. Ask him how he felt about that fall from grace. The guilt, the humility, the longing that can all be summed up in the phrase he repeated over and over:
“[…] There is no deity except You; exalted are You. Indeed, I have been of the wrongdoers.”(Qur’an 21:87)
And what was the result? God tells us, “And had he not been of those who exalt Allah, he would have remained inside its belly until the Day they are resurrected.” (Qur’an 37:143-144)
So Prophet Yunus (Jonah) `alayhi as-salaam (peace be upon him), the companion of the whale, was saved. He was saved because he turned to Allah and never gave up. We can remain in darkness, if we choose to. It is those, and only those, who believe that there is no way back who never return.
To those that say, “I used to be religious,” or even, “I was never religious”, there is always a way back. When the Prophet Muhammad ﷺ (peace and blessings be upon him) tells us, “Allah is happier about the repentance of one His slaves, than one of you would be about finding your camel which had strayed away from you in the middle of the desert,” (agreed upon). He ﷺ is also talking to those of us who have strayed. Tawba is to return. It is not simply to repent after committing a hideous sin, although that is a big part of it. He is also talking to those of us who wonder if we can ever recover or achieve that zeal and energy and purpose. We need to return.
So don’t give up. Don’t give in to that feeling that tells you to do the bare minimum. Allahsubhanahu wa ta`ala (exalted is He) would not create you to be a useless addition to this world. You can be something special—something special to Him—if you don’t give up. If you take that step. Why are we reminded by the Prophet ﷺ in so many sayings that Allah (swt) accepts the servant who returns? Why are we told when we come one step closer to Allah (swt), He comes to us at speed? It is to remind us that Allah (swt) wants us to reach our potential, to take that first step despite the fact that the first step might be the hardest.
If you haven’t woken up for fajr (the pre-dawn prayer) for years, set five alarms today. Make a sincere du`a’ (supplication) to Allah (swt) before you sleep. Do it over and over again. Seek forgiveness and plead with Him to let you pray. You will not be disappointed. If you once had a big dream for your community but were dejected by people telling you to “be real,” pick up where you left off. Even if they are right and you never make it, because your intention was for Him, you already made it. Any achievement in this dunya (worldly life) is temporary, but “[…] indeed, the home of the Hereafter – that is the [eternal] life, if only they knew.” (Qur’an 29:64)
Don’t give in. “[…] Despair not of relief from Allah. Indeed, no one despairs of relief from Allah except the disbelieving people.” (Qur’an 12:87)
I truly believe that everything that we do and everyone that we meet is put in our path for a purpose. There are no accidents; we're all teachers - if we're willing to pay attention to the lessons we learn, trust our positive instincts and not be afraid to take risks or wait for some miracle to come knocking at our door.
HBV is a DNA virus. Eight genotypes of HBV have been identified and labeled A through H, Genotype D being most common in pakistan. I tried to compile key points from AASLD management guidelines. Taking treatment decision requires concept of different phases of chronic Hepatitis B infection so first we will discuss these four phases and then key points for the management of chronic hepatitis B infection.
Phases Of Chronic Hepatitis B Infection:
Chronic Hep B:
◦Positive for the hepatitis B virus (HBsAg) for more than six months
There are four Phases Of Chronic Hep B Infection
1. Immune tolerant Phase
2. Immune active Phase:
3. Inactive (Immune Control) Phase:
4. Immune Escape Phase:
Indications for treatment:
◦clearance of HBV DNA
◦normalization of liver enzymes.
Duration Of Treatment:
Hepatitis B in pregnancy:
There is either HBV dominance, which means high HBV DNA levels and low HCV RNA levels or HCV dominance defined by the high HCV RNA levels and low HBV DNA.
HBV Dominance – treat HBV
HCV Dominance – treat HCV
AASLD Guidelines: American Association for the Study of Liver Diseases
About The Author: Usman
M Usman Javed is the CEO and Founder of MedArcade.com. With a long time passion for Entrepreneurship, Self-development & Success, Usman started his website with the intention of educating and inspiring likeminded people all over the world to always strive for success no matter what their circumstances. Usman’s passion for what he does shows through the continual growth of MedArcade.com's online community. Connect with him on LinkedIn or keep upto date by subscribing this website through the box at About page.
Sometimes you can be chastised as an introvert for being a pessimist. Whether you feel it’s a choice or if you simply could never stop being so negative, in some way you may actually like it. Let’s face it we all see that overly happy person at work, serving us food, or taking our order for something, and we think “How can they be so happy?”. So many videos and posts urge us to have this outlook on life. They say we would be much better off being positive and happy. What if we don’t want to? Some people just want to watch the world burn, and nothing will stop us from having such a nihilistic viewpoint, which we prefer. So what are some of the earmarks of liking your own unhappiness?
When the glass is always half empty
For as long as I can remember I have thought of the glass as being half empty. If a glass is presented to you that has a liquid level of exactly half of its volume, what would you say the level of it is? Is it half full, or half empty? Recently I have changed my response to a more realistic one. I just tend to say that there is only half there. But with that new response there is a resistance to change; for ages I had thought of the glass as being half empty. The question of the glass has always been one of optimism versus pessimism. Now that I am older and wiser I know that being negative is not always the best thing, yet my reluctance to even simply say that the glass may be half full is apparent. Now there’s just half a glass. Baby steps.
When you feel stuck, and put conditions on your happiness
There was a point in my life where I had begun to feel positive. I had positive thoughts and emotions, my relationship was going well, and my work life couldn’t have been better. This terrified me! I had never had these feeling before; I’ve never been a happy person, luckily it didn’t continue and my unhappiness reared it’s ugly head once more. I once again stumbled about life trying to find my way and the ultimate goal of my ideal happiness, is that really the life for me?
That’s right, I too aspired to be happy. But there’s a catch– I put so many conditions on my happiness that it became almost unattainable. I’d like to make X amount of money, live in X house, and have the partner that has X qualities. What happens when we are trying to attain these goals? We’re usually stricken with the kind of unhappiness that I’ve felt over the years. And when we do meet these goals for happiness? Well it just so happens that more goals are placed on the pile to achieve before we can become a “happy person”– that way we are always unhappy.
When your personality separates you from others and makes your unhappiness grow
Some people are more comfortable with a solitary life, they would rather stay in and not go out. An introverted person will avoid personal encounters with even the people they are most familiar with. It’s not that they don’t want talk, they just won’t have the sort of open and happy conversation you’re looking for. Introverted people know the daily struggle of being seen as shy or awkward, and when they open up and talk they hear things like “Wow I really brought you out of your shell.”, or they’re told something about how well they speak. It’s wasn’t that they were never a good speaker and couldn’t speak, maybe they just didn’t value the low brow conversations they had heard before? As introverts, we really don’t like small talk.
When you feel the whole world is against you
Some of my relationships are the source of my happiest times. Most of my relationships, however, have been a headache, or ended in heartbreak. The difference between the two is subtle. Some relationships fall together like they were meant to be. They don’t always have to be romantic ones, in fact most of my happiest relationships are with friends of the same sex. My unhappiness in relationships has been the result of failed romantic endeavors. If you’re currently single then all of your romantic endeavors up until this point have failed. With romance, it’s a mutual thing, and you have to look at the cause of the failure; you can’t say that it was entirely their fault. Maybe you will be destined for unhappiness, and if you’re looking for love on Tinder or other dating apps this is likely. The only form of comfort we can hope for is to share our cynical perspective and unhappiness with someone equally as unhappy as we are.
Conclusion: Live for today
I won’t tell you some spiritual nonsense about learning to love yourself. This plight is certainly not due to the fact that one cannot love the inner self that you retreat to when society seems cruel and uncaring. When all your relationships have failed you and even your family and close friends have grown and become distant you will need to find something to hold on to. You can read a book or other helpful articles on Lifehack.org on the same topics.
If you’ve found that the world inside yourself has become grey and dull from the unhappiness you experience find another world to explore. Life can be mundane at best, and wherever you travel humanity has a way of being indistinct in certain cruel or pernicious ways.
But find the love, find it whenever you can and hold on to it. It has a nasty habit of slipping through your fingers sometimes but if you feel you have lost it, just remember there is a whole world out there where you can look for it. It may be in the tiniest of books, or URLs. It could be in the smallest laugh of a child or whimper of a baby animal, and sometimes when you’re looking for too long, it might be right inside yourself that you find the cure for your unhappiness. The help you can give to others, even a stranger, can open up the most trod upon of hearts and emotions. This too, I’m sure you will hate, for it is a thankless act.
Letting go is often quite hard, but there comes a time when we must. That is one of the most important life lessons each one of us must learn. It is only by letting go that we are able to move on with our lives. It is only by letting go that we can forgive and, hopefully, forget.
Letting go doesn’t mean that you don’t care about someone or something anymore. It just means that you realize that the only thing you truly have control over is yourself. It doesn’t mean you wanted to, it just means that you had to. You had to because letting go is a necessary process of adapting to the ever-changing realities of life.
As is often the case with matters of the heart, you will know deep down within yourself when it’s time let go, when it’s time to turn the page. A quick gut check and sobering words of wisdom from trusted friends or great thinkers can provide all the confirmation you need.
Here are 30 powerful quotes about letting go that will move you. Because sometimes letting go is the only way to move forward.
Thromboelastography (TEG) is a method of testing the efficiency of blood coagulation. It measures the dynamics of clot development, stabilization/strength, and dissolution. Assuming the body’s ability to achieve hemostasis is a function of these clot properties, TEG provides specific, real-time indicators of a patient’s in vitro hemostatic state. This is in contrast to routine screening coagulation tests such as aPTT and PT/INR which are run with blood plasma alone and therefore do not take into account the cellular components of clotting.
TEG creates a graphical representation of the movement of a small pin suspended in a cup of whole blood as hemostatsis occurs. As the blood begins to clot and adhere to the pin, the movement of the pin increases. This increasing movement is interpreted by the computer as increasing amplitude on the TEG graph.
A small sample of blood is taken from the selected person and rotated gently through 4º 45', six times a minute, to imitate sluggish venous flow and activate coagulation. A thin wire probe is used to measure, which the clot forms around. The speed and strength of clot formation is measured in various ways, typically by computer. The speed at which the sample coagulates depends on the activity of the plasma coagulation system, platelet function, fibrinolysis and other factors which can be affected by genetics, illness, environment and medications. The patterns of changes in strength and elasticity in the clot provide information about how well the blood can perform hemostasis, and how well or poorly different factors are contributing to clot formation.
Four values that represent clot formation are determined by this test: the reaction time (R value), the K value, the angle and the maximum amplitude (MA). The R value represents the time until the first evidence of a clot is detected. The K value is the time from the end of R until the clot reaches 20mm and this represents the speed of clot formation. The angle is the tangent of the curve made as the K is reached and offers similar information to K. The MA is a reflection of clot strength. A mathematical formula determined by the manufacturer can be used to determine a Coagulation Index (CI) (or overall assessment of coagulability) which takes into account the relative contribution of each of these 4 values into 1 equation.The G-value a is log-derivation of the MA and is meant to also represent the clot strength using dynes/sec as its units. There are some studies which suggest that an elevated G-value is associated with a hypercoagulable state and therefore increases the risk for venous thromboembolic disease. However, there are no studies dosing of prophylactic heparin products based on the G-value. TEG also measures clot lysis which is reported as both the estimated percent lysis (EPL) and the percentage of clot which has actually lysed after 30 minutes (LY 30,%). Although a normal EPL can be as high as 15% and a normal LY 30 can be has high as 8%, some studies in the trauma population suggest that a LY30 greater than 3% is associated with risk of hemorrhage.
Thromboelastometry (TEM), previously named rotational thromboelastography (ROTEG) or rotational thromboelastometry (ROTEM), is another version of TEG in which it is the sensor shaft, rather than the cup, that rotates. Blood (300 µl, anticoagulated with citrate) is placed into the disposable cuvette using an electronic pipette. A disposable pin is attached to a shaft which is connected with a thin spring (the equivalent to Hartert’s torsion wire in thrombelastography) and slowly oscillates back and forth. The signal of the pin suspended in the blood sample is transmitted via an optical detector system. The test is started by adding appropriate reagents. The instrument measures and graphically displays the changes in elasticity at all stages of the developing and resolving clot. The typical test temperature is 37°C, but different temperatures can be selected, e.g. for patients with hypothermia.
Sonoclot is the latest version of Thromboelastography which takes into account the initial viscosity changes (which typically happens before Fibrin polymerization) and later the elastic changes of the developed clot.
Case 1: 14 year-old male who presents with a chief complaint of rash. He states the rash came on over the past week and he also has noticed spots of blood when he blows his nose. He does not take any medications or supplements. On physical exam you note flat, red, non-blanching lesions on his bilateral lower legs. As you begin to examine his nose he starts to exsanguinate from the nares.
Case 2: 26 year-old male arrives in the ER 30 minutes after sustaining 2 Gunshot wounds to the chest. Vitals: BP 60/40 HR 115 O2Sat 88% on nonrebreather. Resuscitation is started and you send off a TEG.
Case 3: 42 year-old female arrives in the ER 40 minutes after an Motor Vehicle Collision in which she was ejected from the car. Emergency services reports they found her significantly obtunded with a large contusion on her forehead and obvious bilateral femur deformity. Vitals: BP 110/60 HR 107 O2Sat 93% on room air. As the R3 prepares for intubation you notice that she has significant bleeding around the site of her IV. You send off a TEG.
Which TEG parameters are abnormal?
HAPPY LEARNING :-)
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