Nomenclature
Infection. Coronavirus Disease 2019 a.k.a. COVID-19
Virus. SARS-CoV-2, 2019 Novel Coronavirus
NOT “Wuhan Virus”

Biology

• 30 kbp, +ssRNA, enveloped coronavirus
• Likely zoonotic infection; source/reservoir unclear (Bats? / Pangolins?-> people)
• Now spread primarily person to person;
• Can be spread by asymptomatic carriers!
• Viral particles enter into lungs via droplets
• Viral S spike binds to ACE2 on type two pneumocytes
• Effect of ACE/ARB is unclear; ACE vs ARBs may even have opposite effects
• Other routes of infection (contact, enter c) possible but unclear if these are significant means of spread

Epidemiology

• Attack rate = 30-40%
• R0 = 2-4 (similar to influenza)
• CFR = 3.4% ( worldwide num bers)
• Incubation time = 4-14 days typically (up to 24 days)

Timeline:

• China notifies WHO 2019-12-31
• First US case in Seattle 2020-1-15
• WHO declared pandemic 2020-3-11
• National emergency 2020-3-12
• Disease clusters: SNFs, Conferences, other
• Strategies: contact tracing, screening, social distancing

Diagnosis / Presentation

Symptoms:

• 65-80% Cough
• 45% febrile on presentation(85% febrile during illness)
• 20-40% dyspnea
• 15% URI Symptoms
• 10% GI Symptoms

Labs

• CBC:Leukopenia & lymphopenia (80%+)
• BMP: BUN/CR ( Increased )
• LFTs: AST/ALT/Tbili (Increased)
• D-dimer (Increased), CRP (Increased), LDH (Increased)
• IL-6 (Increased), Ferritin (Increased)
• Procalcitonin (Decreased)

* PCT may be high w/bacterial superinfxn*

Imagine

• CXR: hazy bilateral, peripheral opacities
• CT: ground glass opacities (GGO), crazy paving, consolidation, *rarely may be unilateral*

• POCUS: numerous B-lines, pleural line thickening, consolidations w/air bronchograms

Isolation

• Phone call is the best isolation(e.g. move to telemed)
• Place patient in mask, single room, limit/restrict visitors

Precautions

• STANDARD + CONTACT (double glove)+
• Either AIRBORNE (for aerosolizing procedures: intubation, extubation, NIPPV, suctioning, etc) or DROPLET (for everything else)
• N95 masks must be fit tested; wear eye protection
• PPE should be donned/doffed with trained obsesrver
• Hand hygiene: 20+ seconds w/ soap/water or alcohol containing hand gel

Treatment

• Isolate & send PCR test early (may take days to result)
• GOC discussion /triage
• Notify DOH,CDC,etc
• Fluid sparing resuscitation
• +/- empiric antibiotics
• Intubate early under controlled conditions if possible
• Avoid HFNC or NIPPV (aerosolizes virus) unless individualized reasons exist(e.g. COPD, DNI Status, etc); consider helmet mask interface (if available) if using NIPPV
• Mechanical ventilation or ARDS
  • LPV per ARDSnet protocol
  • 7P’s for good care of ARDS patients e.g. PEEP/Paralytics/Proning/inhaled Prostacyclins, etc
  • ?High PEED ladder may be better
  • ?ECMO in select cases (unclear who)
• Consider using POCUS to monitor/evaluate lungs
• Investigational therapies:
  • Remdesivir –| block RNS dependent polymerase
  • Chloroquine –| blocks viral entry in endosome
  • Tocilizumab –| block IL-6
  • Corticosteroids –| reduce inflamation
• None of these investigational therapies are proven, but literature is evolving quickly.

Prognosis

• Age and comorbidities (DM, COPD, CVD) are significant predictors of poor clinical outcome; admission SOFA score also predicts mortality
• Lab findings also predict mortality
  • d-dimer(increased),
  • ferritin(increased)
  • troponin (increased)
  • cardiac (increased)
  • myoglobin
• Expect prolonged MV
• Watch for complications:

Secondary infection VAP, Stress CM, etc

This technique is used in various clinical procedures:

Urinary catherization

IV line and IV drug administration

Wound care

AIM:

Maintain aseptic field

Good hand hygiene practice

Avoid touching key parts of components used in clinical procedures

For example in IV medication administration:

• Tips of syringe
• Needles
• Fluid and diluents
• Spikes of giving sets
• Air inlets
• End of luer connectors
• Bungs
• Hubs
• Ports
• Collect drug chart and check allergy
• Take plastic tray and clean it with detergent wipe, air dry
• Wash your hands thoroughly with soap/alcohol gel and water
• Wipe tray with 70% alcohol solution and leave it to air dry
• Collect all items you need for task and place next to tray
• Decontaminate hand using alcohol gel
• Wear gloves
• While opening the packages, do not tear paper as it will create a viable air borne particles which will lead to contamination.
• Assemble the needle and syringe ensuring key parts are not contaminated
• All liquids must be drawn with needles
• Remove dust cap and wipe with alcohol gel
• Take the tray to bedside for administration as soon as possible
• Dispose gloves and decontaminate hand
• Take patient’s consent and explain procedure
• Decontaminate hand and wear disposable apron
• Check IV access site for signs of infection
• Decontaminate hand and wear pair of gloves
• Clean the port with alcohol gel and give 30 seconds to dry
• Administrate drugs
• Dispose all used equipment appropriately
• Remove apron and gloves and dispose
• Decontaminate hands with alcohol gel
• Complete your documentation
• Clean the tray and return to preparation area

How to perform in ANTT skills testing in wound care?

• Check the scene for safety and undertake risk assessment, for example move any objects near patient.
• Decontaminate hand using alcohol gel
• Introduce yourself to patient and confirm patient’s details and check ID band.
• Check for allergies. Please ensure you check allergies for adhesives, latex and plasters.
• Explain to patient what you are doing and gain consent. Ensure patients confidentiality.
• Check for pain and ensure they are comfortable before you start a procedure.
• Inspect wound dressing site including bed linen (verbalize)
• Explain to patient that you will dispose the gloves and prepare the articles needed.
• Wash your hand using 7 step.
• Ensure trolley is cleaned with soap and water.
• Clean with alcohol wipes after putting disposable gloves and apron.
• Wipe trolley from upper shelf to bottom, from farthest point to nearest one.
• Dispose gloves and decontaminate hand
• Prepare equipment and assemble all articles in bottom shelf. Check packets are intact and expiry date.
• Check  there is no precipitate in saline or liquid solution
• Gloves, alcohol wipes and hand gel.
• While moving a trolley, do not touch shelf and hold on legs of trolley.
• Return to patient and put clean pair of gloves
• Gain consent to remove any covering clothes and remove dressing edge
• Open dressing pack without tearing paper, clean hands and unwrap the pack holding its edges only
• Grab orange bag and arrange articles as needed
• Use the same orange bag and remove the used dressing and reverse it back. Stick it in bottom shelf of trolley.
• Perform another hand wash and clean saline sachet with alcohol wipes for 30 seconds and let it dry for 30 seconds
• Open dressing materials into the sterile field
• Clean hand and wear new pair of sterile gloves and drape patient.
• Clean the wound categorizing cleaned and dirty hand. Make sure you don’t touch dirty hand with clean hand while passing materials. Clean the wound with gauze soaked in saline solution. Clean wound from clean to dirty area in single stroke

• Apply the new dressing taking care not to contaminate. Disposed all the waste materials. Clean the trolley and cover the patient.

• After dressing, check if patient is comfortable and let them know you are available if they have any issues.
• Decontaminate hand and complete documentation stating that you completed procedure using ANTT.

SCENARIO I: A PATIENT IS BROUGHT IN BY PARAMEDICS AFTER A ROAD TRAFFIC ACCIDENT. YOU ARE THE FIRST DOCTOR THEY MEET. WHAT WILL YOU DO?

SCENARIO II: A PATIENT AFTER HEMIARTHROPLASTY HAS A HIGH K+ LEVEL 4 HOURS AFTER. WHAT INVESTIGATIONS WILL YOU DO AND WHAT

SCENARIO III: YOU ARE IN A & E, A PATIENT COMES IN WITH EXACERBATION OF COPD. HOW WILL YOU APPROACH AND MANAGE THIS PATIENT.

SCENARIOS IV: A PATIENT WHO IS A KNOWN CASE OF COPD PRESENTS WITH SOB. ON EXAMINATION PATIENT HAD BI-BASAL CREPITATION, WHAT WOULD YOU DO?

• First assess ABC and connect him to monitor.
• If O2 is < 88% start 24% oxygen via Venturi mask.
• Start medications which should include Salbutamol and Hydrocortisone and give him Furesemide.
• Perform chest X-ray and ABG

SCENARIO V: A PATIENT HAS COME TO YOU WITH BREATHLESSNESS AND WHEEZE. SHE IS AN OLD LADY WHO IS A KNOWN CASE OF COPD. HER SPO2 IS 88%. HOW WILL YOU MANAGE?

• I will do A, B, C, D assessment and APVU assessment.
• I will then start her with 24 % oxygen via mask and monitor her spO2
• Then I will start her on Salbutamol and hydrocrtisone if needed.
• Once the patient is comfortable I will take detailed history and examination.
• I will inform my senior.
• I will then send patient’s investigations which should include CBC, electrolytes and Urea to do CURB65 scoring in any case if she has differential as Pneumonia, LFTs, ABG, Chest X-ray.
• If an infection is suspected and established by investigations I will consult with my senior and give her antibiotics according to hospital protocol.
• ABG report shows pH to be low, pCO2 high and pO2 low, how will you manage further: I will repeat ABG and if pCO2 is still high despite all treatments we have given I will consider her for non-invasive ventilation after consulting my senior and a respiratory physician. If she still doesn’t respond  and has low pH and high PCO2  I will inform my senior and consult anesthetist and discuss intubating my patient.

SCENARIO VI: A PATIENT COMES WITH CENTRAL CHEST PAIN. WHAT WILL YOU DO AND WHAT DIFFERENTIAL DIAGNOSIS WILL BE IN YOUR MIND?

SCENARIO VII: A 60+ YEAR OLD MALE COMES WITH LIF PAIN. HE SCORES THE PAIN AROUND 7 /10. HIS BLOOD PRESSURE IS 110/70 mm Hg AND RR IS 14 b/ min. WHAT WILL YOU DO FOR HIM? WHAT INVESTIGATIONS WIL YOU DO? WHAT DO YOU THINK HE HAS?

SCENARIO VIII: THERE’S A TWO PATIENT WHO COMES IN SIMULTANEOUSLY. ONE BANGED HIS HEAD AND LOST CONSCIOUSNESS AND THE OTHER HAS K+ 7.5. YOU ARE THE ONLY DOCTOR IN THE CORRIDOR AND YOU GET THE BLEEP ABOUT THESE TWO PATIENTS. HOW WILL YOU MANAGE THIS SITUATION?

(checking if you can triage patients, coping with stress, realize your limits)

-> First of all, call your registrar and inform him about the two bleeps and he or she will guide as to what to do next.

-> Start him on Calcium gluconate to prevent cardiac arrest and ask nurse to get ECG done for a patient with K+ 7.5 as you already know there will be ECG changes with high potassium level. And go to the patient who has LOC, get more information including bleeding from nose and ears and vomiting. Check ABC his GCS and depending on his status either plan for intubation or/ and ask A & E staff to get his CT scan done. In the mean while go and see the ECG of other patient.

-> Inform your registrar about what you did and ask him if he would like you to add anything in management.

ENT-HEAD AND NECK SURGERY SCENARIOS:

SCENARIO I: You are in operation theater assisting a case. You are also an on call for that day. You got a call from post operative ward saying there’s a patient who is bleeding. At the same time you got the call from emergency department asking you to attend a patient who has come with airway obstruction. What will you do in such situation.

SCENARIO II: There’s a patient in ward who has tracheostomy, how will you care this patient.

SCENARIO II: In Head and Neck cancer ward, there are lot of patients with laryngectomy. How will you take care of patient with laryngectomy?

TRAUMA AND ORTHOPAEDICS SCENARIOS:

SCENARIO I: YOU ARE CALLED TO AN EMERGENCY DEPARTMENT TO SEE A PATIENT WITH FEMORAL NECK FRACTURE. WHAT WOULD YOU DO ? HOW DO YOU CLASSIFY FEMORAL NECK FRACTURE ?

SCENARIO II: A PATIENT COMES IN WITH A SWOLLEN PAINFUL KNEE AND FEVER. THERE’S NO HISTORY OF TRAUMA BUT HAD HIP REPLACEMENT 10 YEARS AGO, WHAT IS YOUR DIAGNOSIS AND HOW WILL YOU MANAGE?

-> Septic Knee Arthritis

SCENARIO III: A PATIENT HAD UNDERGONE A HIP REPLACEMENT 7 DAYS BACK AD NOW HE HAS sob AND HYPO-TENSION. WHAT DO YOU SUSPECT? HOW WILL YOU MANAGE?

-> PE and D/Ds

-> I will introduce myself and take history. I will make sure patient is safe by going through a, b, c

GENERAL SURGERY SCENARIOS:

SCENARIO I: A WOMAN POST MASTECTOMY PRESENTS WITH FEVER AND RASH IN SURGERY DEPARTMENT. HOW WILL YOU MANAGE?

SCENARIO II: WHAT IS PULSE LESS ELECTRICAL ACTIVITY AND IN WHAT CONDITIONS CAN YOU GET THESE?

SCENARIO III: YOU ARE THE ONLY DOCTOR ON THE POST. THERE ARE 2 PATIENTS IN THE WARD. ONE OF THEM DEVELOP

SCENARIOS IV: A 25 YEAR OLD GIRL COMES TO HOSPITAL WITH ABDOMINAL PAIN. WHAT WILL YOU DO?

SCENARIOS V: AN MRI SCAN WAS DONE FOR A MAN AND WAS DISCOVERED HE HAS A BRAIN TUMOUR. HE IS CURRENTLY WITH HIS WIFE IN WARD WHO IS LOOKING VERY ANXIOUS AND WAITING FOR SOMEONE TO TALK WITH. THERE IS NO CONSULTANT OR SENIORS AND YOU ARE LEFT WITH SENIOR NURSE. HOW WOULD YOU BREAK THE NEWS?

GYNAECOLOGICAL SCENARIOS:

SCENARIOS I: A LADY PRESENTS WITH POST MENSTRUAL BLEEDING IN THE CLINIC . HOW WILL YOU APPROACH THE PATIENT IN TERMS OF HISTORY AND EXAMINATION.

SCENARIOS II: YOU ARE IN THE WARD AND NURSE CALLS YOU ALERTING THAT ONE OF POST OPERATIVE PATIENT IS BECOMING HYPOTENSIVE ALL OF A SUDDEN. WHAT CAN BE THE CAUSES AND HO WILL YOU APPROACH IT.

SCENARIOS III: YOU HAVE A PATIENT WHO PRESENTED WITH POST PARTUM HAEMORRHAGE. HOW WILL YOU APPROACH?

PAEDIATRIC EMERGENCY:

SCENARIOS I: WHAT WILL YOU DO IN A SITUATION WHEN YOU SEE A 11 MONTHS OLD CHILD WITH HUMERUS FRACTURE AND YOU ARE SUSPECTING NAI IN CHILD. HOW WILL YOU APPROACH TO THE CASE?

COUNSELLING SCENARIOS

SCENARIO I: WHAT WILL YOU DO IF A PATIENT WITH SORE THROAT COMES IN A & E AND YOU KNOW IT’S NOT AN EMERGENCY

SCENARIO II: YOU DEVELOPED A MANAGEMENT PLAN FOR A PATIENT BUT ONE OF YOUR COLLEAGUES DISAGREE  WITH YOU, WHAT WILL YOU DO IN SUCH SITUATION?

SCENARIOS III: SAY YOU ARE ON YOUR OFF DAYS AND ONE OF YOUR COLLEAGUE ASKED YOU TO COVER FOR HER. HOW WILL YOU APPROACH TO THIS ? (They are basically checking if you are a team player or not?)

SCENARIOS IV: You saw your colleague in the ward trying to treat a patient in such a way that you feel it might cause harm to the patient. What will your next step be? What will you do if you see what he is doing will cause immediate harm to patient?

• Take 2 cups of Luke warm water and add 2 table spoon of baking soda  and 1 table spoon of apple cider vinegar ( or normal one if not available).
• Mix these until it forms a paste.
• Clean your feet and apply this mixture gently massaging over your heels.
• Apply this cream two times a day regularly to get soft heels sooner.

BAD HAIR DAY: GET NICE FRAGRANCE ON YOUR HAIR WITHOUT WASHING !!

If you have no time to wash it, do not worry !!

• Get your favorite perfume and spray directly on to your hair brush.
• Brush your hair thoroughly  with it and get amazing fragrance on your hair.

DULL FACE: GET FRESH AND MOIST FACE FOR ALL DAY:

• Buy or cut aloe plant leaf and get the gel portion carefully out from it.
• Add 3 table spoon of rose water to the ratio of 1 table spoon of extracted aloe gel.
• Blend it and prepare a creamy consistency.
• Apply it to your face and render your skin soft and supple.

SPARKLING WHITE TEETH:

• You need baking soda and also need to purchase fresh strawberries.
• Crush the berries in the blender.
• In a clean bowl, add 1 table spoon of berry paste  and add 1 table spoon of baking soda and stir gently for 1 minute.
• Apply this mixture on your tooth brush and brush your teeth using this as tooth paste regularly. You will get white teeth shining when you smile

SUNBURN: SOOTHE AND REMOVE REDNESS DUE TO BURN

• Take required amount (according to the extent of sun burn area) of baking soda in a bowl and add water.
• Stir continuously until it forms a paste and then add coconut oil to it and stir until it forms a creamy consistency.
• Apply all over the sun burn area and leave it for around 15 minutes and gently wash it off with clean water.
• Pad it dry without rubbing.
• Apply this mixture three times a day or more as required.

DARK ARMPITS: WHITEN IT WITH SIMPLE REMEDY

• Take one potato..
• Peel it well and grate it.
• Squeeze the grated potato to get juice and now mix the juice with 1 table spoon of baking soda.
• Clean the armpits and apply this mixture.
• Leave it for around 20-30 minutes and wash it well.
• Use this mixture regularly and sooner you will achieve white underarm area.

WHAT IS CLINICAL GOVERNANCE?
-> Clinical governance is defined as “a system through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”

WHAT ARE THE MAIN COMPONENT/ PILLARS OF CLINICAL GOVERNANCE?
-> The following are main components of clinical governance:
1) Risk Management
2) Clinical Audit
3) Education, Training and continuing professional development
4) Evidence based care and effectiveness
5) Patient and carers experience and involvement
6) Staffing and staff management
7) Information management

WHAT IS AN AUDIT?
-> Clinical audit is a process that has been defined as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”

WHAT ARE DIFFERENT TYPES OF AUDIT?

1. Standards-based audit – It involves defining standards, collecting data to measure current practice against those standards, and implementing any changes that is necessary. It also involves further audit to see if these changes made is successful or not.
2. Adverse occurrence screening and critical incident monitoring – This is often used  for cases which have caused concern or cases in which there was an unexpected outcome. The multidisciplinary team discusses individual anonymous cases to reflect upon the way the team functioned and to learn for the future. In the primary care setting, this is described as a ‘significant event audit’.
3. Surgical audit – It involves data collection of all surgical cases, followed by ongoing review and assessment of performance and outcomes.
4. Peer review – An assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine whether the best care was given. This mainly focuses ‘interesting’ or ‘unusual’ cases rather than problematic ones.
5. Patient surveys and focus groups – These are methods used to obtain patient’s views about the quality of care they have received.

DO YOU KNOW THE BASIC STEPS/ STAGES OF AUDIT?

-> The following are the basic steps of audit:

• Stage 1: Identify the problem or issue : involves the selection of a topic or issue to be audited
  
• Stage 2: Define criteria and standards : A criterion here is a measurable outcome of care, aspect of practice or capacity and a standard is the threshold of the expected compliance for each criterion.
• Stage 3: Data collection : data collected should be precise, and only essential information are to be collected.
• Stage 4: Compare performance with criteria and standards
• Stage 5: Implementing change
• Re-audit: Sustaining Improvements

HAVE YOU EVER BEEN A PART OF AN AUDIT?

-> Yes/ NO

HAVE YOU EVER SEEN ANYONE AT WORK CONDUCT AN AUDIT?

-> Yes/ No

WHAT IS RESEARCH?

->Clinical research is the study that determines the safety and effectiveness of new treatments, approaches and medications intended for human use for better health and care ,

It involves collection of evidence to establish that a new treatment or approaches are safe and effective.

HOW IS AUDIT DIFFERENT FROM RESEARCH?

[table id=50 /]

HAVE YOU EVER BEEN A PART OF AN RESEARCH?

-> Yes/ No

HAVE YOU EVER SEEN ANYONE AT WORK CONDUCT AN RESEARCH?

-> Yes/ No

WHAT IS EVIDENCE- BASED PRACTICE?

-> Evidence-Based Practice (EBP) is defined by  Dr. David Sackett. EBP as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

-> It is an integration of best research evidence with clinical expertise and patient values which means that when health professionals make a treatment decision with their patient, they base it on their clinical expertise, the preferences of the patient, and the best available evidence.

WHAT ARE THE BASICS STEPS IN EBP?

DO YOU HAVE AN IDEA ABOUT HIERARCHY OF MEDICAL EVIDENCE?

AETIOLOGY:
Mesothelioma is invariably associated with exposure to asbestos.
More than 80% of mesothelioma cases are caused by exposure to asbestos.
Asbestosis is a group of minerals made of microscopic fibres that used to be widely used in construction. These asbestosis can easily get into the lung tissue and stuck there damaging the lung and eventually leading to cancer.
Patient usually develops mesothelioma after more than 20 years of exposure.

Other risk factors includes:
genetics
infection with the simian virus 40.
The mesothelium consists of a single layer of flattened to cuboidal cells forming the epithelial lining of the serous cavities of the body including the peritoneal, pericardial and pleural cavities.
Deposition of asbestos fibers in the parenchyma of the lung may result in the penetration of the visceral pleura from where the fiber can then be carried to the pleural surface, thus leading to the development of malignant mesothelial plaques. The processes leading to the development of peritoneal mesothelioma remain unresolved, although it has been proposed that asbestos fibers from the lung are transported to the abdomen and associated organs via the lymphatic system. Additionally, asbestos fibers may be deposited in the gut after ingestion of sputum contaminated with asbestos fibers

TYPES OF MESOTHELIOMA

There are three main histological subtypes of malignant mesothelioma:

1. Epithelioid: Epithelioid mesothelioma is characterized by high levels of calretinin.
2. Sarcomatous: Sarcomatous mesothelioma does not express high levels of calretinin.
3. Biphasic.

Other morphological subtypes have been described:

1. Desmoplastic
2. Clear cell
3. Deciduoid
4. Adenomatoid
5. Glandular
6. Mucohyaline
7. Cartilaginous and osseous metaplasia
8. Lymphohistiocytic

PRESENTATION:

Mesothelioma does not have many symptoms initially but as they grow and starts pressing on a nerve or another body organ, then patient starts to develop symptoms.
The symptoms can vary according to the site:

Pleural mesothelioma
The following are different symptoms if mesothelioma affects pleura:

• chest pain
• breathlessness
• tiredness (fatigue)
• sweating
• raised temperatures
• a persistent cough
• loss of weight
• loss of appetite
• difficulty swallowing
• a hoarse or husky voice

Peritoneal mesothelioma
The patient of mesothelioma involving peritoneum may present with the following symptoms:

• pain in the tummy (abdomen)
• swelling in the abdomen
• feeling or being sick
• poor appetite
• losing weight when not dieting
• diarrhoea or constipation

End stage or advanced mesothelioma

As the disease progresses there may be multi system involvement which can present with the followings:

• Blood clots in the veins, which may cause thrombophlebitis
• Disseminated intravascular coagulation, a disorder causing severe bleeding in many body organs
• Jaundice, or yellowing of the eyes and skin
• Low blood sugar level
• Pleural effusion
• Pulmonary emboli, or blood clots in the arteries of the lungs
• Ascites: severe
• changes in the shape of their fingers and nails (called finger clubbing)

The most common sites for metastases includes the liver, adrenal gland, kidney, or other lung.

DIFFERENTIAL DIAGNOSIS

1. Metastatic adenocarcinoma
2. Pleural sarcoma
3. Synovial sarcoma
4. Thymoma
5. Metastatic clear cell renal cell carcinoma
6. Metastatic osteosarcoma

DIAGNOSIS:

If a person presents with the above symptoms and is particularly have a history of exposure to asbestos
in the past, a clinical suspicion about mesothelioma must be made.

A number of different tests may help to diagnose mesothelioma and show how far it has spread. These tests includes:

1. An X-ray of your chest or tummy
2. A computerised tomography (CT) scan – a number of X-ray images are taken to create a detailed image of the inside of the body
3. Confirmatory tests are either examining fluid produced by the cancer or by a tissue biopsy of the cancer. These includes:

• fluid drainage – if there’s a build-up of fluid around the lungs or in the tummy, a sample may be removed using a needle inserted through the skin so the fluid can be analysed.
• a thoracoscopy or laparoscopy – the inside of your chest or tummy is examined with a long, thin camera that’s inserted through a small cut (incision) under sedation or anaesthetic; a sample of tissue (biopsy) may be removed so it can be analysed

TREATMENT:
There are different treatment options available but the appropriate treatment is decided based on patient and disease factor. The following are different range of options:

1. chemotherapy – main treatment for mesothelioma and involves using medicine to help shrink the cancer
2. radiotherapy – this involves using high-energy radiation to kill cancer cells and it may be used to slow the cancer down and keep it under control
3. surgery – an operation to remove the cancerous area can be done if mesothelioma is detected at a very early stage, although it’s not clear whether surgery is helpful
4. Pleurodesis: It is a procedure which involves using substances such as talc to scar together the pleura, may be used to prevent more fluid from building up around the lungs

Newer options of treatments are:

• Immunotherapy
  -intrapleural inoculation of Bacillus Calmette-Guérin (BCG) to boost the immune response
  -in vitro lysis by LAK cells following activation by interleukin-2 (IL-2) but has major side effects (trial suspended)
• Heated intraoperative intraperitoneal chemotherapy
  This technique is used in conjunction with surgery. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent,
  heated to between 40 and 48 °C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained. High concentrations of selected drugs are then administered into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells

Unfortunately, mesothelioma is often diagnosed at an advanced stage, treatment is usually focused on controlling the symptoms and prolonging life for as long as possible. This is known as palliative or supportive care.

PROGNOSIS:
The prognosis for mesothelioma tends to be poor. This is because it is usually diagnosed in advanced stages when it becomes symptomatic. It is unfortunate that it can progress quite quickly once it reaches this stage.
Typical survival despite surgery is between 12 and 21 months depending on the stage of disease at diagnosis with about 7.5% of people surviving for 5 years
Overall:

• around half (50%) of people with mesothelioma will live at least a year after diagnosis
• around one in every 10 people (10%) with mesothelioma will live at least five years after diagnosis

1. If we require constant plasma concentration of the drug.
2. If an administration of a more concentrated solution would be harmful so we dilute and provide via infusion.

The following are things that needs to be cared for:

1. Add only one drug to any infusion container.
2. Make sure the components are compatible.
3. If available use read and prepared solution.
4. Avoid adding drugs to blood products, mannitol or sodium bicarbonate.
5. Before using the solution make sure you thoroughly shake and also check for any particulate matter.
6. Maintain asepsis.
7. Do not use the giving set for more than 24 hours.
8. Monitor patient throughout for any reaction and also examine an infusion solution for any cloudiness, crystalline or change in colour or contamination.
9. Labell the infusion container with the following information without interfering with information on manufacturer’s label:

• Name of patient
• Name and quantity of additives
• Date and time of addition

10. Do not throw away the used container immediately because it might be required for any investigation if
required.

1. EASY REACH TO YOUR GEARS:

Don’t put away your gear in some corner of your closet because when things are out of sight they are out of mind! Do you agree? To have a exercise on the brain, you must have your gears like sneakers and workout clothes in plain sight. Place your dumbbells, balance ball, a yoga mat, and a jump rope purposely throughout the house to receive visual cues. Trust me it is a wake-up call to your brain.

3. SPEND MORE ON WORK OUT GEARS:

Spend some money on sport bras, cute tops, shorts and tights. When you feel good, you are enthusiastic about everything in life. Having the right clothing makes you comfortable and also it reinforces your identity as a person who works out . And when exercising is an integral part of your identity, it isn’t optional anymore. It becomes an essence of your life. More to that, you’ve got to wear those adorable new workout clothes somewhere.

4. SHOW OFF YOUR EXERCISE RESULT:

Showing off specially in online social network might not be good in all cases but when it comes to exercise its for good. Post a workout update on Facebook and Instagram and trust me it offer an extra layer of social support. Use a social platform like Facebook as fitness tool to show your progress you get achieve by working out every day. Let your friends know that you usually exercise and bag all those compliments which keeps you motivated !

5. REWARD OR PUNISHMENT:

Any thing you do deserves a reward or punishment depending how you perform. If you stay committed to your goals and you achieve what you aimed to achieve in that week or month, buy yourself a healthy meal or new fitness gear. If otherwise, donate some bucks for a good cause or buy meal to your friends and lose some bucks as punishment. This might make you feel suddenly, working out is mandatory and you will stay committed to get good result. After all we all love rewards,right?

6. MAKE WORK OUT BUDDIES:

Environment and people around you influence you in some ways. So be friend with one who loves working out. This not only boost your social health by making you feel better when you spend time with gym buddies but also it is more likely that you are want to exercise because you have fun time with friend.

7. CREATE A COMPETITIVE FEEL:

Organize an exercise contest among your workout buddies. The contest can be for anything: most steps walked, most hours logged at the gym, highest percentage of body weight lost. To keep your circle engaged, constraint the competition to six-week rounds and have weekly check-ins, when people who score lower must put money in the jar. Competitions helps to convert a solitary pursuit into a fun group one. By trying to beat each other, while you compete you are actually helping each other along

Keep working out, keep fit and Stay healthy with lustwithlife.com

If you are smart enough to act on your diet plan you can build muscle, burn your fats and make a recovery ass best it can. Today we discuss on what should be taken or what kind of food is better for your pre and post workout schedule. We shall present you with pictures of 25 Pre  and Post Workout Snacks  !!!

Lets hit the road

Here is the list of 25 Pre Work out Snacks :

01. Stuffed Avacados

Photo: Closet Cooking

02. Tzatziki Greek Yogurt Chicken Salad

Photo: Hot and Toast

03. DIY Sports Drink

Photo : Forks and Folly

04. Almond Butter Banana and Coconut Energy Bowl

Photo: Whole Earth Foods

05. Caprese Avocado Toast With Cottage Cheese

Photo: FoodieCrush

06. Baked Broccoli Cheese and Pepper Omelet

07. Rice Cakes With Almond Butter

Photo : The Chic Brulee

08. Protein-Packed Cauliflower Hummus and Carrots

Photo : Lemons and Lyme

09. Turkey Avocado Wrap

Photo: California Avocado Commission

10. Strawberry Banana Oatmeal Greek Yogurt Waffles

Photo: Ambitious Kitchen

11. No-Bake Buckwheat Peanut Butter Energy Bars

Photo : Beauty Food Blocks

12. Leftover Meal Prep Chicken, Sweet Potato, and Green Beans

Photo : Pinterest

13. Peanut Butter and Banana Chia Seed Toast

Photo: Working Womens Food

14. Homemade Apricot and Almond Energy Bars

Photo: Rosanna Davison Nutrition

15. Hard-Boiled Egg Avo Toast

Photo: Seek Satiation

16. 5-Minute Protein Peanut Butter Energy Balls

Photo: Youtube

17. Fresh Strawberry Parfait With Cottage Cheese

Photo: Easy Home Meals Blog

18. Mocha Protein Shake

Photo: Daily Burn

19. Apple Peanut Butter Energy Bites

Photo : Joyful Healthy Eats

20. Banana Bread Greek Yogurt Parfait

Photo: Emeals

21. Blueberry Banana Protein Smoothie

Photo: The Foodie Physician

22. High-Protein Oatmeal

Photo: Fitness Magazine

23. Almond Coconut Mocha Smoothie 

The Gold Lining Girl

24. Whole Orange Smoothie

Photo: Living Loving Paleo

25. Perfect Yogurt Parfait

Photo: Foodal

POST EXERCISE SNACKS !!!

Now since you have gone through snacks that are very healthy enough to eat before doing your workout and exercise, You might be wondering what would be the best snacks right after the light or heavy exercise.

If you have not gone through Pre Workout Snacks then Here is the Link to it ==> Click Here 

Donot worry at all, we are gone through various research and found the best 25 snacks that are beneficial post workout.

Below are the pictorial presentations of snacks for post workout.

Here is the list of 25 Post Work out Snacks :

01 . Paleo Chicken Hash

Photo: Wicked Spatula

02. Sweet Potato and Avocado Egg Scramble

Photo: Nutrition in the Kich

03. Hummus and Pita Bread

Photo: The Owl’s Nest

04. Freezer-Friendly Breakfast Sandwiches

Photo: Betty Crocker

05. Banana Vanilla Orange Smoothie

Photo: Food Faith Fitness

06. Nut Butter Roll-Up

Photo: Betty Crocker

07. Hard-Boiled Eggs With Carrot Sticks and Nuts

Photo: Peanut Butter Fingers

08. Fresh Strawberries, Cottage Cheese, and Whole-Wheat Cereal Parfait

Photo: The Seamans Mom

09. Easy Spinach and Egg White Omelette

Photo: Yummy Health Easy

10. Healthy Homemade Chocolate Muscle Milk

Photo : Deserts With Benefits

11. Apple Cheese Crackers

Photo: 30 Pounds of Apple

12. Chocolate Fudgicles

Photo: The Healthy Kitchens

13. Chunky Monkey Rice Cake

Photo: Clean Eating Veggie Girl

14. Post-Workout Green Smoothie

Photo: Gimme Some Oven

15. Sweet Potato Protein Bars

16. Microwave Egg and Vegetable Breakfast Sandwich

Photo : Budget Bytes

17. Peanut Butter Chocolate Protein Shake

Photo: Skinny Ms

18. Avocado Tuna Salad

Photo: The Healthy Maven

19. Chicken Pasta With Butternut Squash, Caramelized Onions, and Tart Cherries

Photo: Love & Zest

20. Orange Mango Recovery Smoothie

Photo: Sally’s Baking Aadiction

21. Healthy Peanut and Caramel Protein Bar

Photo: Deserts With Benefits

22. Post-Workout Banana Bites

Photo: Brit + CO

23. Sweet Potato Pie Protein Shake

Photo: LivLangdon

24. PB&J Protein Pancakes

Photo: Spoon University

25. Trail Mix

Photo: Food Network