You NEED to go follow @SyattFitness right now for the best workout and nutrition page on Instagram. @SyattFitness @SyattFitness @SyattFitness @SyattFitness - ☕There has long been a myth in the fitness industry. A myth that has led many to believe there is something called the, "anabolic window." A window of time, if you will, in which you MUST eat your post workout meal or else your entire workout will have been a waste. - 🦄Some muggles say the window is 30 minutes, others 45 minutes, several squibs say 60 minutes, and I've heard a cauldron full of goblins say 90. - ☕Truth is...it doesn't matter. Most important of all is your total calorie and protein intake at the end of the day. As long as those are met, you're good. - 🦄Not to mention, if you eat a solid pre-workout meal, the amino acids and other nutrients will still be digesting by the time you finish working out. Making the "need" for an immediate post workout meal to meet your "anabolic window," irrelevant. - ☕I will say, if you workout early morning on an empty stomach, you would do well to get a post workout meal in focusing on carbs and protein. However, it's not an issue of urgency, and it doesn't matter if you wait 30min or 3hrs...just get something in because training off an overnight fast does increase the important of getting nutrients in. - Now....GO FOLLOW @SyattFitness RIGHT MEOW for the best workout and nutrition page on Instagram!!!! #fitness#nutrition#workout#coach#anabolic#calories#caloricdeficit
Liver transplantation for an extensive polycystic liver disease! A 51-year-old woman with polycystic liver and kidney disease had undergone renal transplantation 21 years before presentation. She had no evidence of cerebrovascular malformations. Both her father and aunt also had polycystic kidney disease. After the renal transplantation, her liver had become progressively diseased and enlarged through cystic changes. Early satiety, malnutrition, and abdominal pain necessitated a liver transplantation. A 9.1-kg liver (white arrow) was removed and replaced with a whole graft that was one tenth the weight of the diseased liver (black arrowhead). A large cyst at the dome of the native liver had to be decompressed (white arrowhead) to allow for access to the recipient's suprahepatic vena cava. She made an excellent recovery and had normal kidney and liver function at 4 years of follow-up.
Hand stuck in a meat grinder pulled back almost perfectly!!! Hand injury caused by meat grinders are resulting in varying degrees of deformities. The patient arrived in the emergency room with the injured hand still firmly wedged in the meat grinder. The patient was taken to the operating room, under general anesthesia, the hand was extricated by turning the grinder in reversed direction with an adjustable wrench, while gently pulling on the forearm. After removal of the grinder, there were multiple level crush injuries on the metacarpophalangeal level, the digit is damaged and unsuitable for replantation. Debridement and amputation were performed on the level of metacarpo-phalangeal joints index, middle, ring and little fingers. After performing excision of non-viable tissue, sutures were applied. He was treated with antibiotic, irrigation of the wound, analgesic, and surgical repair.
A magnificent view of Circle of Willis with the optic chiasm at the center! The Circle of Willis is an arterial polygon formed as the internal carotid and vertebral systems anastomose around the optic chiasm and infundibulum of the pituitary stalk in the suprasellar cistern. This communicating pathway allows equalization of blood-flow between the two sides of the brain, and permits anastomotic circulation, should a part of the circulation be occluded. These vessels branch from the internal carotid arteries (seen ligated with black sutures) on each side, which branches laterally into the middle cerebral artery that gives branches toward the front and back of the brain, into the anterior and posterior cerebral arteries. These paired arteries are interconnected and communicating, thus giving us the Circle of Willis. The middle cerebral artery is often invoked in the case of stroke, aneurysms, and rupture which subsequently leads to intracranial bleeding (subarachnoid hemorrhage) and is an emergency situation. The optic chiasm or chiasma is the midline structure where the nasal (medial) fibres of the optic nerves decussate to continue posteriorly as the optic tracts. It is completely encircled by the circle of Willis.
This heart is just beating peacefully on its own outside the body, prior to a transplantation surgery! That's a classic representation of cardiac automaticity, which is the property of a specialized cardiac cells called pacemakers to generate spontaneous electrical impulse. The heart has its own pacemaker independent of the brain. As long as it has oxygen, it continues to beat. The heart could actually be removed from the body, placed in saline solution, given oxygen, and still continue to beat. This is why although the brain is dead, the heart continues to beat. Cells capable of generating an impulse are in the sinus node and AV node, which fire at regular intervals and leads to the beat. So as you might guess, the cardiac action potential and regulatory mechanisms lie within the heart itself and depends on these intrinsic nodes rather than the CNS.
What's shown here is Vasa Previa, which was discovered accidentally during a cesarean section. It's a rare condition in which fetal blood vessels within the placenta or the umbilical cord are trapped between the fetus and the opening to the birth canal (internal cervical os), this situation carries a high risk the fetus may die from hemorrhage due to a blood vessel tearing at the time the fetal membranes rupture or during amniotomy (when the amniotic sac is deliberately or artificially ruptured). It presents as with painless vaginal bleeding on membrane rupture in addition to fetal bradycardia or a sinusoidal heart rate tracing. Unfortunately, due to its rarity, no one knows for sure what causes vasa previa. It occurs with a low-lying placenta (due to scarring of the uterus by a previous miscarriage), an unusually formed placenta (e.g. bilobed placenta), an in-vitro fertilization pregnancy, and multiple pregnancies (twins, triplets, etc). C-section in indicated when a diagnosis of vasa previa is established. The C-section is typically made prior to rupture of the membranes (i.e. before labor starts) and can save the baby's life. It should be done early enough to avoid an emergency, but late enough to avoid problems associated with prematurity.
Deep injury from a piece of glass! A boy age 16 football player with no medical history that got a deep foot wound from a piece of sharp glass which lacerated his foot vessels. He loss a considerable amount a of blood and rushed to the ER and immediately got stiches in the operating room performed by a podiatric surgeon. Photo by @dr_raisa.c
Incision and drainage of a submandibular abscess has never been more satisfying to watch!! This is the management of an extensive right submandibular abscess under general anesthesia. Submandibular abscess develops beneath the tissues in the floor of the mouth. Pus collects under the tongue, pushing it upwards and toward the back of the throat, which can cause breathing and swallowing problems. An abscess formation usually happens secondary to dental or odontogenic infection. Inflammation caused by dental caries leads to edema and hypoxia of the dental pulp resulting in pulp necrosis. This environment allows for easy bacterial invasion of the bone tissue. Spread of infection within the bone occurs in all directions until a cortical plate is encountered. If infection perforates the bone above the mylohyoid, fascial space involvement occurs. Spread of infection through fascial planes into deep neck spaces, such as the submandibular space, can result in local abscess formation. Extension of odontogenic infection into the deep neck spaces and massive abscess formation is an unusual, but potentially life threatening. Examination findings included moderate to severe trismus and marked right submandibular swelling. Treatment involves maintenance of airway patency, surgical incision and drainage of the abscess, and antibiotics to cover both oral anaerobes and aerobes (eg, clindamycin, ampicillin/sulbactam, high-dose penicillin).
This is a case of severe gout!!! Numerous large tophi with associated joint deformity in the hand of this young patient. Gout is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot, and swollen joint, where crystals in the form of monosodium urate form inside and around joints (called tophi). The most known hallmark of the disease is hyperuricemia, but by itself it does not indicate gout. Hyperuricemia means an increased production of uric acid due either a defect or hyperactivity in different enzymes and increased cell turnover (or cell breakdown) in patients that use chemotherapy for cancer, have chronic hemolysis, or have hematologic malignancies. Another, even more common reason for gout is decreased excretion of uric acid by the kidneys due to renal disease or NSAID or diuretics usage. Inflammation typically develops when uric acid collect in the synovial fluid as the extracellular fluid becomes saturated with the acid which is then phagocytized by polymorphonuclear cells. This process develops inflammation. Pain typically comes on rapidly in less than 12 hours. The joint at the base of the big toe is affected in about half of cases. It may also result in tophi, kidney stones, or urate nephropathy. Severe gout is characterised by frequent polyarticular flares, numerous tophi, joint damage, and musculoskeletal disability. This is a preventable condition and in many cases, represents a disease that has been insufficiently managed for years. Standard management recommendations may be insufficient for patients with severe gout; these patients frequently require intensive individualised pharmacological management with combinations of urate-lowering therapy and anti-inflammatory agents.
Nuchal cord with multiple loops! This is a case of a post dated pregnancy in a primigravida. She was taken up for immediate c-section due to abnormal cardiotocography, which showed fetal heart rate tracing abnormalities, specifically abrupt decreases in the heart rate below the baseline of varying depth and duration (variable decelerations). There were four loops of cord seen wrung around the baby’s neck. The baby was cyanotic but survived after the cord has been unwrapped immediately after delivery. She cried after resuscitation and liquor was meconium stained. Both the mother and baby were discharged uneventfully. A loop of umbilical cord around the fetal neck (nuchal cord) is a common finding at delivery and is dangerous when it is wrapped very tightly and compresses the neck 360 degrees. It is caused by movement of the fetus through a loop of cord. In most cases, it is not associated with a significant increase in the rate of any clinically important adverse fetal/neonatal outcome. In others, tight nuchal cords have been associated with adverse outcomes, including lowered blood flow, hypoxia (low oxygen levels), fetal asphyxia and demise. Once delivered, the cord can be unwrapped and left intact to allow the trapped blood and the placental transfusion to return to the baby. Resuscitation with ventilation may be needed while this is taking place over the next 3 to 5 minutes.
The world's biggest splinter injury by a massive tree log! Paraglider crashes into a woodland and is left with a tree branch sticking out of his shoulder! A paraglider was skewered by a giant splinter after crash landing in a forest. These extraordinary pictures show how a tree branch impaled the 36-year-old from Belarus. He was flying when a strap snapped and he span out of control, plummeting into a forest. A sharp log spiked his shoulder as he crashed. Rescuers cut him free from the wreckage of his powered paraglider and took him to hospital, with the giant log still embedded in his shoulder. He posed for pictures as he waited to have the branch removed by emergency ward medics. Doctors later freed him from the giant splinter. The paratrike pilot told local media he had crashed into some pine trees and at first he didn't realise he had been impaled. 'I'm thinking: "I fell so softly, all is okay. I'll stand up and go" then something holds me back,' he said. 'I looked and it was a giant log there. I tore my shirt and there was a branch in my arm, thick as a watermelon.' Astonishingly, he retained his sense of humor during the horrific accident, joking that he was like American cartoon superhero Groot. 'Many people came. I told them: "Take out this splinter". And they say: "No, are you crazy? If we take it away, you'll bleed to death." And I was like: "I am Groot!"' he said. For now, he is recovering at hospital surrounded by friends and family, but insistes he’ll be back and flying in no time!
Our artistic nervous system isolated by plastication into major systems and individual branches!! This master control system is what keeps sanity and insanity apart. It is complex with many interactive units that are changing constantly to reflect human behavior and activity. Our sophisticated nervous system is the one that allows us to perceive, comprehend, and respond to the world around us. Responsible for the control of the body and communication among its parts. An incredible pattern-matching machine, with billions of neurons, each connecting a thousand other neurons. Photo by Body worlds exhibition
These blood blister formed due to extreme heat while she was playing basketball for an hour on asphalt on a 100 degree weather day!!! Swipe left to see a video of the blood being evacuated from it! A blood blister is marked by a raised section of skin filled with blood. They are very similar to blisters caused from friction that fill with a clear fluid. In the case of blood blisters, pressure broke blood vessels and mixed blood with the clear fluid. This combination fills the pocket. As the feet are filled with many nerves and blood vessels and are under pressure most of the waking day, blisters on the feet can be especially painful. Depending on where a blister is on the foot, it can be disabling and hard to treat. Most blisters are harmless and resolve spontaneously, but if they get big, manual drainage or evacuation is the favorable method of treatment.
This is what a massive pulmonary embolism looks like outside of the body!! Pulmonary thromboembolism is an occlusion of the pulmonary vasculature by a blood clot and is not a disease in and of itself. Rather, it is a complication of underlying venous thrombosis, usually from a thrombi that originate in the deep venous system of the lower extremities. After the thrombi dislodges, it travels through the vena cava and into the right side of the heart to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise. A drop vein thrombi and subsequent thromboembolic disease is suspected in patients that have long plane rides or are bed-bound following a major surgery or can infrequently occur with upper extremity, subclavian, and internal jugular vein thrombosis, which occurs in patients when intravenous catheters are placed in the associated veins. Also, in the pregnant patient, thrombosis may occur initially in the pelvic veins rather than follow the usual course of starting in the distal and then extending to the proximal veins. present with sudden onset of dyspnea, pleuritic chest pain, hypotension, tachycardia, tachypnea, right heart failure, and syncope. In patients with massive acute embolism, either catheter embolectomy or surgical embolectomy may be considered if they have clinical evidence of an adverse prognosis (ie, new hemodynamic instability, worsening respiratory failure, severe right ventricular dysfunction, or major myocardial necrosis).
A true survivor against all odds! Little Conner James is less than a month old in these photos. He had a rough beginning, being taken away from his mom due to not being able to breath right away and turning blue (cyanotic). He was flown to a better hospital for more care to figure out what’s wrong. There they thought it would only be a week stay turned into much longer. He was diagnosed with tetralogy of Fallot and other anomalies including Choanal atresia. Tetralogy of Fallot is a congenital defect of the heart characterized by 4 combined anomalies - right ventricular (RV) outflow tract obstruction, RV hypertrophy, overriding aorta, and ventricular septal defect. The condition presents with cyanosis and acute hypoxemia due to diversion of blood from the right ventricle into the aorta instead of the pulmonary artery, practically skipping oxygenation. Choanal atresia is a congenital nasal malformation that is caused by failure of the posterior nasal passage to canalize completely, leaving either a bony or membranous obstruction. When these 2 anomalies happen in conjunction, CHARGE syndrome is suspected, with possible more anomalies involved. Due to the lack of doctors that could help him at the first hospital he got flown to Mayo Clinic. The stay was anticipated to be months long, his condition wasn’t getting any better and was even getting worse. He underwent surgical repair to his obstructed nasal passage and was starting to breath and do better. But this better wasn’t enough to go home. They hesitated doing his heart surgery due to how small he was. On may 9th he got his heart surgery lasting only 11 hours. He was recovering nicely and had difficulty feeding. 9 days later he had to do another surgery and get a G-tube put in. He was diagnosed with possible CHARGE syndrome and that was something this family has never heard of. But after a long month and a half of recovery, it was finally over. He left the hospital only gaining one pound from his birth
Rectal foreign body!! Here we have a patient who may or may not be a chemist? Any guesses on what this rectally-inserted object might be!? To us, it looks like a chemistry lab flask or a vase. Anorectal foreign bodies are usually inserted transanally for sexual or medicinal purposes. Rectal foreign bodies may also be observed with body packing or stuffing or after previous oral ingestion of the object. Patients have usually made multiple attempts to remove the object before presentation in the emergency department and may create unusual stories to explain how the object became lodged in the rectum. Removal of such objects can be challenging depending on the shape, material and orientation within the rectum. If possible, they should be removed via the anus, although in some cases a laparotomy may be required. Photo by @drcellini
A characteristic gross appearance of an extensive ulcerative colitis case, many pseudo-polyps to count!! Hundreds of pseudopolyps can be seen clearly as raised red islands of inflamed mucosa. Ulcerative colitis is a chronic inflammatory and ulcerative disease that arises from the bowel mucosa and is characterized by bloody diarrhea, pain, and fever. Unlike Crohn’s disease which is characteristically a transmural disease, ulcerative colitis is usually limited to the mucosa and submucosa. It typically remains localized to the rectum or extends upwards to involve other parts, sometimes the entire colon, as one continuous inflammatory lesion. The inflammation affects the mucosa and submucosa, and there is a sharp border between normal and affected tissue, as seen above. The ileocecal valve is seen at the lower left and just above this valve in the cecum is the beginning of the mucosal inflammation with erythema and granularity. As the disease progresses, the mucosal erosions coalesce to linear ulcers that undermine remaining mucosa. Diagnosis is made by sigmoidoscopy with biopsy. Usually, the disease is chronic with repeated exacerbations and remissions and increased risk of colon cancer proportional to the duration of the disease and amount of colon affected. Total colectomy is curative of both the intestinal symptoms and of the potential risk of colorectal carcinoma.
Stepped into boiling water!! This is a case of third degree burns on both feet after dipping them in boiling water. The patient is suffering from diabetic peripheral neuropathy and did not feel the burn until it was too late. Photo by @reconst.surg.col
Bang bang to the heart! This video shows a cardiac gunshot wound with blood spurting out of the ventricle with each contraction of the heart! Most gunshot wounds to the heart are rapidly lethal because of cardiac tamponade or exsanguinations. The immediate clinical manifestations or cause of death from a retained missile are usually related to cardiac bleeding with or without tamponade. Cardiac results of gunshot injuries are prone to be complex; they create septal shunts, disrupt valves or papillary muscle apparatus, cause pericardial insult, myocardial rupture or might lacerate coronary arteries, particularly the left anterior descending artery. Such injuries can cause ventricular septal defect or cardiac tamponade depending upon the distance, direction and velocity of the bullet. The intermediate manifestations of cardiac injury include myocardial infarction with cardiogenic shock, and bullet embolus to a peripheral artery. Late complications include missile erosion through the myocardium, endocarditis, pseudoaneurysm, ventricular septal defect, and valvular damage. Stable patients can be subjected to investigations like computed tomography to avoid unnecessary intervention, but unstable patients should be rushed to the operating room. An urgent surgical intervention and removal of bullet from the heart using cardiopulmonary bypass (CBP) might be necessary to avoid possible complications. The use of CPB for these injuries allows for extensive rotation and retraction of the heart in a bloodless and motionless operative field.
Necrotising fasciitis by a “flesh-eating bacteria”!! This is the foot of a 57-year-old male with a past medical history of type 2 diabetes mellitus, hypertension, alcohol abuse, significant tobacco abuse, and depression. He said that he has been living in the woods and homeless and staying at friends places when he could. His foot started hurting about 4 months ago but he just thought it was his diabetes. He doesn’t have any extra clothes so he just keeps his socks on and really hasn’t looked at his feet in 4 months according to him. He also was rendered immobile and unable to walk on it secondary to pain. At presentation he was septic with necrotizing fasciitis. His foot literally smelled so bad they had to put a fan outside his room to blow the smell back in his room with air fresheners all over. Necrotizing fasciitis is a life-threatening, rapidly progressive subcutaneous soft-tissue infection that may extend to the deep fascia, but is superficial to muscles, and is accompanied by secondary necrosis of subcutaneous tissue. It is referred to as the "flesh-eating infection/bacteria”, commonly caused by anaerobic bacteria or group A streptococci (pyogenes), but it can be a polymicrobial infection with both aerobic and anaerobic organisms too. The infection typically enters the body through a break in the skin such as a cut or burn. Clinical manifestations include sepsis and fever with an area of erythema. When progressed, the tissue begins to turn necrotic and into gangrene, which appears gray/black. It spreads quickly and aggressively from the primary infected area and beyond and can result in amputation, shock, and death if not treated by a combination of surgical exploration, debridement (removing necrotic tissue), and appropriate antibiotic therapy. Credit and further antibiotic discussion found at @pance_panre_usmle_review