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He has also emphasized on preventive aspects of the illness and side effects of the commonly used drugs and in particular care to be taken for drugs used for prolonged periods generic ciplox 500 mg online. This book should be useful not only for the patient and the caretakers but also for the medical students and the physicians and those involved in the management of neurological illnesses generic 500 mg ciplox fast delivery. Singhal Professor & Head Department of Neurology Bombay Hospital Institute of Medical Sciences Mumbai buy generic ciplox 500mg on-line. It comprises of 100 billion neurons or nerve cells linked in networks that give rise to an amazing array of cognitive functions such as intelligence ciplox 500mg with mastercard, creativity, emotion, consciousness and memory. Over the past few decades, intense research in clinical and basic neuroscience has enabled us to gradually unravel the biological foundations of complex mental functions and diseases that impair these functions. In my dealings with patients and their relatives for more than a decade I have seen first-hand how anxious they are to gather information on diseases that afflict the brain. Much of my personal experience in this matter comes from my years of practising medicine in my clinic “Neurology Centre” in Ahmedabad, Gujarat as well as in the renowned V S General Hospital, Dr. Since such information was not available in Gujarati (a local language of Gujarat state) or in other languages in a comprehensive manner in one place, I got the inspiration that I should write something about the diseases of the brain and nervous system. In September 1999, a few lectures of mine on various diseases of the brain were arranged on Akashvani - Radio during the morning programme ‘Pahelu Sukh’ - and on Doordarshan - Television `Swasthaya Sudha’. Thus, I was inspired to write about major brain disorders and this project took shape in the form of a “Health Education Guide”. I would like to mention here that in the month of August 2000, the first edition of this book in Gujarati language was released by his Excellency the Governor of Gujarat, Shri Sundersingh Bhandari in the presence of dignitaries of Ahmedabad city, including Hon. There was a tremendous appreciation from all quarters including patients and their relatives, physicians, family doctors and well-wishers. Singhal (Bombay Hospital), with whom I had an opportunity to learn neurology, advised me to make an English version of the book so that people from other states also can be benefited and thus this book is before you. Singhal who has gone through this English version and has blessed me by writing a foreword for this book. It can be understood that the main aim of this book being imparting knowledge about healthcare and awareness regarding diseases to the general public, in depth information according to the medical science has not been given. An attempt has been made to include the latest researches and drugs in this book, but it should be kept in mind that new researches are going on continuously and new discoveries are being made everyday. Here, I would like to clarify that medicines are to be taken only under the advice of the doctor and one should not try to self medicate. The contribution of my wife Chetna Shah has also been tremendous and it was only due to her excellent time management, that I could write about all these diseases properly, in spite of constraints of time. My friend Shri Upendra Divyeshvar has taken personal interest and has read each and every manuscript right from the beginning to the publishing of the book. Oza who was kind enough to give constructive suggestions about the Gujarati version of this book and to write an introduction for that book. After reading this book if at least a few readers will awaken to the concept of prevention of diseases and if timely diagnosis is able to save even a few lives, I shall feel happy. Sudhir V Shah is reflecting in this book, a simple and lucid presentation of his experiential hindsight, for the cause of Health Education. The human race is superior and special to the other living beings due to the unique anatomy and physiology of human nervous system. Especially the cortex of the brain (the grey layer of the brain surface) is highly evolved and complex. Other organs of the human beings are similar or even weaker as compared to those of the other animals, but the humanrace proves superior because of the exceptional mental power & ability, as well as logic, memory and vocabulary all due to the cortex of the brain. According to an estimate, an average person uses about 5 to 10 percent of his brain capacity, but a genius uses his brain up to 15 percent. Therefore it can be said that any person can become a genius by learning how to use his brain more and putting it frequently to task. Though our brain weighs only 1 to 2 percent of total body weight, it uses up approximately 25 percent of the oxygen intake of the body and 70 percent of the total glucose available to the body. The lower group of chordate animals do not have a developed organ like brain and therefore their functions are autonomous. The brain rests securely inside the skull and is covered by three membranes to protect against friction. It extends right from the centre of the brain to the spinal cord, as well as in the outer membranes of the brain and spinal cord. F range from assisting the metabolism of the brain to the prevention of friction: As the cells of the brain perform complex functions, they need extra nourishment and oxygen. If the supply of blood and oxygen to the cortex stops completely for more than five minutes, the cortex stops functioning permanently, resulting in death. Cerebellum is located in the posterior region of the skull and is divided into two - left and right - parts. The brain stem, which joins the two sides of the brain, consists of mid-brain, pons and medulla oblongata, which truncate into the spinal cord. The frontal lobe is basically responsible for the movements of the limbs, the personality and the behavior of an individual. The temporal lobe and the limbic system are associated with memory as well as basic instincts, and according to some it can be the seat of special powers like the sixth sense, etc. The left side of the brain of a right handed person (who uses his right hand for writing, eating, throwing etc. However, others believe that the mana may exist either in the temporal lobe, in the limbic circuit, or in the pineal gland of the brain. It is actually a complex biochemical and electromagnetic process and it is the limitation of our science and brain that we do not have the proper understanding of this subject. Similarly, Hypothalamus is an important centre and is the final control point of the sympathetic and the parasympathetic nervous system. It is associated with functions of our involuntary muscles, as well as physical processes like stress. This type of nervous system autonomously controls the extremely important functions of the heart, intestines, eyeballs, blood pressure, respiration etc. We have thus studied the anatomy of the brain, but brain has some amazingly unique features also, which make man superior to all living beings. There is a kind of electrical impulse emanating from the cells of the brain, which is rhythmic and constant. This electrical impulse travels chemically across one nerve cell to the other through neurotransmitters and receptors which form an amazing network and can transmit information from one part to another in a 1000th fraction of a second. Transmission of messages from one person’s minds to the other, as in telepathy can be called an electronic process. Moreover, the human brain is endowed with developed features like thinking, intelligence, the power to differentiate between good and bad, memory, creativity, etc. Though anatomically the heart is situated in the chest, the way poets have described the emotional heart it appears that in fact they are referring to the mind.

Prolactin hormone: it acts on the mammary gland and helps in the formation and flow of milk during lactation buy cheap ciplox 500 mg online. Luteinising hormone: it is required for the growth of follicle in the ovary and stimulates ovula­ tion order ciplox 500 mg. Oxytocin acts on the smooth muscles especially that of the uterus and produces powerful contractions of the uterus and helps in parturition ciplox 500mg with mastercard. The sex glands: The sex glands including the ovaries of the female and the testis of the male are important endo­ crine structures generic 500mg ciplox with mastercard. The male sex gland secretes hormone called testosterone and is responsible for secondary sex characteristics. The female sex gland secretes a hormone called estrogen and it stimulates the develop­ ment and functioning of the female reproductive organs. The sensory impressions which are supplied by the nerves carried to the brain where sensa­ tions are interpreted for e. We apparently taste with the nerve endings in the tongue, hear with those in the ear and so on, but in reality it is the brain that appreciate these sensations. Numerous structures such as glands, sense organs and appendages such as hair nails are embedded in the skin. The Stratum Lucidum: This is a thin more or less transparent layer, in which the cells are indistinct. The Stratum Granulosum: It consists of three to five layers of flattened cells, containing dark granules of irregular shape. The innermost cell of this layer contains pigment granules called melanin which give the skin its colour. Dermis: Situated below the epidermis is the thickest dermis formed mostly of connective tissue which is richly supplied with blood vessels and nerves. The boundary line between the dermis and epidermis is neither smooth nor straight; it is rather zig zag because of the conical projection of the dermis into the epidermis. These muscle fibre, called errectores pilorum are attached to the hair follicle and when these muscles contract, the hairs become vertical and ‘goose­skin’ is brought about. Each sweat gland consists of a long tube, which at one end opens on to the surface through the sweats pore. In the coiled portion of the sweat gland there and glandular cells, which separate water and small quantities of metabolic waste products from the blood that circulates through the capillary network associated with the gland. The oily secretions (sebum) of the glands make the hair, water proof and protect the skin from drying effects of the atmosphere due to high temperatures and low humidity. Sensory Nerve Endings: Numerous sensory nerves specialized to pick up stimuli that cause; sensations of touch, pressure, pain, heat and cold are scattered in the skin. Stimuli picked up by the sense organs are transmitted to the brain when they are interpreted to give the correct information. Appendages: Hair and nails are appendages of the skin formed as a result of the out growth or thickening of the epidermis. Functions of the skin: The skin is not merely an outer covering for the body but it serves a variety of functions. Tongue consist of 3 parts Root ­ Attached with the hyoid bone Body ­ surfaces Apex ­ Touches the posterior surface of lower surfaces incisor teeth Surfaces: Body containing dorsal surface and inferior surface. Upper surface has a velvette ap­ pearance covered by three varieties of papillae 1) Circumvallate papillae – these papillae are arranged in a “V” shape at the back of the tongue and taste buds are found numerous in the walls of the circumvallate and fungiform papillae. The filaments of the nerve arise in the upper part of the nasal cavity is called olfactory portion of the nose and lined with highly specialized cells. The olfactory nerves and connections The olfactory bulb is an outlying portion of the brain is the slightly enlarged portion of the olfactory nerve tract which lies above the cribriform plate of the ethmoid bone form the olfactory bulb sensation is passed along the olfactory tract by several relaying stations until it reaches the final receiving area in the olfactory centre which is in the temporal lobe of the cerebral hemisphere where the sensation is interpreted. The nerve supplying this special sense is the eighth cranial or auditory nerve The ear has the following parts 1) External ear 2) Middle ear or tympanic cavity 3) Internal ear. External ear consist of 1) Pinna or auricle ­ collects the sound waves 2) External auditory meatus ­ conveys the vibrations of sound Middle ear consist of 1) Ear drum ­ communicates to the mastoid process 2) Eustachian tube ­ maintaining the pressure of air in the tympanic cavity 3) Auditory ossicles­ are 3 small bones. They are 58 Malleus Incus This chain of bone serves to transmit the vibrations of sound from the drum to the internal ear Stapes Mastoid process is the part of the temporal bone lying behind the ear an air space communicates in the middle ear Internal ear Consists of cavities called the bony labyrinth and membranous labyrinth. The fluid within the membranous labyrinth is endolymph and the fluid in the bony labyrinth is the perilymp. The fenestra vestbuli and the fenestra cochlea are windows directed towards the middle ear and allow the vibrations transmitted to peri and endo lymph to acti­ vate the nerve endings of the auditory nerve Hearing: Sound waves pass along the external auditory canal cause the tympanic membrane to vibrate. By movement of these bones, magnify the vibrations, then communicated to the vestibular fenestra to the perilymph and to the endolymph in the canal of the cochlea. This stimuli reaches the nerve endings in the organ of corti, conveyed to the brain by auditory nerve. The sensation of hearing is interpreted by the brain as a pleasant or unpleasant sound (noise or music). Balance: The change in the position of the fluid in the semicircular canals helps in order to maintain balance of the body and this canal distributed by the vestibular nerve which conveys to the brain the 59 impulse generated there by alterations in the position of the fluid in these canals which have to do with the knowledge of the sense of the position of the head in relation to the body Organs of special sense ­ The eye and sight: Eye ball is spherical in shape situated in the anterior 2/3 of the orbital cavity and it is embedded in the fat of the cavity. The optic or second cranial nerve is the sensory nerve of the sight The eye ball composed of 3 layers 1) Outer ­ Fibrous and supporting layer 2) Middle ­ Vascular 3) Inner ­ nervous layer (Retina) 1 Fig 2. It protects the delicate structure of the eye and helps to maintain the shape of the eyeball Cornea: ­ Is a transparent front portion, avascular and continuous with the sclera. It consist of several layers and it helps to focus images on to the retina Vascular layer: ­ Choroid: ­ It is highly vascular and pigmented layer, supplies nutrition to the outer layer of retina, absorbs the light and prevents reflection of light Ciliiary body: ­ It lies between the choroid and the iris and has circular muscle fibers and radiat­ ing fibers helps in maintaining the accommodation of the eye Iris: ­ It is a circular, contractile and pigmented diaphragm. It is the color curtain in front of the lens and it contains 2 sets of involuntary muscle fibers, one set contract the size of the pupil & other set dilates the pupil Pupil: ­ It is the dark central spot which is an opening in the iris through which light reaches the retina Nervous layer (retina): ­ Composed of number of layers of fibers, nerve cells, rods and cones. At the middle side of the macula there is a circular pale area which is insensitive to light called blind spot 60 Sight When an image is perceived the rays of light from the object seen, pass through the cornea, aqueous humor, lens and vitreous body to stimulate the nerve endings in the retina. The stimuli received by the retina pass along the optic tracts to the visual areas of the brain to be interpreted. Male and female sexual reproductive organs: The sex organs in the male and female can be divided as 1. Primary sex organs in male and female: There are a pair of testes producing spermatozoa (male gametes) while in females are a pair of ovaries producing ovum (female gamete). These primary sex organs in addition to producing male and female gametes secrete male and female hormones as well. Many septate from this layer divide the testes into pyramidal lobules in which lie seminiferous tubules and interstitial cells. The interstitial cells called Ludwig cells lie between the tubules and secrete the testosterone (male sex hormone). The prostrate gland lies at the base of the urinary bladder and is covered with fibrous capsule which by a number of septa divides into many follicles. The prostrate adds another fluid to the semen, which makes the sperms more active in swimming to reach the ovum.

Streptomycin penetrates into cells poorly generic ciplox 500 mg without a prescription, and thus it is active mainly against extracellular tubercle bacilli discount ciplox 500 mg free shipping. Streptomycin crosses the blood- brain barrier and achieves therapeutic concentrations with inflamed meninges buy ciplox 500mg on line. It is employed principally in individuals with severe order ciplox 500 mg, possibly life-threatening forms of tuberculosis (meningitis and disseminated disease), and in treatment of infections resistant to other drugs. Combination Chemotherapy of Tuberculosis The duration of therapy for a patient with tuberculosis depends upon the severity of the disease, the organ affected and the combination of agents. There are two phases in the treatment of tuberculosis; the intensive phase, which lasts 8 weeks, makes the patients noninfectious. The continuation phase, which lasts 6 months or more and at least two drugs should be taken. During the continuation phase drugs have to be collected every month and self-administered by the patient. These patients are: - Relapses; Treatment failures; Returns after default who are pulmonary tuberculosis positive. The drugs should be taken under direct observation of the health worker throughout the duration of Retreatment including the continuation phase. It consists of 8 weeks of treatment with Rifampicin, Isoniazid and Pyrazinamide during the intensive phase followed by 6 months of Ethambutol and Isoniazid. Second-line antitubercular drugs include ethionamide, para-aminosalicylic acid, capreomycin, cycloserine, amikacin, ciprofloxacin, etc. These agents are considered during failure of clinical response to first-line drugs under supervision of their adverse effects. Drugs Active against Atypical Mycobacteria Disease caused by "atypical" mycobacteria is often less severe than tuberculosis and not communicable from person to person. Azithromycin or clarithromycin, plus ethambutol are effective and well-tolerated regimen for treatment of disseminated disease. Because of increasing reports of dapsone resistance, treatment of leprosy with combinations of the drugs is recommended. Therefore, the combination of dapsone, rifampin, and clofazimine is recommended for initial therapy. Sulfones are well absorbed from the gut and widely distributed throughout body fluids and tissues. Because of the probable risk of emergence of rifampin-resistant M leprae, the drug is given in combination with dapsone or another antileprosy drug. Clofazimine The absorption of clofazimine from the gut is variable, and a major portion of the drug is excreted in feces. Clofazimine is given for sulfone-resistant leprosy or when patients are intolerant to sulfone. The most prominent untoward effect is skin discoloration ranging from red-brown to nearly black. The antifungal drugs fall into two groups: antifungal antibiotics and synthetic antifungals. Antifungal antibiotics Amphotericin B Amphotericin B is poorly absorbed from the gastrointestinal tract. Oral amphotericin B is thus effective only on fungi within the lumen of the tract. The pore allows the leakage of intracellular ions and macromolecules, eventually leading to cell death. Adverse Effects: The toxicity of amphotericin B which may occur immediately or delayed include fever, chills, muscle spasms, vomiting, headache, hypotension (related to infusion), renal damage associated with decreased renal perfusion (a reversible) and renal tubular injury (irreversible). It has activity against yeasts including; Candida albicans and Cryptococcus neoformans; molds, Aspergillus fumigatus. Clinical Use: Amphotericin B remains the drug of choice for nearly all life-threatening mycotic infections. Used as the initial induction regimen for serious fungal infections (immunosuppressed patients, severe fungal pneumonia, and cryptococcal meningitis with altered mental status). Nystatin Nystatin has similar structure with amphotericin B and has the same pore-forming mechanism of action. Nystatin is active against most Candida species and is most commonly used for suppression of local candidal infections. Nystatin is used in the treatment of oropharyngeal thrush, vaginal candidiasis, and intertriginous candidal infections. Griseofulvin Griseofulvin is a fungistatic and used is in the treatment of dermatophytosis. Griseofulvin is deposited in newly forming skin where it binds to keratin, protecting the skin from new infection. It must be administered for 2-6 weeks for skin and hair infections to allow the replacement of infected keratin by the resistant structures. Nail infections may require therapy for months to allow regrowth of the new protected nail and is often followed by relapse. Adverse effects include an allergic syndrome much like serum sickness, hepatitis, and drug interactions with warfarin and phenobarbital. Griseofulvin has been largely replaced by newer antifungal medications such as itraconazole and terbinafine. Clinical Use: Active against Cryptococcus neoformans, some Candida species, and the dematiaceous molds that cause chromoblastomycosis. Clinical use at present is confined to combination therapy, either with amphotericin B for cryptococcal meningitis or with itraconazole for chromoblastomycosis. Adverse Effects: The adverse effects of flucytosine result from metabolism (intestinal flora) to the toxic antineoplastic compound flucytosine. Bone marrow toxicity with anemia, leukopenia, and thrombocytopenia are the most common adverse effects, with derangement of liver enzymes occurring less frequently. Azoles Azoles are synthetic compounds that can be classified as imidazoles and triazoles. The antifungal activity of azole drugs results from the reduction of ergosterol synthesis by inhibition of fungal cytochrome P450 enzymes. The specificity of azole drugs results from their greater affinity for fungal than for human cytochrome P450 enzymes. Imidazoles exhibit a lesser degree of specificity than the triazoles, accounting for their higher incidence of drug interactions and side effects. Azoles are active against many Candida species, Cryptococcus neoformans, the endemic mycoses (blastomycosis, coccidioidomycosis), the dermatophytes, and, Aspergillus infections (itraconazole). Most azoles cause abnormalities in liver enzymes and, very rarely, clinical hepatitis. Clinical use: it has limited use because of the drug interactions, endocrine side effects, and of its narrow therapeutic range. Ketoconazole is used in treatment of mucocutaneous candidiasis and nonmeningeal coccidioidomycosis.

Long bones are rarely involved but the short long bone involvement is somewhat common buy discount ciplox 500mg line. Referral Criteria No need to refer anywhere since the patient is already in a tertiary care hospital purchase 500 mg ciplox with visa. Who does What Doctor – Diagnosis order ciplox 500mg online, chemo therapy advice and surgery Nurse – General care like nutrition advise buy 500 mg ciplox amex, care of the wounds. Introduction: India is classified as a country with a high burden and the least prospects of a favourable time trend of the disease. The average prevalence of all forms of tuberculosis in India is estimated to be 5 per thousand. Neurological complications and progressive deformity are the dreaded complications of tuberculosis of spine. It is imperative to diagonose this condition early and initiate early medical treatment while recognising and treating patients requiring surgical interventions for optimal outcomes. Osteoarticular tuberculosis is always secondary, so primary infection should be treated effectively for sufficient time. Once diagnosed, close follow up, regular anti tubercular treatment and aggressive surgical approach may prevent dreaded complications V. Any back pain not responding to conservative treatment for more than 6 weeks and/or accompanied by constitutional symptoms should be investigated further Neurologic abnormalities occur in 50% of cases and can include paraplegia, paresis, impaired sensation, nerve root pain. The following are radiographic changes characteristic of spinal tuberculosis o Paradiscal involvement with decreased disc space o Increased anterior wedging o Collapse of vertebral body 13 o Enlarged psoas shadow with or without calcification o Fusiform paravertebral shadows suggest abscess formation. Goals of management in active tuberculosis Eradication/ Control of Disease Decompression of spinal cord Prevention of progressive deformity and later neurological complications Early mobilization of the patient. In Patient In patients without deficit,chemotherapy alone is sufficient if the risk of progressive deformity is not there. A close watch on development of neurological symptoms is to be kept and at signs of deterioration, the patient may be referred. In Patient Tuberculosis spine with no neurological deficit Chemotherapy alone is sufficient if there is no risk of progressive deformity Efforts should be made to identify patients who are at risk of developing kyphosis in active disease. Growing children with dorsal and dorsolumbar caries with more than 3 body involvement or in which there is destruction more than 1. Indications of surgery Failure to respond to conservative treatment Deformity/risk of progresion Recurrence of the disease 15 Doubtful diagonosis Tuberculosis spine with neurological deficit Middle path regime In patients with mild deficit trial of chemotherapy can be done, however a close observation is must Indications for surgery for management of tuberculosis with deficit Severe neurologic symptoms Progressive neurologic symptoms Unsuccessful nonoperative treatment Instability with spinal deformity, Spinal tumour syndrome. By providing structural support and by its osteogenic potential, the graft may prevent progression of kyphosis. Anterior grafting procedure should be accompanied by instrumentation either anterior or posterior. Out Patient Regular follow up of operated patients as well as patients on conservative treatment. At each follow-up detailed neurological examination should be performed and serial x rays should be taken and deformity progression should be noted. Doctor Clinical diagnoses Investigations Clinical decision making Surgical procedure Maintenance of record and follow up b. Indications and Timing of surgery There is a definite role of conservative management in neck pain and radiculopathy with minor sensory symptoms. Patients with very mild and subtle signs of myelopathy can be managed conservatively but close observation and regular follow up is must. Once moderate signs and symptoms of myelopathy develop patients are less likely to improve on their own and surgical intervention is required. Manipulation and traction are not recommended in myelopathy because of potential risk of aggravating neurological deficit Indications for surgery in degenerative disease of cervical spine – Cervical spondylotic myelopathy – Radiculopathy with a significant motor deficit – Radicular pain not responding to conservative treatment – Intractable Neck pain due to pseudarthrosis Choice of Surgical approach The decision of which surgical approach is to be used should be based on: 1. Primary focal ventral pathology causing cord compression is best treated by anterior approach. Primary posterior compression related to facet hypertrophy and ligamentum flavum should be tackled by posterior approach In multisegmental pathology(>3 levels) In presence of lordotic spine either posterior approach or anterior approach should be considered. Supplemental posterior procedure may be needed in multilevel corpectomy Anterior approach Anterior plating improves the rate of fusion, reduces the length and type of postoperative immobilization, reduces the prevalence of graft-related complications, and leads to less postoperative kyphosis, particularly in patients undergoing two or more levels of anterior cervical discectomy and fusion Autograft is superior to allograft in terms of fusion rates,duration to fuse and graft collapse. Long-term results will be needed before use of structural supports such as metallic cages or synthetic spacers in conjunction with local autograft or allograft can be unequivocally recommended. In revision cases when a contralateral anterior approach is contemplated, preoperative laryngoscopy should be done to rule out subclinical vocal cord paresis on the previously treated side. Myelopathy due to single level disc herniation in absence of facet joint or posterior disease. Posterior approach Indicated in multisegmental pathology in a lordotic spine or posterior pathology. Only laminectomy without fusion is contraindicated as it might lead to sequalae such as segmental instability, kyphosis, swan neck deformity, perineural adhesions etc. Laminoplasty or laminectomy with instrumented posterior fusion is the procedure of choice for cervical spondylotic myelopathy. Significant preoperative neck pain is a relative contraindication to laminoplasty and laminectomy with fusion may be preferred. Patient and his/her attendants must be counselled regarding postop complications and possible requirement of ventilatory support. Pain around elbow joint which increases on movement Examination – Swelling, Deformity, Bruising, Tenderness, Crepitus, Instability. Check for any signs of Compartment Pressure Check for Distal Pulses & Neurological deficits, of Ulnar, Radial and Median Nerves 4. Treatment: Initial Management – Splint the Limb with elevation & Ice Packs applc’n along with Anti-Oedema measures. Complications:  Postoperative infection  Nerve injury, especially ulnar nerve palsy  Vascular injury  Elbow stiffness  Hardware prominence  Loss of fixation  Nonunion  Malunion  Heterotrophic bone formation 7. When to Refer :  In cases with Polytrauma (Head / Chest / Abdominal / Pelvic Injuries) – “Life before Limb”  In cases with Vascular Injury – for Vascular repair  In cases with Neurological Injury – for Immediate / Delayed Nerve repair. Radial head fracture is given as 33% of elbow region while distal radius as 1/6 of fracture (not known) of what? If we refer all type B & C fracture for all fractures than how the patients in Village, Tehsil, District will be treated as we do not have any networking of referral centers (they are all concentrated in the cities. Is it to stop small centers in cities to stop operating the particular type of fractures and force them to refer or to make a national policy for the overall effective management of the orthopaedic patients? Radial head fracture is given as 33% of elbow region while distal radius as 1/6 of fracture (not known) of what? If we refer all type B & C fracture for all fractures than how the patients in Village, Tehsil, District will be treated as we do not have any networking of referral centers (they are all concentrated in the cities. Is it to stop small centers in cities to stop operating the particular type of fractures and force them to refer or to make a national policy for the overall effective management of the orthopaedic patients?

B. Yokian. International Fine Arts College.