QUIZ 1

What is your diagnosis?

Summary:

Patient is a 10 year-old boy presented with fever 3 days and diffuse, general erythematous reticular lesions 2days duration. No history of sore throat or streptococcal infection.

Faget sign by Jean-Charles Faget

fever + bradycardia = Faget Sign

F - Fever (Yellow / Colorado Tick)

A - abortus brucellosis (Mediterranean Fever)

G - Gram negative bacillus (Legionella pneumophila)

E - Extracellular parasites attaches to Epithelial cells, treat with EES ( Mycoplasma infection)

T - Typhoid Fever/ Tularaemia

Are you troubled with Passenger Car engine oil leak

normally it is caused by degenerated / hardened seals or gaskets

Troubleshoot the followings:-

1) distributor,

2) camshaft 

3) crankshaft (on the pulley and the GB side),

4) crankcase (also known oil sump) and 

5) cylinder head

Notez:

Following is the spec for wira 1.5A year 2003

Engine model 4G15P
Displacement, cc 1468
Max.power (Net), kw(PS)/rpm 91 ps (66.93 kw) / 6000 rpm
Max.torque(Net), N*m(kg*m)/rpm 12.4 kg*m (121.60 N*m) / 3000 rpm
Power density 9.01
Engine type Serial 4 cylinder SOHC12 valve
Engine information MVV
Fuel system ECI multiple
Turbocharger No
Fuel type Unleaded regular gasoline
LEV system (Low emission vehicle) No
Compression ratio 9.4
Bore, mm 75.5
Stroke, mm 82
Fuel consumption at 10-15 modes, l/100km 4.7

NEW VIRUS FOUND - CREDIT CRISIS ETIOLOGY

Virus Name: SubPrime Mortgage (SPM)

Mode of transmission: predominantly through financial systems namely it is transmitted from bank to another bank. 

Vector: Housing Boom + Consumer Spending

Pathogenesis:-

1) Booming of the housing REIT

2) Lower interest rate

3) Higher consumer expenditure

4) Subprime lending 

5) Banks sell credit risks to investors through securitization process. Investors called it Mortgage Backed Securities (MBS) and Collateralized Debt Obligations (CDO)

6) Risks involved include credit risk, asset price risk, liquidity risk & counterparty risk. 

Clinical pictures: 

1) sub acute presentation

2) when subprime occurs, 

3) lack of liquidity in the market, 

4) money locked-in papers / bad debts

5) unable to liquidate asset 

6) cascading series of consequential credit crunch impacts

Investigation:

1) reassess your own credit status

2) get rid of bad debt

3) increase in liquidity (% investment lock in = 100 minus age, the rest keep in liquidity)

4) opportunities in crisis (buy discounted stocks)

Treatment/ Prevention: 

1) personal financial planning crucial step for prevention

2) understanding bad debt vs good debt

3) strong financial sheet

4) never greed is a good way to prevent

References:

1) http://en.wikipedia.org/wiki/Subprime_mortgage_crisis

2)

http://www.nypost.com/seven/10132008/postopinion/opedcolumnists/spreading_the_virus_133375.htm

3) http://bayareahousingreview.com/2007/08/08/the-subprime-mortgage-virus-has-spread/

4) http://www.tigersharktrading.com/articles/9361/1/The-Subprime-Virus/Page1.html

Notez:-

1) When bad debt goes systemic, it affects non financial sector. THENCE the BIG R (Recession) crawls or jumped in

2) When US having coughs, the whole world gets the flu

3) Few issues here includes: saving our faces vs letting the nature take its course and learn from mistake vs do it right the first time

4) Can we contain this contagious virus?

5) Is there exact treatment for this virus? ie injection of USD700bil bail out will actually works?

6) Can we actually dissociate our economy from the world biggest consumer? 

7) Disclaimer: the above pathogenesis may be totally wrong keeping in view i am no expert in finance or economy. But these are the info i got it from the references.

CAR ENERGY EFFICIENCY - SAVING THE PENNIES

YOKOHAMA DNA EARTH 1

intelligent Dual and Sequential Ignition (i-DSI) engine

Diagram above showed car energy distribution

http://www.fueleconomy.gov/FEG/atv.shtml

1) AERODYNAMICS - DRAG COEFFICIENT

-Smoother vehicle shapes have already reduced drag significantly, but further reductions of 20-30% are possible.

2) AIR FUEL RATIO (AFR) = MAGIC FIGURE IS 14.7 TO 1

LESS THAN 14.7 TO 1 = RICH MIXTURE

MORE THAN 14.7 TO 1 = LEAN MIXTURE

in Naturally aspirated engines (powered by octane) Max power with AFR ranging 12.5 to 13.3

The main drawback of lean burning is the large amount of NOx being generated at relatively high air/fuel ratios.

CHOOSE the engine with lean burning potential.

3) LOWERING ROLLING RESISTANCE TIRE 

IDEALLY = smooth ride, minimize noise, & good traction in a variety of weather conditions. 

But they are rarely optimized for efficiency. Tires can cause a sginificant amount of drag while driving. Therefore in Hybrid cars, special tires that are stiffer and inflated to a higher pressure than conventional tires. The result is that they cause about half the drag of regular tires.

4) WINDOWS UP vs DOWN

Studies showed that low velocity, window down improve fuel efficiency

However, driving at high velocity (>90km/h), window up is better than window down due to aerodynamics and drag coefficient.

5) START STOP SYSTEM (integrated starter/generator)

Helps to cut energy loss during traffic jams. Stop the engine when brake is pressed, restarting it instantaneously when the accelerator is pressed.

Currently it is used in Volkswagen, BMW & Citroën models.

Toyota and Mazda will be introducing stop-start technology in 2009 year model.

Renault will introduce the technology in all of its European models by 2010.

6) DRIVELINE LOSSES

- Energy is lost in the transmission and other parts of the driveline. Technologies, such as automated manual transmission (AMT) and continuously variable transmission (CVT), are being developed to reduce these losses.

7) USE LIGHT WEIGHT MATERIALS

- Reducing the overall weight of a car is one easy way to increase the mileage.

Composite materials like carbon fiber or lightweight metals like aluminum and magnesium can be used to reduce weight.

Reference:-

1) http://auto.howstuffworks.com/ten-green-driving-tips.htm

2) http://en.wikipedia.org/wiki/Lean_burn

3) http://www.bkkautos.com/2009-Honda-City-Chalks-Up-4500-Sales-in-2-Weeks

4) http://en.wikipedia.org/wiki/Start-stop_system

5) http://www.fueleconomy.gov/FEG/tech_adv.shtml

6) http://en.wikipedia.org/wiki/Honda_L_engine

7) http://www.ukipme.com/engineoftheyear/

NOTES:-

1) 62% of the fuel's energy is lost in the internal combustion engine (ICE)

2) ICE engines are very inefficient at converting the fuel's chemical energy to mechanical energy, losing energy to engine friction, pumping air into and out of the engine, and wasted heat.

3) diesels are about 30-35% more efficient than gasoline engines, and new advances in diesel technologies and fuels are making these vehicles more attractive.

4) Honda’s new Advanced VTEC (AVTEC) engine combines continuously variable valve lift and timing control with the continuously variable phase control of valve timing to achieve a good combination of better performance, fuel economy, and lower emissions.

5) Conventionally, one spark plug per cylinder but the i-DSI engine uses a radical twin-spark ignition system with just two valves per cylinder.

6) At lower velocity, spark plug nearest the inlet valve is fired much earlier than usual while the plug nearest the exhaust valve is fired later than usual.

7) At higher velocity, the sparks are fired simultaneously.In a normal engine, fuel and air enters the cylinder of an engine through the inlet valve, designers concentrate on optimizing the swirl of the mixture to ensure fuel is atomized thoroughly and evenly.

8) The 1NZ-FXE Hybrid Synergy Drive in the Toyota Prius has won several International Engine of the Year awards

9) 1NZ-FXE based on Atkinson cycle rather than the conventional Otto cycle.

10) Michelin XM1 vs Yokohama DNA EARTH 1 - which one better???

Children Learning Disability - dyslexia

\dis-ˈlek-sē-ə\ 

definition = a variable often familial learning disability involving difficulties in acquiring and processing language that is typically manifested by a lack of proficiency in reading, spelling, and writing 1

Signs: 2

a) Pre-school

-persistently jumble up phrases

-later than expected speech development

-substitute words

-difficulty of learning nursery rhyme

-unable to remember objects

-walked early but did not crawl

-not paying attention

-difficulty of catching balls

-difficulty of clapping hands

b) Primary school age.

-difficulty with reading and spelling

-putting letters and figures the wrong way round

-difficulty in memories

-occasionally confuses 'b' and 'd' and words such as 'no/on'.

-use fingers or marks on paper to make simple calculations.

-Poor concentration.

-understanding problems

-takes longer than average to do written work.

-problems processing language at speed.

-difficulty with tying shoe laces, tie, dressing.

-difficulty telling left from right, order of days of the week, months of the year etc.

-poor sense of direction and still confuses left and right.

-lacks confidence and has a poor self image.

c) 12 or over.

-reads inaccurately

-difficulties in spelling.

-Gets 'tied up' using long words, e.g. 'preliminary', 'philosophical'.

-Confuses places, times, dates.

-difficulty processing complex language or long series of instructions at speed.

-poor confidence and self-esteem

Types:

1. Surface dyslexia
   
2. Phonological dyslexia
   
3. Double deficit dyslexia

Evaluation:3

-reading ability testing

-tests of rapid naming, 

-short term memory evaluation 

-sequencing skills

-nonword reading to evaluate phonological coding skills. 

-IQ test (identify learning strengths and weaknesses)

-vision and hearing testing

...................................................................................................................................

Management:

*The Dore programme, previously known as DDAT (Dyslexia Dyspraxia Attention Treatment) is a drug-free course of treatment for dyslexia and other learning difficulties4

*Treatment programs for dyslexic children fall into three general categories: 5

a)developmental - the child needs extra time & attention

b)corrective - small groups in tutorial sessions,emphasizes child's assets and interests

c)remedial - resolve the specific educational and psychological problems that interfere with learning.

*Multisensory approach

*Rewiring Dyslexic Children's Brains Using Sound Training6

References:-

1 http://medical.merriam-webster.com/medical/dyslexia

2 http://www.bda-dyslexia.org.uk/

3 http://en.wikipedia.org/wiki/Dyslexia

4 http://en.wikipedia.org/wiki/Dore_(dyslexia_treatment)

5 http://www.healthscout.com/ency/68/267/main.html#cont

6 http://www.medicalnewstoday.com/articles/87170.php

Notez:

1\ Is there any role of low dose benzodiazepine?

2\ Is there any role of piracetam (nootropil) for dyslexic?

3\ Is there any role of ginkgo biloba for dyslexia?

4\ Dyslexia is four times more common in boys than it is among girls.

5\ Although the condition is known to be hereditary, there is no consensus among scientists about the exact cause.

6\ It is linked to a "cerebellar deficit".

7\ Dyslexia is linked to reduced activity in a primitive part of the brain that controls movement, co-ordination and balance, scientists have claimed.

New Paradigm of CardioMetabolic Syndrome - Mother of all diseases

FIGURES: VICIOUS CYCLE OF CARDIO-METABOLIC SYNDROME

HOW'S YOUR MEASUREMENT?

OBESITY: waist circumference > 40 inches men

    waist circumference > 35 inches in women

LDL > 2.6mmol/L

HDL <>

TG > 1.9mmol/L

Blood Pressure >130/90 mmHg

Fasting Blood Sugar > 6.1mmol/L

............................................................................................................................

INTERVENTIONS?

1) LIFESTYLE MODIFICATIONS

-STOP SMOKING

-EXERCISE, EXERCISE, EXERCISE

-MORE VEGE LESS RED MEAT

-LESS SUGAR

-LESS FAT

-LESS SALT

2) ROLE OF ANTIHYPERTENSIVE

-ESPECIALLY RAS BLOCKADE (IE ACE INHIBITOR, ARB, CCB)

-?DIURETICS INCRESES RISK OF DIABETES ONSET?

3) LIPID LOWERING DRUGS

-FIBRATES & NICOTINIC ACID FOR HIGH TG

-STATINS FOR THE REST

-EXERCISE FOR HDL :-) ops not a drug its a STYLE OF LIFE

4) INSULIN SENSITISER

-METFORMIN, ACARBOSE, THIAZOLIDINDIONES

-?ROSIGLITAZONE ON CARDIAC OUTCOME

5) ANTIOBESITY DRUGS

-SIBUTRAMINE (affecting monoaminergic system)

- ORLISTAT (gastrointestinal pancreatic lipase inhibitor)

- RIMONABANT (endocannabinioid, CB1 receptor antagonist)

6) ANTITHROMBOTIC DRUGS

-insulin resistance promotes pro-thrombotic states (coagulation vs fibrinolysis system)

-LOW DOSE ASPIRIN / CLOPIDOGREL

7) ?ANTI-INFLAMMATORY DRUGS

-insulin resistance recognised as inflammatory disease

-CRP + PLASMINOGEN ACTIVATOR INHIBITOR 1 & IL-6 HIGH CONCENTRATION

references:

1) DASH TRIALS

2) MEDITERRANEAN DIET

3) ATP III GUIDELINES & IDF GUIDELINES

4) ESH/ESC GUIDELINES

5) ASCOT TRIAL

6) The Rimonabant In Obesity (RIO) program

7) ATHEROGENIC DIET

NOTES:-

1) PREDIABETES STATE

2) AN APPLE A DAY KEEPS YOUR DOC AWAY STILL HOLDS TRUE

3) TO TACKLE THIS MOTHER OF ALL DISEASE IS TO KEEP YOUR BUTT OFF YOUR CHAIR/ COUCH

4) CUT DOWN ON SIMPLE CARBOHYDRATE/ FATTY FRIED FOOD

CRYPTIC DISEASE - DENGUE HEMORRHAGIC FEVER (DHF)/ DENGUE SHOCK SYNDROME(DSS)

Exact pathogenesis is not known

Clinical manifestations 

-severe thrombocytopenia, vascular leakage, and hepatomegaly.

Immunologically:

-4 serotypes, DENV1, DENV2, DENV3, DENV4

-each serotypes has its own antigenic character (induces a different antibody against each type)

-Infection by one serotype will give lifelong immunity against the same serotypes of virus but not other serotype

ANTIBODY DEPENDENT ENHANCEMENT (ADE) effect 

-antibodies raised against one serotype will provide us protection for future infections of the same serotype but induces a massive immune response for different serotype infection

DENGUE VIRUS NON-STRUCTURAL PROTEIN 1 (DENV NS 1)

-Antibodies directed against DENV NS 1 showed cross-reactivity with human platelets and endothelial cells

-this lead to platelet and endothelial cell damage, inflammatory response and abnormal immune responses caused by DEN infection, including cytokine and chemokine production (TNF-a, IL-6, IL-8, and RANTES), complement activation and immune cell activation. 

-hypothesize that anti-DV NS1 is involved in the pathogenesis of DF and DHF/DSS, and this may provide important information in dengue vaccine development

Progression of DHF/DSS

1)effect of virus load

2)virus variation, 

3)abnormal immune responses of the host after DV infection may also account for the progression of DHF/DSS.

Persistent thrombocytopenia post DF hypothesis

a) Dengue virus induces bone marrow suppression

(b) Dengue virus can bind to human platelets in presence of virus specific antibody

and immune mediated clearance of platelets

(c) Spontaneous aggregation of platelets to vascular endothelial cell pre-infected by virus inducing aggregation, lysis and platelet destruction

(d) Anti-platelet antibodies generated after dengue virus infection causes destruction of platelets

References:-

1. http://www.searo.who.int/en/Section10/Section332/Section1985_9826.htm dengue vaccine 
2. http://www.unimas.my/research/ihcm/ihcm_dengue.htm
   
3. http://www.searo.who.int/en/Section10/Section332/Section1985_9804.htm
   
4. http://www.ajtmh.org/cgi/content/full/72/4/370
   

boon or bane - The Credit Story

1) The ability to build saving helps you to build HIGH SELF NET-WORTH

2) Identify areas to cut for more savings

-bills (water/ electricity/ petrol/ mobile phone)

-credit cards

-hire purchase loans (interest rate advertised = fixed, no rest basis)

*Rule of thumb, to obtain the True Effective Annual rate, you need to Double the advertised rate and add one to it*

3) The discipline to save can check overspending in other areas. Always keep the ultimate financial goal in mind in order to avoid being swayed by temptation and overspending on the little things.

4) Understand the difference between the need and wants

5) Wise credit management falls on fundamental, knows the difference between a good debt and bad debt.

6) Principle of sound utilisation of credit remains the same, if debt is used to fund consumptive behaviour it will destroy lives ie credit crisis 08

7) If debt is used to build a business or buy appreciating assets it can be a heaven sent boon

8) It it not wise to get into a debt situation over a depreciating asset

9) Identify what is assset and what is liabilities

10) If people is aware of the charges they are paying they would be more careful about the credit they are taking on.

Reference:-

1) Personal Money issue #49 September 2005.

Notes:-

1) if you can hardly get by because you own two or three cars, that's bad. If you can hardly get by because you own three houses, you can always sell off one house.

2) for credit card holders, identify the purpose of your card and stay focused. If its for payment purposes so that you dont have to carry so much cash around, that's fine.

3) Credit card could also be used for emergencies