Insights into epileptogenesis from post-traumatic epilepsy

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4 April 2024

Insights into epileptogenesis from post-traumatic epilepsy

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9 Healthy Tips to Manage Mental Exhaustion

By

udento_com

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4 April 2024

0

Struggling with stress and feeling tired all the time? You might be dealing with mental exhaustion.
Everyone knows that tired feeling after a long day of work. You know, heavy eyes, a foggy brain, just wanting to be cozy at home. But what if every week leaves you even more tired? Your to-do list keeps growing, deadlines keep coming, or life throws unexpected challenges.
But how do you know you are having a mental fatigue episode? Let us talk about it in detail. Keep reading for outstanding tips for managing your mental health and everyday tasks. Let’s get into it.

What is Mental Exhaustion?
Mental fatigue is when your brain is highly stressed because you have been thinking a lot. It can make you feel tired, like your body has run a marathon because your brain has used a lot of energy.
How is mental exhaustion different from everyday stress or feeling worn out from work (burnout)?
They’re related, but mental fatigue is a long-term version. It’s an ongoing thing, not just a temporary stress.
Imagine stress as a quick thing and burnout as feeling tired, specifically because of work. Mental exhaustion, though, can happen because of work or other things in your life.
Simply put, stress is like a short visit; burnout is when work makes you tired. Mental exhaustion is a more constant, ongoing tiredness in your brain, also known as cognitive dulling in scientific terms.
What Causes Mental Exhaustion?
You can get mental fatigue for many reasons, including

Overwhelming workload: Too much work can tire your brain because it’s always working hard.
High-pressure, demanding job: Jobs that require a lot from you and put on a lot of pressure can make you mentally exhausted.
Job dissatisfaction: If you don’t like your job, it can stress your brain out and make you tired.
Family or at-home stress: Problems at home, like arguments or difficulties, can also tire your mind.
Significant life events: Big life changes, losing someone important or having a baby can be mentally exhausting.
Uncertainty about the future: Not knowing what will happen next can tire your brain.
Chronic illness or mental health issues: Long-term sickness or problems with your mental health can tire out your mind.
Overextended commitments: Doing too many things at a time with many responsibilities can tire your brain.
Societal or global stressors: Stress from things happening around you, like news or events, can impact your mental energy.
Not prioritizing self-care: Forgetting to take care of yourself, like not getting enough rest or relaxation, can contribute to mental exhaustion.

Sometimes, you can feel mental exhaustion due to chronic health issues. If so, consult an internal health specialist like Prof. Aziz ur Rehman. He is one of the best doctors in his field, with 25 years of experience.
What Are the Symptoms of Mental Exhaustion?
You know you are going through mental fatigue if you have some of these symptoms:

Persistent fatigue: Feeling tired all the time, even after resting.
Difficulty concentrating: Struggling to focus or pay attention to things.
Memory problems: Forgetfulness or having a hard time remembering things.
Reduced performance: Finding it tough to accomplish tasks or work efficiently.
Irritability: Feeling easily annoyed or frustrated.
Emotional sensitivity: Being more sensitive or emotional than usual.
Insomnia or disturbed sleep: Trouble falling asleep or staying asleep.
Physical symptoms: Experiencing headaches, muscle tension, or other physical discomfort.
Withdrawal from activities: Losing interest or avoiding usual activities is a behavioural sign of mental exhaustion.
Increased susceptibility to illness: A weakened mental state may make the body more vulnerable to getting sick.

Tips to Get Rid of Mental Exhaustion
We must pay extra attention to our brain and cognitive health in this fast-paced time. If you are feeling mental fatigue, don’t overlook it. Start employing these tips to manage and handle mental fog better:
Make Time To Relax!
Give yourself a break before you get too stressed. Use your free time to relax, whether it’s during vacations or on your regular days off.
Find activities that help you unwind, like a digital detox, mindfulness, or just taking it easy with a good book or TV show.
Suggested Read: How to Take a Digital Detox?
Get Better Sleep
Quality sleep matters. Stick to a regular bedtime, avoid screens before sleep, and invest in a comfy mattress.
This way, you can make the most of your sleep, helping your brain and body recharge.
Prioritize Healthy Food
Eat for your brain health by choosing foods rich in omega-3s and flavonoids. Skip the unhealthy snacks and opt for dark leafy greens, salmon, walnuts, dark chocolate, fresh berries, or citrus fruits.
Declutter Your Space
A tidy environment reduces stress and makes you feel more in control. Spend some time organizing your home and work spaces, especially if you work remotely.
Cleaning up common areas like your desk, bedroom, and kitchen can improve your overall mindset.
Move Your Body
Exercise is a great stress reliever.
You don’t need an intense workout – just 10 minutes a day can positively impact your mental health.
Take a short walk during your lunch break for a mood boost and some vitamin D from the sun.
Take Back Control of Your Calendar
Set boundaries by time-blocking your priorities.
Allocate specific time slots for tasks, habits, and breaks so your schedule is manageable with back-to-back commitments.
Say No.
It’s okay to decline some requests. You can only do some of the time.
Politely say ‘no’ to unnecessary meetings, extra commitments, or social invitations that may add unnecessary stress.
Suggested Read: How to Say No to the Wrong So You Can Say Yes to the Right!
Consider Your Job Satisfaction!
If your job constantly stresses you out, consider whether it’s a good fit for your long-term mental well-being.
Reflect on your job satisfaction, how long you’ve been feeling exhausted, and if there are ways to address your concerns with your employer.
Reach Out for Help
You don’t have to face mental exhaustion alone. Don’t hesitate to ask for help from friends, family, or mental health professionals when you need guidance and understanding.
Healthwire is Here to Help!
At Healthwire, we strongly advocate work-life balance to keep mental exhaustion at bay. You can do that with realistic planning and goals. However, to err is human. We can make mistakes, feel hopeless, and fall prey to mental fog. Don’t shy away from consulting a psychologist about your mental well-being.
You can book an appointment with the best psychologists in the city using Healthwire’s platform. Remember! Balanced mental health is just a click away.

The Whole Tooth – Queen of Dental Hygiene

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4 April 2024

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The Whole Tooth - Queen of Dental Hygiene

Group Smiles are the best!

Today’s post is about some teeth “basics”. What their functions are, what they are made of, and their inner workings. For most, this may be just a review, but important information because the next few articles will be about tooth sensitivity: its causes, and how to help stop or at least reduce it. For that, you need this basic information first.

Tooth Basics

So, for those new to the whole “teeth” thing: They have some very important jobs to do and often they get no respect. They literally start the process of digestion. They help you speak clearly. They develop and maintain the shape of the face. For animals, teeth are used for defense. And for humans, they are part of a beautiful smile and a source of self-confidence.

Teeth really are incredible. They work hard for you every day chewing, grinding, and mashing food. Teeth on the whole should silently do their “jobs”. Their jobs depend on where they are located in the mouth. Teeth should never hurt or be sensitive. If they do, that’s their cry for help.

Unlike sharks, who can get up to 50,000 teeth in their lifetime, humans only get two sets of teeth.

Sharks get lots of teeth!

The “baby teeth” and the “adult teeth”. Adults should end up with 32 teeth but most only have room for 28 (that’s a post for another day). We call that the permanent dentition. (At least it should be permanent and that’s why I write this blog, to help you make things healthier and more permanent.)

Baby Teeth

Baby’s First Tooth is a Celebration

Your baby will have 20 teeth by the time they are three years old, with their first tooth coming in around six months. (Although every baby has their timetable for “erupting”. And, it literally is an eruption into the mouth, and yes, it is painful.) In dental lingo we call this the “primary dentition” and we call baby teeth- “deciduous” teeth. You may know it as baby teeth or milk teeth.

Baby teeth are just as important as permanent teeth. They perform all the same functions as adult teeth- start the digestive process, grind food, help with proper pronunciation and speech, and contribute to self-esteem. Who doesn’t love a toothy/gummy baby smile? You smile back and that releases hormones and stimulates the baby’s brain development. Smiles tell your baby all is loving and right in their world. And, getting those cheeky, happy smiles makes you feel good too.

Care for baby’s teeth just as you care for your own. Brush them well. Feed them good, nutritious foods. Skip the baby foods which are too mushy. Teach baby to chew. Chewing is critical to proper jaw and facial growth, clean healthy teeth, and proper airway development. Harder foods are healthier foods (for the most part.) Breastfeeding is best feeding and does not cause cavities. It is the mushy, sticky carbohydrate foods that babies and toddlers eat that are the big part of the cause of tooth decay.

Healthy baby teeth hold the space for the permanent teeth to erupt into the jaw. The primary teeth need to have enough spaces between them so they look like a picket fence. Ideally there is enough room in-between teeth so you could (theoretically) put a nickel between each front tooth.

Babies get tooth decay and feel pain in the same way adult teeth do. Please do not dismiss it as unimportant with the idea they will fall out so they don’t matter. (I have heard parents say these things.) Baby teeth start falling out around age five and continue to do so until about age 12/13/14. They are there for a long time so they really need loving care.

The Dentition

The Maxillary Dentition

We call the development and arrangement of teeth in the mouth the “dentition”. “Dens” is the root meaning of tooth and the “ist” is the person who “does or makes”. Hence, the dentist is one who fixes and repairs teeth.

Incisors

Central Incisors and Lateral Incisors Cut and Tear Food.

We call the upper jaw the maxillary arch and the lower jaw the mandbular arch. Both arches have the same types of teeth. We start with the four front teeth called the incisors: two central incisors – your front teeth and next to them are the lateral incisors. Both the primary and permanent dentitions have these eight incisors. Besides looking pretty, their main job is to bite into and tear food. They also help us pronounce and enunciate words clearly, and support the lips which supports our airways.

The incisors are NOT made for chewing and breaking down food. If they are used for chewing food they will start falling apart. (No surprise… but they also should not be used as tools either- tearing bags or opening bottles are a big no-no.)

Cuspids

Cuspids are at the Corners of the Mouth. Their Job is Tearing Food.

Each arch has two cuspids- you know them as canine or eye teeth. These teeth are the anchors of the arches and make the jaws nice and rounded. They are the teeth with the longest roots. Without them, faces look flat. They guide the teeth into proper alignment when the mouth closes and the jaws come together in a chewing motion. Their sharp point assists in tearing food. In the animal world, they are used for self-defense.

Bicuspids

In the permanent dentition, right behind the cuspids and in front of the molars are two premolars on each side of the mouth and on both arches. They are also called the bicuspids. (We in dentistry are fancy and call them the “first bi” and the “second bi”. Now you can amaze and dazzle your dental hygienist with all the proper lingo.) You will have eight of them. The bi’s have two cusps or peaks, thus the name. These are transition teeth- between the front of the mouth to the back molar teeth. Their job is to grind and mash food.

Bicuspids with Recession along the Gum Line

Primary dentitions do not have bicuspids. They go from the canine directly to the baby first molars. The baby molars hold the space for the bicuspids to erupt into the jaw at about the age 12 to 13.

Molars

The Tooth Fairy and her Traveling Molar

And the workhorse of the mouth – the molars. Baby dentitions have eight molars and the permanent dentition should have 12 molars. They have just as fancy names- “first molar”, “second molar” and “third molars”. You know third molars as “Wisdom Teeth”. Sadly, most people do not have room in their jaws for their third’s so they are removed by oral surgeons regularly.

Impacted Lower Widsom Tooth. (Plus LOTS of tooth decay)

Molars have four or more cusps and their main job is chewing, crushing and grinding our food. Ninety percent of chewing takes place between the molars.

There are four baby molars on each of the arches. Baby molars have the same job as permanent molars. They are in the mouth until the child is 12 to 13 years old so caring for these teeth is critical. Baby teeth are place holders for permanent and do the same jobs for children as permanent teeth SO, they need the same care. I hope you sense a theme here. I cringe and am deeply saddened when I hear parents say “they are ONLY baby teeth”.

Around age five the first central incisors erupt.

To make discussing teeth easier, in our dental lingo we identify teeth by number. In the permenant dentition, we number teeth from one to 32, starting with the third molar on the upper right as tooth #1 all the way over to the upper left third molar as #16, then the lower arch third molar is #17 all the way over to the lower right third molar is named #32. Baby teeth are identified by letters. A, J, K, T are the last teeth on each arch. (They are also a family member’s initials so that helps me remember baby teeth letter names.)

Tooth Anatomy Lesson

Tooth Anatomy

Above the Gumline

The crown portion of the tooth is covered above the gum line with enamel. Enamel is the hardest substance in the body. It is made up of hydroxyapatite, calcium and phosphorous, magnesium, sodium and carbonate.

Below the Gumline

Shark Teeth have Short Roots

Fun shark fact: Shark teeth have no roots so they break off easily but, the next tooth is waiting in line to take its place. They can have up to 15 rows of teeth and are continuously growing new ones.

Human teeth, on the other hand, have long roots below the gum line. The roots of the teeth are covered by the cementum and are housed in the bone. The cementum and the periodontal ligament fibers anchor the tooth to the jawbone. Cementum is made up of 45 to 50 % hydroxyapatite crystals, 50 to 55% organic matter, and then water. The unique thing about cementum is it is living tissue and constantly repairs itself throughout life. The main function of the cementum is to anchor the tooth into the bone, and protect and cover the roots. The cementum is yellowish in color. It is not as hard or as thick as enamel. It meets up with the enamel at the gumline at what is called the cemento-enamel junction or in dental parlance: the”CEJ”.

Underneath it All

Beneath both the cementum and the enamel is the layer called the dentin. Dentin is made of hydroxyapatite crystals, organic material, and water. It is also yellowish in color although that can vary more. It is also softer than cementum or enamel.

The dentin is composed of dentinal tubules. Miles of tubules- somewhere I learned it was on average about three miles of dentinal tubules – I can’t verify but am still looking so when I find my soucre I’ll link it here. But, suffice it to say there are many, many, many tubules.

Dentinal Tubules – Your tooth is like a box of straws

These tooth tubules are filled with fluid. This dentinal fluid flow is called the dentinal transport system and brings nourishment from the pulp chamber to the rest of the tooth. Research shows this fluid moves through the entire tooth and out into the mouth. It brings the tooth vitamins, minerals, enzymes, and other nutrients from the inner workings of the body and through the pulp chamber to the rest of the tooth. The key to tooth health is this fluid. The problems start when this fluid flow is stopped or reversed – think “backwash” from the mouth into the tooth bringing with it acids, and bacteria, and other microbes from the mouth, down the tubules, and into the inner tooth structure. This is part of the root cause of tooth decay as well as tooth sensitivity which we will dive into in the next post.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Teeth Basics

Teeth put up with a lot: clenching, grinding, acidic environment, and so much more. Yet for the most part silently work hard for us every day. In our next posts, we will dive into how a tooth gets damaged and its responses to that. (I hate it when a tooth talks back!) Then we’ll address how to help heal the tooth and when it’s not possible. I want you to be able to enjoy a glass of ice water on those hot summer days.

Hope you learned a few new basic teeth things, enjoyed your lessons in dental lingo and the fun facts on shark teeth!

Selfcare – note the invisalign braces buttons! Doing some expansion.We’ll talk about that too in a future blog post.

Warmly,

Barbara Tritz

Queen of Dental Hygiene and Princess of Shark Teeth

My Shark Teeth!

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4 April 2024

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Brushing and flossing are essential to maintaining oral health. But did you know that the nutrients you consume or the lack of them can also have a significant impact on your oral health? Your mouth, teeth, and gums are the first points of contact your body has with the foods you eat, and dental health is essential to start the digestion process. Nutrient deficiencies can lead to oral diseases such as inflammation and tooth loss. This means that taking the right vitamins and minerals through foods and supplements can help keep teeth and gums healthy. Keep reading to know the most important vitamins for teeth and gums health.

1. Calcium

Calcium is not just limited to your bones, it is also necessary for the health of your teeth. You may actually be getting some form of calcium in your daily diet right now by consuming dairy products like milk and yogurt, which is easy for your body to absorb.

Calcium is a mineral that everyone knows is good for your bone spur. In fact, tooth enamel is primarily composed of calcium. Therefore, the extra amounts consumed means a strong enamel layer and better prevention of tooth decay.

Some foods containing calcium:

Dairy products such as milk, yogurt, cheese

Fortified nuts

Leafy vegetables (broccoli, kale, bok choy)

Calcium-fortified orange juice

Beans and lentils

2. Phosphorus

Phosphorus is another essential mineral for healthy teeth. It helps absorb and use calcium in the body and strengthens teeth by protecting and regenerating tooth enamel. Our body already contains adequate amounts of phosphorus and most of it can be found in the teeth.

Calcium once again comes into play as it works with phosphorus to build and protect tooth enamel. Keep your baby’s teeth and emerging permanent teeth healthy with protein-rich foods that contain phosphorus.

Red meat, eggs, nuts, legumes, whole grains, seafood (such as tuna and salmon), and dairy products are examples of foods in which phosphorous is found.

3. Vitamin D

Vitamin D plays an important role in maintaining the health of your teeth. Because vitamin D plays an important role in bone and tooth mineralization, it is considered as one of the key vitamins for teeth. Vitamin D deficiency can lead to several oral health disorders, such as gingivitis, cavities, and gum disease.

Vitamin D not only increases mineral density, but also helps absorb, transport, and deposit calcium in the bones that support your teeth. This vitamin is an essential vitamin for the absorption of calcium by the body and thus strengthens the teeth.

Oily fish, such as salmon, sardine, herring, and mackerel are the best vitamin D sources. In addition, eggs, beef liver, fortified milk, breakfast cereals, and mushrooms are great to get your vitamin D.

Our body also produces vitamin D naturally when exposed to the sun, so getting some sun outdoors is also beneficial.

4. Vitamin C

Vitamin C is not only good for your teeth, but it is also a great vitamin for your gums. It plays an important role in keeping teeth strong and healthy. Its deficiency can lead to bleeding gums and gum disease. In addition, vitamin C supplements also reduces erosive tooth decay in early childhood and prevent teeth defects like enamel hypoplasia.

Vitamin C helps in the production and repair of collagen—a protein found in connective tissues. Collagen is the main structural protein found in the gums and helps hold the teeth in place by bonding them to the surrounding bone structure. It also helps strengthen tooth enamel to prevent erosion.

Because vitamin C is water-soluble and not stored in the body, it is important to get it from your diet every day. Good sources of vitamin C include citrus fruits, berries, peppers, broccoli, spinach, sweet potatoes, Brussels sprouts, cantaloupe, and oranges.

5. Vitamin A

Vitamin A is great for your mouth, especially your saliva production. Saliva helps break down food and also removes bacteria from between your teeth.

For healthy gum tissue, you need plenty of vitamin A to maintain strong tissue. Your gums may become inflamed or swollen with lack of necessary vitamins for teeth and gums. This irritation can cause the gums to bleed when brushing or flossing. Eating a diet rich in this nutrient can help maintain healthy gums and reduce the risk of gingivitis and other gum problems.

Oranges, carrots, sweet potatoes, bell peppers, fish, egg yolks, spinach, and almonds are just some foods high in vitamin A.

6. Potassium

Like vitamin D, potassium does wonders for your bone mineral density. It also helps the gum tissue heal faster. Bananas are one of the best sources of potassium. Vegetables with dark leaves, potatoes, avocados, dried plums, milk, and cheese are other foods rich in potassium.

Time to take vitamins and minerals

A healthy diet can provide you with plenty of these vitamins and minerals for your teeth and gums. Taking supplements can be an option in some cases. If you want to take a supplement, talk to your dentist or doctor, as some dietary supplements may react or interact with some prescription medications.

If you are concerned about your vitamin levels, talk to your dentist about supplements or foods you can add to your diet. Understanding how these vitamins affect your teeth can help you take care of your mouth and teeth in the long run.

5 Simple Ways on How to Get Rid of Tired Eyes

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4 April 2024

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Dark circles, puffy eyelids, under-eye bags, and signs of aging – feeling any of these currently? These may happen due to dehydration, UV damage, and genetic predisposition, leading to tired-looking eyes. So, how to get rid of tired eyes?
That’s our question of the day. Let’s discuss why your eyes feel and appear tired and what you can do about it. After all, eyes are our windows to the soul and must radiate, right?
Let’s get into it.

What are the Causes of Tired Eyes?
To get rid of tired eyes, you need to understand why your eyes get strained in the first place. Here are some common reasons:
Digital Eye Strain
Dr. Muhammad Saad Aziz suggests prolonged exposure to digital screens, such as those on computers, tablets, and smartphones, can cause digital eye strain. The screens emit blue light, leading to eye fatigue, dryness, and difficulty focusing.
Regular breaks and using blue light filters on devices can help alleviate this strain.
Suggested Read: Is Dark Mode Better for Your Eyes?
Insufficient Sleep
Lack of proper sleep not only affects overall well-being but also impacts the eyes. During sleep, the eyes undergo crucial restorative processes.
Insufficient rest can result in swollen, puffy eyes, dark circles, and general eye fatigue.
Dry Eyes
Insufficient lubrication on the eye’s surface leads to dry eyes.
Environmental factors like low humidity, excessive screen time reducing blink rates, certain medications, and age-related changes can contribute to inadequate tear production, causing discomfort and tiredness.
Eye Allergies
Allergic reactions to substances like pollen, dust, or pet dander can manifest in the eyes, leading to itching, redness, and swelling.
Persistent exposure to allergens can cause chronic eye fatigue, emphasizing the importance of identifying and managing allergies.
Incorrect Prescription or Vision Problems
Wearing outdated or incorrect prescription glasses can strain the eye muscles as they work harder to focus.
Undiagnosed vision problems, such as astigmatism or hyperopia, can contribute to eye fatigue.
What Happens to the Eyes with Untreated Tiredness?
Consistent tiredness of the eyes, if left unaddressed, can lead to various eye-related issues. Here’s a detailed explanation of what happens:
Eye Strain
Prolonged use of digital devices or focusing on tasks for extended periods without breaks can cause eye strain. This strain results in discomfort, headaches, and blurred vision.
The eye muscles become fatigued, making it challenging to maintain focus.
Dry Eyes
Continuous screen time or environmental factors can contribute to insufficient tear production, leading to dry eyes. The eyes lack proper lubrication without an adequate tear film, causing irritation, redness, and a gritty sensation.
Dry eyes can worsen if not addressed, affecting overall eye health.
Dark Circles and Puffiness
Lack of sleep and fatigue contribute to dark circles and eye puffiness.
The skin around the eyes is delicate and prone to fluid retention, leading to a tired and worn-out appearance.
Decreased Productivity
Consistent eye tiredness can impact daily activities, reducing productivity and efficiency.
Tasks that require sustained focus become more challenging, affecting work or academic performance. You may need help to concentrate and complete tasks effectively.
Increased Sensitivity to Light
Tired eyes often become more light-sensitive, causing discomfort in well-lit environments. Bright lights, including those emitted by screens, may exacerbate eye fatigue.
This increased sensitivity can make it challenging to engage in activities that involve prolonged exposure to sunlight.
Headaches and Migraines
Eye strain and tiredness can trigger headaches and migraines. The eye muscles, when overworked, can lead to tension headaches.
Moreover, the connection between the eyes and the brain means that eye fatigue can contribute to migraine episodes in vulnerable people.
Impaired Vision
Prolonged eye fatigue may result in temporarily blurred or distorted vision. It can affect the ability to see clearly, especially when focusing on objects up close.
You may experience difficulties in reading or performing tasks that require visual acuity.
Increased Risk of Eye Infections
Tired eyes may be prone to infections due to reduced tear production and compromised eye hygiene.
Rubbing tired eyes with hands that carry bacteria or dust can introduce pathogens, increasing the risk of eye infections such as conjunctivitis.
How to Get Rid of Tired Eyes?
If you want healthy eyes, you must pay attention to tired eyes. We have compiled some tips on how to get rid of tired eyes in an easy way.
Follow the 20-20-20 Rule
Take a break every 20 minutes by looking at something 20 feet away for at least 20 seconds. This simple rule helps relax your eye muscles and prevents continuous strain from staring at screens.
It’s like giving your eyes a mini-free time during work or study sessions.
Blink Regularly
Blinking is like a natural refresh button for your eyes. When you’re focused on a screen, you tend to blink less, leading to dry and tired eyes.
Make a conscious effort to blink frequently; it helps spread moisture over your eyes, reducing dryness and fatigue.
Adjust Screen Settings
Tweak the brightness, contrast, and font size on your devices. Bright screens can strain your eyes, especially in low-light environments.
A well-adjusted screen can make a significant difference, reducing eye strain and fatigue. Consider using blue light filters to minimize the impact of digital screens.
Stay Hydrated
Drink plenty of water throughout the day. Proper hydration ensures your eyes stay moist and comfortable.
Dehydration can lead to dry eyes, causing irritation and fatigue. Think of it as giving your eyes a sip of water to keep them happy and refreshed.
Apply Warm Compress
A warm compress is like a spa treatment for your eyes. It improves blood circulation and relaxes eye muscles.
Place a warm, damp cloth over closed eyelids for a few minutes. It’s a soothing ritual that helps reduce eye strain, leaving your eyes feeling rejuvenated and less tired.
When Should You See an Ophthalmologist?
You should consult an ophthalmologist if you experience persistent eye fatigue that doesn’t improve with rest. Seeking professional eye care is crucial if your tired eyes have other symptoms, such as blurry vision, headaches, or eye discomfort.
We recommend regular eye check-ups if you work extensively on digital screens or have health conditions that may affect your eyes.
Consult the best eye doctor in Lahore by booking an appointment via Healthwire.

Ways to Change Negative Thinking

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4 April 2024

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We all have thoughts that invade our brains from time to time and mess with our moods. We all get down.Whether it’s your job, your social life, your family, or something completely different, sometimes the negativity can be too much.”We all have it. We all have it,” says Mark Reinecke, a professor emeritus of psychology and behavioral sciences at Northwestern University’s Feinberg School of Medicine.Natalie Dattilo, PhD, a clinical health psychologist at Brigham and Women’s Hospital in Boston, agrees.”Thoughts that we have that we would classify as negative or unhelpful are pretty normal. We all have thoughts that somebody might say, ‘Oh that’s kind of negative.’ “Sometimes it is, and sometimes that’s just kind of an accurate description of a bad situation.”But what can you do about those negative thoughts?They may be common, but negative thoughts aren’t harmless or to be taken lightly. Research shows that having them over and over, while you have depression and anxiety, can lead to serious emotional and physical problems. A bout of negative thinking now and then or a random negative thought here or there may not mean much. But having them over and over for a period of time can quickly overwhelm a person. Using words like never or always — “It’s always going to be like this,” or “I’m never going to be any good” — are a red flag.Ruminating — dwelling on negative thoughts — can be dangerous.”People often talk about thought loops and thought spirals, this sort of chaining of bad things,” Dattilo says. “It does tend to snowball. And that’s the part where it can become problematic.”It’s less about the content of the thought, and more about the process, and the inability to let it go, having it run through your mind over and over and over again,” she says “Those tend to be negative for people. People are rarely ruminating on other things.”How can you tell that the way that you’re thinking is doing more harm than good? “Is it affecting your relationships? Is it affecting your work? Is it leading you to do things that are really harmful, like alcohol and drug use? Are the ways that you’re coping with it getting you into trouble? If they are, you probably need to talk to somebody,” Reinecke says.”If it’s persistent, if it goes on for more than 2 weeks, if you just can’t get out of this cycle, you probably need to talk to somebody.”If you have suicidal thoughts, and particularly if you make any behavior — you write a suicide note or pick up that bottle of pills in the medicine cabinet — you need to talk to somebody,” he says.Reinecke suggests several ways to help break the grip of negative thinking. Many of the methods he suggests fall under the umbrella of cognitive behavioral therapy (CBT), a treatment that focuses on ways to change unhealthy ways of thinking and behaving. Essentially, it’s thinking about the way we think. A psychologist or psychiatrist can help you with it.In the meantime, some ideas:Acknowledge the emotions. Feeling sad because of the death of a loved one? Laid off? Anyone would be sad. It’s serious stuff. You have to realize that it’s natural to have negative thoughts.Identify and clarify the thought. Pick apart the most distressing thought. Why is it bad to feel this way? Understand the implications of the way you’re thinking. Treat the thought as an object.Evaluate the emotions. Sit back and think it through. What’s the evidence for and against this way of thinking? By trying to be clear and rational, you often come to a new insight. Set the thought aside, even for just a moment: “Hmmm, that’s interesting,” or “Well, there you have it.” Taking the emotions out of the equation can help you gain a different perspective.Come at it from a different angle. Is there another way to look at this? Example: How could this be of benefit to me? Maybe you’ll recognize that adversity builds character, resilience comes from loss, and that good can come from pain. So what? “And by so what,” Reinecke says, “I mean ‘so what?’ ” The idea is that whatever you’re going through, in the grandest scheme of things, is not that big of a deal. Death is part of life. People go on, and even thrive, after broken relationships all the time. Keep whatever is causing your negative thoughts in perspective, don’t be reactive, and take the longer-term view.Experts suggest a range of other methods to cope with negative ways of thinking:Distractions like exercise, reading, doing a puzzle, meeting with friends — simply trying to clear your mind of the problems that affect it — is certainly one way. Writing things down, a form of clarifying your thoughts, is another. “Sometimes the answer is right there in front of you,” Dattilo says.Friends and family members can help by staying engaged with, and not withdrawing from, those who are wrangling with unhealthful ways of thinking. Acknowledging their point of view, maybe offering a sympathetic ear — “Well, sounds like you have a lot on your mind,” or “Do you think it would help to think about it like this?” — can be useful. Certainly, professional help is always an option. The key to quelling harmful, negative thoughts may be more in how we think, rather than what we think.”There’s a lot of people who tend to see the world [as] glass half-empty but believe that they’re fully justified in the way that they see it,” Dattilo says. “My job isn’t to necessarily argue with them about that, or to convince them to see the world differently.”My question to them would be, ‘How does it make you feel to think that way?’ And if your goal is to feel better, or have better relationships, or to have more fun, ‘Does thinking like that help you?’ “

Ulcerative Colitis vs Crohn’s Disease | IBD

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4 April 2024

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Ulcerative Colitis vs Crohn’s Disease | IBD

Introduction
There are two main types of idiopathic inflammatory bowel disease (IBD) – ulcerative colitis and Crohn’s disease.
Although both share many similarities in the signs, symptoms and pharmacological management, key distinctions can be made from the location of the inflammation and the histopathological findings.
Want discounted access to all Geeky Medics products, including our medicine flashcard collection? Check out our bundles to save money and supercharge your learning 🔥
Ulcerative colitis
Ulcerative colitis is a chronic inflammatory disease with a relapsing-remitting course. The disease is localised to the colon, with the rectum being the most commonly affected site.1
The underlying aetiology isn’t clear, but it is thought to be linked to environmental and epigenetic factors, including a positive family history.2 Smoking is thought to protect against developing ulcerative colitis.3
Clinical features
Clinical features of ulcerative colitis include:1

Diarrhoea (often bloody ± mucus)
Faecal urgency/incontinence
Tenesmus
Abdominal pain (often felt in the LLQ) and bloating
Fatigue/malaise
Anorexia
Fever
Weight loss

Extra-intestinal manifestations of UC
Extra-intestinal manifestations can be present in up to 30% of patients and include:1,4

Musculoskeletal conditions: pauci-articular arthritis, enthesitis, tenosynovitis, dactylitis
Ophthalmological conditions: episcleritis, scleritis, uveitis
Bone disease: osteopenia, osteomalacia and osteoporosis
Skin lesions: erythema nodosum, pyoderma gangrenosum, aphthous mouth ulcers
Hepatobiliary conditions: primary sclerosing cholangitis, gallstones, autoimmune hepatitis
Haematological conditions: thromboembolism, anaemia

Investigations
Relevant blood tests include:1,5

Relevant stool tests include:

Faecal calprotectin: raised in inflammatory bowel disease but not irritable bowel syndrome (IBS)
Stool microscopy and culture (screen for Clostridium difficile toxin and other infectious microorganisms)

Diagnosis
Ulcerative colitis is usually diagnosed with endoscopic imaging and a biopsy. Options include:5

Flexible sigmoidoscopy: imaging is limited to the distal colon but requires less bowel preparation than a colonoscopy
Colonoscopy: may be required if disease extends more proximally
Abdominal X-ray: sometimes requested to screen for bowel obstruction or toxic megacolon
CT scan with contrast: may be considered to rule out other pathologies and diagnoses

Histology
Histopathological analysis in ulcerative colitis shows:6,7

Continuous inflammation that does not extend beyond the colonic submucosa
Erythema ± ulceration
Crypt abscesses and neutrophil infiltration
Depleted colonic goblet cells
Inflammatory polyps

Management
Management is broadly divided into inducing remission and maintaining remission.
Pharmacological options include:1

Aminosalicylates (e.g. mesalazine and sulfasalazine)
Corticosteroids (can be given topically, orally or intravenously)
Calcineurin inhibitors (e.g. tacrolimus or ciclosporin)
Immunosuppressants (e.g. thiopurines or methotrexate)
Biologics (e.g. infliximab and adalimumab)

Surgical management
There are a few different options for surgery, including a subtotal colectomy with ileostomy, colectomy with ileo-rectal anastomosis, proctocolectomy with ileostomy and restorative proctocolectomy with ileo-anal pouch.8

Crohn’s disease
Like ulcerative colitis, Crohn’s disease is a relapsing-remitting chronic inflammatory disease of the gastrointestinal tract.
However, Crohn’s disease can affect any part of the gastrointestinal tract.9
Again, the aetiology of Crohn’s disease is thought to be linked to a mix of genetic factors, including a positive family history and environmental/lifestyle factors, with smoking being one of the key risk factors.10,11
Clinical features
Clinical features of Crohn’s disease include:9,12

Persistent diarrhoea (may be bloody ± mucus ± pus)
Abdominal pain (RLQ pain/mass may be reported if terminal ileum affected)
Tenesmus
Fever
Malaise/fatigue
Anorexia
Aphthous ulcers
Perianal lesions (fissures, abscesses, fistulas)
Weight loss/faltering growth

Extra-intestinal manifestations of Crohn’s disease
Extra-intestinal manifestations of Crohn’s disease include:9

Musculoskeletal: pauci-articular arthritis (most common extra-intestinal symptom), enthesitis, tenosynovitis, dactylitis
Skin: erythema nodosum, aphthous mouth ulcers, psoriasis, pyoderma gangrenosum
Eyes: episcleritis, uveitis
Bone disease: osteopenia, osteomalacia and osteoporosis
Hepatobiliary conditions: gallstones, primary sclerosing cholangitis

Investigations
Relevant blood tests include:9,12

Full blood count: may show anaemia, leukocytosis and/or thrombocytosis
Urea & electrolytes: as a baseline
Liver function tests: surveillance for primary sclerosing cholangitis
Vitamin B12, vitamin D and folate
CRP/ESR
Iron studies: may show iron deficiency
Coeliac screen: to exclude this as a diagnosis
Yersinia enterocolitica serology: important to exclude

Relevant stool tests include:

Faecal calprotectin: raised in inflammatory bowel disease but not irritable bowel syndrome (IBS)
Stool microscopy and culture (screen for Clostridium difficile toxin and other infectious microorganisms)

Diagnosis
Diagnosis is normally achieved with a colonoscopy with multiple biopsies.9,12
Other imaging options include:

MRI of the abdomen/pelvis
CT abdomen: helps look for other features, including abscesses and fistulas
Abdominal X-ray: can visualise bowel loop distension and rule out other pathologies
Abdominal/pelvic ultrasound

Histology
Histopathological analysis in Crohn’s disease shows:13,14

Transmural inflammation
Cobblestone appearance of the mucosa
Non-caseating granulomas
Skip lesions (due to patchy distribution of inflammation)

Management
Again, management focuses on inducing and maintaining remission.
Pharmacological options include:9

Corticosteroids
Immunosuppressants (e.g thiopurines or methotrexate)
Biologics (e.g infliximab and adalimumab)
Aminosalicylates (e.g mesalazine and sulfasalazine)

Surgical management15
There are several different options for surgery, including strictureplasty, ileocaecal resection, a segmental colectomy, right hemicolectomy, subtotal colectomy with ileostomy, colectomy with ileorectal anastomosis and proctocolectomy with ileostomy.
As Crohn’s disease can affect the entire gastrointestinal tract, surgery is not curative but can greatly improve symptoms.

Summary table
Table 1. Table displaying the key differences between ulcerative colitis and Crohn’s disease

Ulcerative colitis
Crohn’s disease

Clinical features

Persistent diarrhoea (often bloody ± mucus)
Abdominal pain (LLQ)
Tenesmus
Faecal urgency/incontinence
Fatigue/malaise
Weight loss

Diarrhoea (sometimes bloody ± mucus ± pus)
Abdominal pain (RLQ)
Tenesmus
Faecal urgency/incontinence
Fatigue/malaise
Weight loss/faltering growth
Perianal lesions
Aphthous ulcers

Location of disease
Colon (most commonly affected area is the rectum)
Entire GI tract (most commonly affected area is the ileum)

Histopathology

Continuous inflammation that does not extend beyond colonic submucosa
Erythema ± ulceration
Crypt abscesses and neutrophil infiltration
Depleted goblet cells
Inflammatory polyps

Transmural inflammation
Cobblestone appearance of mucosa
Non-caseating granulomas
Skip lesions

Treatment options

Aminosalicylates
Corticosteroids
Calcineurin inhibitors
Immunosuppressants
Biologics
Surgery (can be curative)

Aminosalicylates
Corticosteroids
Immunosuppressants
Biologics
Surgery (not curative)

References

NICE CKS. Ulcerative colitis [Internet]. NICE. 2020. Available from: [LINK]
Childers RE, Eluri S, Vazquez C, Weise RM, Bayless TM, Hutfless S. Family history of inflammatory bowel disease among patients with ulcerative colitis: A systematic review and meta-analysis. Journal of Crohn’s and Colitis. 2014 Nov;8(11):1480–97.
Guslandi. Nicotine treatment for ulcerative colitis. British Journal of Clinical Pharmacology [Internet]. 2001 Dec 24;48(4):481–4. Available from: [LINK]
Lynch WD, Hsu R. Ulcerative colitis [Internet]. Nih.gov. StatPearls Publishing; 2022. Available from: [LINK]
BMJ Best Practice. Ulcerative colitis [Internet]. bestpractice.bmj.com. 2023 [cited 2023 Dec 20]. Available from: [LINK]
DeRoche TC, Xiao SY, Liu X. Histological evaluation in ulcerative colitis. Gastroenterology Report. 2014 Aug 1;2(3):178–92.
Singh V, Johnson K, Yin J, Lee S, Lin R, Yu H, et al. Chronic Inflammation in Ulcerative Colitis Causes Long-Term Changes in Goblet Cell Function. Cellular and Molecular Gastroenterology and Hepatology. 2022;13(1):219–32.
Surgery for Ulcerative Colitis [Internet]. Crohnsandcolitis.org.uk. 2022. Available from: [LINK]
NICE CKS. Crohn’s disease [Internet]. NICE. 2020. Available from: [LINK]
Torres J, Gomes C, Jensen CB, Agrawal M, Ribeiro-Mourão F, Jess T, et al. Risk Factors for Developing Inflammatory Bowel Disease Within and Across Families with a Family History of IBD. Journal of Crohn’s and Colitis. 2022 Aug 9;17(1).
Ss M, Ks M, Re S, Ca H, S G. Smoking and Inflammatory Bowel Disease: A Meta-Analysis [Internet]. Mayo Clinic proceedings. 2006. Available from: [LINK]
BMJ Best Practice. Crohn’s disease [Internet]. bestpractice.bmj.com. 2023 [cited 2023 Dec 18]. Available from: [LINK]
McDowell C, Farooq U, Haseeb M. Inflammatory Bowel Disease [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2023. Available from: [LINK]
Ranasinghe IR, Hsu R. Crohn Disease [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2022. Available from: [LINK]
Surgery for Crohn’s Disease [Internet]. crohnsandcolitis.org.uk. 2022. Available from: [LINK]

Addressing disparities in neurology by building the workforce in LMICs

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4 April 2024

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Addressing disparities in neurology by building the workforce in LMICs

Not enough neurologists exist in the world, and disparities are most apparent in low-income countries, where the World Health Organisation reports only three neurologists for every 10 million people. Physicians without extra training in neurology cannot be expected to teach the bedside examination, train others in the field or even recognize neurology as a possible career path. The aim of my work is to address this gap by improving neurology capacity in LMICs to ultimately improve global brain health.I first began my journey in global neurology at an academic hospital in Harare, Zimbabwe. I was lucky to partner with an amazing internist who had apprenticed with a neurologist years before and was essentially the only neurologist in the country. He wanted to improve inpatient stroke mortality, which was 35% (compared with 2% in the USA).Using a design-thinking approach mixed with literature review, we created an evidenced-based stroke management protocol that can guide physicians even if a CT scan is not available to distinguish ischaemic from haemorrhagic stroke. We moved patients around to create a physical stroke unit, which is known to reduce stroke mortality in countries regardless of income level. The stroke unit enabled a more consistent application of protocols (for example, not feeding individuals at risk of aspiration).One unintended consequence — but possibly the most powerful — was that the stroke unit became a concentrated hub for neurology education and clinical care. Physical therapists were able to give more consistent care to patients with stroke and began to send their students to the unit to learn neuro-rehabilitation. Internal medicine trainees also rotated through the stroke unit and found themselves on a neurology rotation and could visualize the specialty as a possible career. With an emphasis on clinical neurology education, the stroke unit enables sustainable neurology capacity building that will continue to improve neurological health in this region.“the stroke unit became a concentrated hub for neurology education and clinical care”

What Medications Treat Nasal Polyps?

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4 April 2024

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Tired of living with a stuffy nose, postnasal drip, sinus infections, facial pain, poor sense of smell, and the other symptoms that come with nasal polyps? It’s time to seek treatment.“There are a full array of treatments available for nasal polyps,” says Cecelia Damask, DO, an ear, nose, and throat specialist in Lake Mary, FL.Your doctor can create a treatment plan that aims to shrink or eliminate these noncancerous growths in your nostrils and sinus cavities, allowing you to breathe easier.These are the most common medications used to treat nasal polyps:Topical steroids: This is usually the first treatment doctors recommend for nasal polyps. These medications, delivered into your nasal passages via drops, sprays, nebulizers, and inhalers, reduce inflammation and shrink nasal polyps.They’re not only effective, but have fewer side effects than oral steroids, Damask says.Your doctor can prescribe topical steroids, and you can buy over-the-counter versions as well. It’s safe to use them long-term. Your symptoms will return when you stop using them. Many people use them along with other treatments. Research shows that combining topical and oral steroids is more effective to shrink polyps and improve your sense of smell than topical steroids alone.A newer tool called an exhalation delivery system (EDS) may work better than conventional nasal sprays to deliver the medication where you need it. An EDS connects to your nose and mouth. You blow into the device, sending the medication high into your nasal cavity.Oral steroids: Oral steroids are among the most common treatments for nasal polyps. Doctors may prescribe them:When you have serious sinus diseaseIf your nasal polyps tend to come backWhen sprays don’t work to shrink your polyps or reduce symptoms“Oral steroids do a great job,” Damask says.Still, they come with some risks. Repeated use of oral steroids has been linked to serious side effects like high blood sugar, cataracts, glaucoma, osteoporosis, bone fractures, and heart problems, she says.“As few as four lifetime bursts of oral steroids could result in these side effects,” Damask says. Because of the risk of side effects, your doctor probably won’t recommend using oral steroids long term. Their effects usually last for a few months.Injectable steroids: Your doctor can inject steroid medication directly into nasal polyps, which helps more medication reach the site. The effects of injectable steroids should last for at least 3 months.They’re as effective as oral steroids for reducing inflammation, easing symptoms, and shrinking polyps, but tend to have fewer side effects. A few people have had short-term vision loss as a side effect, though.Your doctor may recommend steroid injections if your polyps are serious. But if you have several large polyps, injections may not work to eliminate them.Antibiotics: Nasal polyps and sinus infections often go hand in hand. Your doctor may prescribe antibiotics if you have a bacterial sinus infection along with nasal polyps. (Most sinus infections are caused by viruses, so antibiotics don’t work to treat them.)The antibiotics treat the infection, which causes inflammation. You’ll get other medications, like steroids, to shrink the polyps. Antihistamines and decongestants: While these medications don’t actually treat nasal polyps, your doctor may recommend them in addition to other treatments to help control symptoms such as runny nose, congestion, and itchy eyes, says Yasmin Bhasin, MD, allergist and immunologist at Allergy Asthma Care in Middletown, NY.“Antihistamines and decongestants can also reduce swelling in the nose,” she says.Biologics: In 2019, the FDA approved the use of biologics for nasal polyps. These injectable medications target the proteins that cause inflammation and swelling. Bhasin calls biologics “the ultimate weapon” against nasal polyps.You’ll get the first few doses in your doctor’s office so your doctor can watch for side effects, which can include pain, redness, and swelling at the injection site, she says. If you have no side effects, you can use a special pen to give yourself the injections at home.Research has found that people who took biologics had less severe sinus infections, an improved sense of smell, and smaller nasal polyps.Immunotherapy: Allergies cause inflammation that can trigger the growth of nasal polyps. So it makes sense that getting allergy shots could help. One study found that people with nasal polyps who got immunotherapy injections every 2 weeks for a year had fewer symptoms and fewer polyps. They also had few side effects from the medication.Treating your allergies can also lessen the risk that nasal polyps will return, Bhasin says.Aspirin desensitization: People with an intolerance to aspirin intolerance are at higher risk for developing nasal polyps. Aspirin intolerance appears to increase the release of eosinophils, white blood cells that increase inflammation.Aspirin desensitization involves taking aspirin in increasing doses, under medical supervision. The goal is to prevent nasal polyps from coming back and decrease your need to take steroid medications.While there are many medications available to treat nasal polyps, you might need surgery if they don’t work well enough.But it’s not a cure. Nasal polyps tend to come back. Research found that 79% of people who had the surgery developed additional growths within 12 years. And more than one-third had additional surgeries. Still, treatment is important to keep your symptoms under control and improve your quality of life.“There is a lot that can be done that can really help,” Bhasin says.

Upper Gastrointestinal Bleeding | Acute Management

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4 April 2024

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Upper Gastrointestinal Bleeding | Acute Management

This guide provides an overview of the recognition and immediate management of upper gastrointestinal bleeding (UGIB) using an ABCDE approach.
The ABCDE approach is used to systematically assess an acutely unwell patient. It involves working through the following steps:

Airway
Breathing
Circulation
Disability
Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified, and the patient is re-assessed regularly to monitor their response to treatment.
This guide has been created to assist healthcare students in preparing for emergency simulation sessions as part of their training. It is not intended to be relied upon for patient care.
You may also be interested in our overview of the ABCDE approach and other ABCDE approach guides.

Clinical features of upper gastrointestinal bleeding
Typical clinical features of upper gastrointestinal bleeding include:

Haematemesis: typically ‘coffee-ground’ in appearance due to the presence of partially digested blood
Malaena: black, tarry stools caused by the presence of digested blood
Abdominal pain: typically epigastric in location but can be diffuse
Haematochezia: the passage of fresh red blood per rectum, although more common in lower gastrointestinal bleeding it can occur in the context of profuse upper gastrointestinal haemorrhage due to the rapid transit of blood through the gastrointestinal tract
Haemodynamic instability: tachycardia, hypotension, syncope

Causes
Causes of upper gastrointestinal bleeding include:

Peptic/duodenal ulcers: can be secondary to Heliobacter pylori or NSAIDs
Oesophageal erosions
Mallory-Weiss tear (usually a history of forceful retching preceding any bleeding)
Oesophageal varices due to portal hypertension (e.g. advanced liver cirrhosis)
Malignancy: bleeding tumour or erosion of gastrointestinal vessels

Patients may have clinical signs of the underlying condition causing gastrointestinal bleeding (e.g. ascites and jaundice in advanced liver cirrhosis).
You might also be interested in our premium collection of 1,000+ ready-made OSCE Stations, including a range of ABCDE assessment and emergency stations 🚑
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include:

Treat problems as you discover them
Re-assess regularly and after every intervention to monitor a patient’s response to treatment
If the patient loses consciousness and there are no signs of life, put out a crash call and commence CPR
Make use of the team around you by delegating tasks where appropriate
All critically unwell patients should have continuous monitoring equipment attached
Clearly communicate how often you would like the patient’s observations relayed to you by other staff members
If you require senior input, call for help early using an appropriate SBAR handover
Review results as they become available (e.g. laboratory investigations)
Use local guidelines and algorithms to manage specific scenarios (e.g. acute asthma)
Any medications or fluids must be prescribed at the time (you may be able to delegate this to another staff member)
Your assessment and management should be documented clearly in the notes. However, this should not delay management. The A-E approach can also form the structure for documenting your assessment.

Initial steps
Acute scenarios typically begin with a brief handover, including the patient’s name, age, background and the reason the revie has been requested.
You may be asked to review a patient with UGIB due to tachycardia, hypotension, malaena and/or haematemesis.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient, including your name and role.
Ask how the patient is feeling, as this may provide useful information about their condition.
If the patient is unconscious or unresponsive, and there are no signs of life, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Preparation
Ensure the patient’s notes, observation chart, and prescription chart are easily accessible.
Ask for another clinical member of staff to assist you if possible.

Airway
Clinical assessment
Can the patient talk?
Yes: if the patient can talk, their airway is patent, and you can move on to the assessment of breathing.
No:

Look for signs of airway compromise: angioedema, cyanosis, see-saw breathing, use of accessory muscles
Listen for abnormal airway noises: stridor, snoring, gurgling
Open the mouth and inspect: look for anything obstructing the airway, such as blood, secretions or a foreign object

Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often called the ‘crash team’). You can perform basic airway manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient’s airway using a head-tilt chin-lift manoeuvre:

Place one hand on the patient’s forehead and the other under the chin
Tilt the forehead back whilst lifting the chin forwards to extend the neck
Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to try and remove it. Be careful not to push it further into the airway.

Jaw thrust
If the patient is suspected of having suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

Identify the angle of the mandible
Place two fingers under the angle of the mandible (on both sides) and anchor your thumbs on the patient’s cheeks
Lift the mandible forwards

Other interventions
Airway adjuncts are helpful and, in some cases, essential to maintain a patient’s airway. They should be used in conjunction with the manoeuvres mentioned above.
An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it may induce gagging and aspiration in semi-conscious patients.
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in partly or fully conscious patients than oropharyngeal airways.
Re-assessment
Make sure to re-assess the patient after any intervention.

Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate:

A normal respiratory rate is between 12-20 breaths per minute
Tachypnoea is often the first indication of shock due to hypovolaemia

Review the patient’s oxygen saturation (SpO2):

A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD at high risk of CO2 retention
Hypoxaemia may occur secondary to shock or aspiration pneumonia

Auscultation
Auscultate the chest to screen for evidence of other respiratory pathology (e.g. coarse crackles may be present if the patient has developed aspiration pneumonia or pulmonary oedema secondary to fluid resuscitation).
Investigations and procedures
Arterial blood gas
Take an ABG if indicated (e.g. low SpO2) to quantify the degree of hypoxia.
Chest X-ray
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for evidence of aspiration pneumonia. A chest X-ray should not delay the emergency management of UGIB.
Interventions
Patient positioning
If the patient is conscious, sit them upright, which can help with oxygenation.
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves using a non-rebreathe mask with an oxygen flow rate of 15L. You can then trial titrating oxygen levels downwards after your initial assessment. In COPD, target SpO2 levels accordingly (88-92%) and consider using a Venturi mask: 24% (4L) or 28% (4L)
Adequately oxygenating the patient is important. However, be aware of the risks of aspiration if the patient vomits whilst wearing an oxygen mask.
Re-assessment
Make sure to re-assess the patient after any intervention.

Circulation
Clinical assessment
Pulse
Tachycardia is an early sign of volume depletion in the context of UGIB. The patient’s pulse may feel thready secondary to hypovolaemia.
Blood pressure
Hypotension is a late sign and suggests significant blood loss has occurred (>1500ml).
Fluid balance assessment
Calculate the patient’s fluid balance:

Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts
Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult
Urine output is maintained until significant blood loss has occurred (e.g. 1500-2000 mls)

Inspection
Inspect the patient from the end of the bed and note evidence of pallor indicative of anaemia.
Capillary refill time
Assess the patient’s capillary refill time (CRT):

In the context of UGIB, the CRT may be prolonged (>2 seconds) both peripherally and centrally
The patient’s peripheries may also feel cool secondary to hypovolaemia and peripheral vasoconstriction

Investigations and procedures
Intravenous cannulation
Insert two large-bore cannulae (14-16G) and take blood tests as discussed below.
Adequate intravenous access is essential in upper gastrointestinal bleeding as patients can rapidly deteriorate with haemodynamic instability, requiring large volumes of fluid and blood to be transfused.
Blood tests
Request a full blood count (FBC), urea & electrolytes (U&E) and liver function tests (LFTs) for all acutely unwell patients. In the context of upper gastrointestinal haemorrhage, also request:

Group and crossmatch: to confirm the patient’s blood group and request blood products
Coagulation screen: to screen for coagulopathy and inform resuscitation efforts

Raised urea occurs in the context of UGIB due to the digestion and absorption of blood proteins.
The haemoglobin level is used to guide transfusion.
Interventions
Strict fluid balance
If not already in place, ask for a strict fluid balance to carefully monitor the patient’s fluid status to inform ongoing resuscitation efforts.
Aim for a urine output of greater than 30mls an hour.
Fluid resuscitation
Hypovolaemic patients require fluid resuscitation:

Administer a 500ml bolus of Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).
Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.
If the patient is losing significant volumes of blood, fluid replacement alone is inadequate, and blood transfusion needs to be arranged (see below).
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or isn’t responding adequately to repeated boluses (i.e. persistent hypotension).
See our fluid prescribing guide for more details on resuscitation fluids.
Blood transfusion
Patients with a significant haemorrhage who are in shock need a balanced transfusion of red cells, platelets and fresh frozen plasma.
This is usually arranged via a massive transfusion protocol which simplifies the ordering and administration of large amounts of blood products (usually at least six units of red cells).
Haemodynamically stable patients should receive red cell transfusion if Hb is <70 g/L with a target Hb of 70 – 100 g/L.
Reversal of anticoagulation
Patients on anticoagulation (warfarin or DOACs) should be discussed with a senior clinician to consider the reversal of anticoagulation. This may require haematology input.
Prothrombin complex concentrate can be used in patients taking warfarin and actively bleeding.
Terlipressin
Terlipressin causes vasoconstriction of the splenic artery, reducing blood pressure in the portal system. It is recommended for all patients with suspected variceal bleeding at presentation. It should be stopped once definitive haemostasis has been achieved.
This should be a consultant-led decision.
Prophylactic antibiotic therapy
Administer prophylactic antibiotics to patients with suspected or confirmed variceal bleeding. Follow local microbiology guidelines. Ciprofloxacin 1g once daily for seven days is a commonly used regime.

Proton pump inhibitors
Proton pump inhibitors (PPIs) reduce the amount of acid the stomach produces. They can also reduce re-bleeding rates in patients with non-variceal upper GI bleeding. However, due to a lack of evidence, NICE currently does not advise routine prescribing of intravenous PPIs before endoscopy.

Endoscopy
Endoscopy should be performed on all unstable patients with severe UGIB immediately after resuscitation. It should be performed within 24 hours of admission for all other patients with UGIB. This allows diagnostic confirmation and treatment of bleeding sites.
Patients should be discussed with the on-call endoscopist.
Re-assessment
Make sure to re-assess the patient after any intervention.

Disability
Clinical assessment
Consciousness
In the context of UGIB, a patient’s consciousness level may be reduced secondary to hypotension or hepatic encephalopathy.
Assess the patient’s level of consciousness using the ACVPU scale:

Alert: the patient is fully alert
Confusion: the patient has new onset confusion or worse confusion than usual
Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt)
Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure)
Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient’s pupils:

Inspect the size and symmetry of the patient’s pupils
Assess direct and consensual pupillary responses

Drug chart review
Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).
Also, look for medications which may worsen bleeding:

Warfarin
Direct acting antiocagualants (DOACs): apixaban, rivaroxaban etc.
Antiplatelets

Investigations and procedures
Blood glucose and ketones
Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.
See our blood glucose measurement guide for more details.
Interventions
Maintain the airway
Alert a senior clinician immediately if you have concerns about a patient’s consciousness level.
A GCS of 8 or below, or a P or U on the ACVPU scale, warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway, as explained in the airway section of this guide.
Correct hypoglycaemia
Hypoglycaemia should always be considered in patients presenting with a reduced level of consciousness, regardless of whether they have diabetes. The management of hypoglycaemia involves the administration of glucose (e.g. oral or intravenous).
See our hypoglycaemia guide for more details.
Re-assessment
Make sure to re-assess the patient after any intervention.

Exposure
Exposing the patient during your assessment may be necessary. Remember to prioritise patient dignity and the conservation of body heat.
Clinical assessment
Inspection
Inspect the patient for stigmata of chronic liver disease and/or coagulopathy:

Bruising
Petechiae (e.g. thrombocytopenia)
Spider naevi
Caput medusae
Ascites
Evidence of trauma and bleeding from other sites
Peripheral oedema

Palpation
Perform a brief abdominal examination, which may reveal:

Ascites secondary to cirrhotic liver disease
Abdominal tenderness (e.g. duodenal ulcer)

Temperature
Measure the patient’s temperature:

If fever is present, consider co-existing infection

Rectal examination
Perform a rectal examination to assess for evidence of gastrointestinal bleeding (e.g. malaena).
Interventions
Catheterisation
Catheterise the patient to monitor urine output which can guide fluid resuscitation and the need for escalation.
Re-assessment
Make sure to re-assess the patient after any intervention.

Re-assessment and escalation
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.
Any clinical deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Escalation
Haemodynamically unstable patients with upper gastrointestinal bleeding will require urgent critical care input. The on-call endoscopist should be contacted to consider an urgent endoscopy.
Use an effective SBAR handover to communicate the key information to other medical staff.

Ongoing management
The UK upper gastrointestinal bleeding care bundle guides the management of a UGIB (Figure 1).
Figure 1. The British Society of Gastroenterology upper gastrointestinal bleeding care bundle.
Glasgow-Blatchford score
The Glasgow-Blatchford score (GBS) is calculated before endoscopy and is based on simple clinical and laboratory parameters. Its principal use is to identify low-risk patients who do not require any intervention (blood transfusion, endoscopic therapy, surgery).
Approximately 20% of patients presenting with upper gastrointestinal haemorrhage have a Glasgow-Blatchford score of 0. Such patients can usually be managed as an outpatient, as the mortality in this group is nil.
Rockall score
The Rockall scoring system is used for risk stratification (mortality and risk of rebleeding). Rockall scores can be calculated both before and after endoscopy, but the post-endoscopy Rockall score provides a more accurate risk assessment.

Next steps
Take a history
Revisit history taking to explore relevant medical history, focusing on identifying the cause of upper gastrointestinal bleeding.
See our history taking guides for more details.
Review
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.
See our documentation guides for more details.
Discuss
Discuss the patient’s clinical condition with a senior clinician using an SBAR handover.
Questions which may need to be considered include:

Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
Should any changes be made to the current management of their underlying condition(s)?

The next team of clinicians on shift should be informed of any acutely unwell patient.

References

NICE. Acute Upper Gastrointestinal Bleeding Management. Updated 2016. Available from: [LINK].

Siau K, Hearnshaw S, Stanley AJ, et al. British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding. Frontline Gastroenterology 2020;11:311-323.

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