How to use the knowledge of neuroscience for your own growth: Brain & Mind Growth Hacks

 The use of Prefrontal cortex (PFC) : The prefrontal cortex is the intelligent part of the brain. Never stop dreaming big. It will challenge your prefrontal cortex and it will search the way to find the solutions. It puts your intelligent part of brain on work. It can be done deliberately. Never restrain your dreams because of current situation. have a strong desire for some big goal, Visualise it, subconscious mind understands it so you can pursue it, enjoy the process. Manifestation can be practiced.

  Serotonin: A neurotransmitter which makes you happy. Increase your serotonin level.

  Endorphin is useful hormone. Its level can be increased. Exercise and adopting good lifestyle are easy way of increasing its level.

  Decrease serum cortisol level: avoid unnecessary stress. have good sleep.

   Decrease dopamine level: Avoid addiction forming bad habits.

   Avoid cerebral atrophy: consumption of alcohol and cigarette smoking increases cerebral atrophy. Avoid alcohol addiction and cigarette smoking.

 The most amazing phenomenon is neuroplasticity. The brain is an anatomical structure. Mind is physiological part. Thoughts, Mind, Conscious and subconscious mind are very interesting subjects.  Brain is made up of billion of brain cells (neurons) & trillions of connections (synapses).

Neurons consist of cell bodies (perikaryon), axon & dendrites. Dendrites (dendron means tree) are short,  branched & carry impulses toward the cell body. Axons are usually single and long. Nerve cells convey signals to one another at synapses by releasing chemicals or neurotransmitters.

Human Brain is Born Unfinished. It takes many years to transform from helpless newborn to become an independent person. New born child remains totally dependent on others for survival. Dolphins are born swimming, baby zebra can run within 45 minutes. Is it advantage or limitation? Baby animal brains are wired up for preprogrammed routine. Flexibility, capacity to adopt & ability to thrive in many different environments is possible with human brain because it is born remarkably unfinished.

       

Childhood pruning. The number of brain cells is same in children & adults. Secret lies in how these cells are connected.  At birth, a baby’s neurons are least connected & in first 2 years of life they begin connecting up extremely rapidly as they take in sensory information.In infant, 2 million new connections or synapses/second. By age 2, 100 trillion synapses (2X adult). then neural pruning, carving makes everyone unique.

      All experiences in our life shape the microscopic details of our brain & neural circuits. Because our experiences are unique, brain rewrites our own pattern of neural networks.

  Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively & is able to make a contribution to the community. The mental health moves up & down in response to the life circumstances, it is a state in which same person feels low, euthymic or excited depending upon situation. Not like normal or abnormal. Not like perfect or imperfect. Not like sane or insane.

Range of mental health

No one is perfect, no mental status is permanent, moves up & down with circumstances:

Happy, excited, elated, joyful, optimistic, fulfilment, gratitude

Low energy, feeling negative, disappointed, feeling lonely, sad

Feeling anxious, worried

Life skills

Self awareness, Empathy, Humor

Critical thinking, Decision making, leadership, Problem solving, Effective communication, Interpersonal relationship, Assertiveness

Resilience (Coping with stress and emotions, dealing effectively with challenges)

Ability for adaptive & positive behaviour to deal effectively with the demands & challenges of life (Psychosocial competency)

Value clarification (what is important to me), financial literacy

Habits (Basal ganglia & Prefrontal cortex)

Within 3 weeks a new habit is formed (or break old bad habit & get rid of it)

Tiny/small & incremental changes lead to significant improvement

1% change everyday : walk for 10 minutes, 5 minute aerobics will be enjoyable, requires little effort. So, choose easiest change and repeat. Gradually it will become a habit & create a system

Improve eating habits: balanced diet, eat vegetables, less sugar/salt/oil, less junk food

Practice gratitude, practice appreciation

Maintain Sleep hygiene, Try to wake up early

Practice mindfulness 

Good mental health & subconscious mind

CREATE SYSTEM THROUGH SUBCONSCIOUS MIND 

Emotionally stable

Healthy relationship/connected with other people

Positive outlook, positive self perception

Sound & effective decisions 

Having good sleep

Mindfullness/at peace

Good self care

Feeling happy most of the time

Optimistic, hopeful

Sense of meaning/purpose

Resilient

Pre-frontal cortex

Logical mind 

Planning, decision making, reasoning

Genius of the brain

Put your prefrontal cortex on work ( I cannot afford/ how I can afford? I don’t know/ How I can be expert? )

Amygdala: Emotional control center of brain

Stress, anxiety, fear activate it, which increases cortisol level.

Resilience

        Success is not final, failure is not fatal

• There is no failure. You either win or learn.
• If you survive through  a tough situation, your brain becomes more resilient
• Bounce back, “Rise from the dust.” Recover from setbacks & learn from them
• Turn your failures into stepping stones for success

 You can build resilience

Resilience can be developed, 

Fail fast & learn faster, rapidly testing ideas, learn from mistakes, innovate, encourage mistakes & even celebrate

Helps to face stresses & challenges

Helps to adjust in adverse situations

Bullet proof mindset, act if nothing bothers you

You can outgrow your problems

Neuroplasticity

    Ability of brain to change, adapt & learn new skill  

Billion of neurons & synapses (neuronal connections) make functional networks which change through growth

Dynamic & ever evolving nature of brain

New experience creates new synaptic connections, it helps in personal growth. 

Rewire your brain, fortify your brain, you can consciously & intentionally create new neural connection & level up the mental strength by learning new skills, exposing yourself to new challenges

Brain hacks: Re-train your nervous system : start the day relaxed, meditation, prayer, exercise, watch sun rise, talk to friend or family, choose to slow down little, eat slowly, be relaxed, walk slowly, activates parasympathetic system, learn a new skill/language/musical instrument, non dominant hand exercise ( neurobics ), travel

Neuroplastic rewiring: brain repairs itself, it is core of neuro-rehabilitation concept & practice

  Happy hormones make us happy 

Dopamine

Serotonin

Endorphin

Oxytocin

Mindfulness

Recognise & appreciate things around you & connect to the present moment

Pause, Stillness, calm spend sometime without bothering for anything

Fixed mindset vs growth mindset

   Survive/Thrive 

Linear growth vs exponential growth (compounding)

Most people overestimate what they can achieve in a year and underestimate what they can achieve in 10 years.

“ Your life is a result of the choices you have made. If you don’t like your life, start making better choices ”Zig Ziglar

Risk mitigation & management of neurosurgical complications

The common risk in neurosurgical procedure if occurrence of neurological deficit, bleeding during surgery, oedema due to retraction of the brain tissue, CSF leak, surgical site infection, inadequate decompression of the tumour, brain herniation, etc.

A proper preoperative surgical planning is an important step for risk mitigation.

So, risk mitigation starts with initial clinical work up of the patient. Identification of the co-morbid conditions like diabetes, hypertension, ischemic heart disease, hypothyroidism, endocrinopathy, is the priority of both anesthetist and neurosurgeon. Many co-morbid conditions are not even known to the patient. For example a patient with pituitary tumour may have visual deficits, hemianopia, hypothyroidism, diabetes insipidus of which patient may not be aware. Similarly, patients with brain metastasis may have systemic cancer which remains undetected. 

All exigencies must be considered by a neurosurgeon before operating. For example, during surgery of the spinal cord there is chance of CSF leak. So, dural repair with artificial dura and its reinforcement with fibrin glue must be considered prior to surgery.

In neurosurgery nothing is unexpected. All the steps are well planned. It is like standard operating procedure. It is like checklist of each neurosurgical procedure. 

Prevention and reduction of infection in surgery was possible by introduction of antiseptic principles described by Joseph Lister in 1867. So, the antisepsis must be maintained in operation theatre and also during any invasive procedure in any neurosurgical patient. The use of prophylactic antibiotic significantly reduces the risk of infection in a neurosurgical patient. Part preparation should be done properly and enough time to be given for part preparation. It is surgeon's responsibility to ensure that all staff involved in surgical procedure adheres to the set principles of antisepsis. 

The patients of intracranial brain lesions often present with seizures. Some patients with brain tumours do not present with seizures but are very much likely to develop epilepsy, especially patients with lesions in basifrontal region, at rectus gyrus after surgery. Meningiomas are also epileptogenic. In such patients prophylactic anti epileptic drug be started.

Some intracranial brain lesions have associated vasogenic oedema. So, in high grade gliomas or meningiomas, steroid ( Dexamethasone) to be started before neurosurgical procedure to avoid sudden increase in oedema and any chance of brain herniation.

Sometimes, during surgery, intraoperative Mannitol is given to reduce intracranial pressure. 

Blood loss is a risk during a neurosurgical procedure. So, to reduce blood loss during surgery head end elevation is done during surgery. It reduces intracranial procedure. Enough blood is arranged before surgery depending upon the procedure. 

All neurosurgical procedures are designed in such a manner that there should be minimal retraction of the brain. It reduces need for retraction of the brain and any possibility of post operative edema and subsequent brain schema or brain herniation. It is the basis principle of practising skull base surgical approaches.

Surgical approach to the lesion is always through non-eloquent area of the brain. So, there is immense significance of surface marking and pre-operative surgical planning. Most of the intraparenchymal frontal lobes lesions like frontal lobe gliomas are approached through right middle frontal gyrus just anterior to the coronal suture. Similarly, posteriorly placed intraparenchymal parietal lobe lesions are approached through right sided superior parietal lobe. It is very common practice that ventricular end of the ventriculo-peritonal surgery is introduced either through right middle frontal gyrus just anterior to the coronal suture or through the right superior parietal lobule. The endoscopic third ventriculostomy (ETV) is also done through right middle frontal gyrus by making a bur hole just anterior to the coronal suture in the mid pupillary line.

While planning excision of the cerebral convexity meningioma, the arrangement should be made for dural repair if it involves excision of the tumour along with involved dura.

Since microneurosurgery involves working through narrow surgical corridors a rigid head fixation is essential in order to maintain the desired head position and also even slight head movement may cause damage. So, either Mayfield's head-holder system or Sugita head-holder is used in such neurosurgical procedures. 

Operating surgical chair is to used by neurosurgeon to avoid fatigue and tremors during surgery for better control of cautery, microscope, endoscope, drill, etc.

Neurosurgeon should be the first person to reach the operation theatre and be the last person to leave the operation theatre (If best outcome is expected). never outsource the position of the patient on operation table, marking of the incision, corticectomy to the subordinate. If not sure from the beginning, it will definitely haunt him during the entire neurosurgical procedure. Only after extubation and seeing the expected neurological outcome immediately at the end of neurosurgery ensures homeostasis of any neurosurgical procedure. Only then neurosurgeon becomes sure that operation was done perfectly. It looks a very tough task to spend so much time in surgery and also spending much more time than any body else in your team, but it is true. It must be practised without any exception. It is for perfection. Nobody is perfect but in pursuit of perfection you achieve excellence. 

During spinal surgery bone nibbler is used . it should be used carefully as it may cause damage to the spinal cord. It should just nibble. Don't rotate or tear anything. Don't pull any structure unnecessarily. Use Kerrison ronguers of appropriate numbers, for nibbling small parts of the lamina.

All neurosurgeons are well versed with brain and spinal surgery. Only difference is the expertise in extent excision of the lesion without causing any complication or neurological deficit in a neurosurgical patient. So, risk mitigation is the most important task of neurosurgeon. 

Mastering Neurosurgery Operative Skills

 The neurosurgery operative skill can be mastered by learning 2 basic steps

1. Starts with making Burr hole & craniotomy, corticectomy 

2. Suboccipital craniectomy

2. Laminectomy

4. Laminectomy, durotomy , myelotomy

For operating all supratentorial lesions, craniotomy is done. 

For operating midline posterior fossa or infra tentorial lesions, sub occipital craniotomy is performed.

For operating spinal lesions, laminectomy is very commonly performed. This is basic neurosurgical skill.

The surface marking and understanding of the applied neuroanatomy is important. Once you reach the brain surface after craniotomy and opening of the dura, all he cortical surface looks similar, i.e., clci, gyri, CSF in subarachnoid space, and cortical vessels. So, there is only one way of identifying intracranial cerebral structures, like frontal lobe, parietal lobe , temporal lobe or occipital lobe is by surface marking of the skull, before start of the surgery. Similar principle is applied for identifying motor strip, speech area, hearing area, visual area or any other eloquent area of cerebral cortex, is by surface marking. So, before draping of the surgical area, a marking is made over the scalp.

Majority of the neurosurgical procedures are done through non eloquent area of the brain, especially, right middle frontal gyrus or right superior parietal lobule.

Twist drill and ventriclostomy is a life saving procedure in patients of acute hydrocephalus.

In pyogenic meningitis with hydrocephalus, external ventricular drainage (EVD) is done. 

Vemtriculo-peritoneal shunt surgery (VP shunt) is very common neurosurgical procedure. This procedure must be mastered and it must be repeated many times. Everyone should be well versed with all complications associated with this procedure. 

Endoscopic third vetriculostomy (ETV) is another neurosurgical procedure for treatment of hydrocephalus. 

During surgery, lamina terminals is perforated to drain CSF.

So, if any neurosurgeon regularly practices these 5 procedures, namely twist drill, EVD, VP shunt, ETV, opening of laminate terminals, it means that he or she has perfected the art of CSF diversion procedure.

The management of head injury involves 5 neurosurgical procedures, 1. Depressed fracture, 2. Evacuation of Extradural hematoma, 3. Evacuation of acute subdural hematoma, 4. Evacuation of intracerebral hematoma, 5. Contusectomy. Surgery for depressed fracture is easy. If there is communited depressed fractures and there if lactation over the depressed fracture segment, a linear incision is made in the scalp and retracted. Bone fragments are removed. Sometimes a small bur hole is made just adjacent to the depressed segment, in order to elevate it. Sometimes, dural repair is also required. CT scan is the investigation of choice of managing head injury patients. For evacuation of extradural hematoma a preoperative planning is done to make a craniotomy just over the EDH. Dural hitches are applied in the dura and the incision is closed in layers. For acute subdural hematoma evacuation a very large frontoteporoparietal craniotomy is made along with duratomy to reduce the intracranial pressure. Acute subdural hematoma is very commonly associated with brain edema, so wide decompressive craniectomy is done. 

In cases of intraparenchymal hemorrhagic contusions associated with midline shift, craniotomy and contusectomy is done. Sometimes frontal or temporal lobectomy is done to reduce mortality. Management of head injury is challenging as it requires prompt neurosurgical decisions in emergency situations. Neurosurgeons may be the first responder during management of neurotrauma patients. It necessitates the availability of neurosurgeon round the clock, 24X7, 365 days. This situation makes a neurosurgeon indispensable. It is not only the surgical procedure which matters but it involves management of emotional trauma of the patients and their relatives and managing medicolegal issues. 

Respiratory System, Pneumonia, Chronic Pulmoary Obstructive Disease (COPD)- Emhysema, Chronic Brochitis, Brochiectasis, Asthtma, Carcinoma of lung

Respiratory system is very important in clinical setting. Every doctor must be aware about this system. As oxygen is important for life, similarly understanding of the respiratory system is essential for sustaining the medical practice of any doctor. Good aspect of this fact is that anybody can learn the entire respiratory system in a very simple way and theory of the respiratory system can be understood in one page and its usual practice in clinical setting makes every doctor confident in understanding of the respiratory system.

Common symptoms of diseases of the respiratory system are dyspnea, cough, fever, hemoptysis, chest pain, weight loss. So, just knowing the details about each symptom can help in making a provisional diagnosis of diseases of the respiratory system.

History-

Dyspnea or Dyspnoea is difficulty in breathing which may be in the form of breathlessness.

Cough may be dry of with sputum ( Expectoration).

Dry cough is commonly seen in Legionella.

Purulent Sputum- Klebsiella ( Thick Red Currant Jelly like sputum )

So, the history taking is important in making a diagnosis of respiratory system. History of tubercular contact is common in Tuberculosis. History of smoking is common in COPD and lung carcinoma. History of significant weight loss is common in Tuberculosis and lung carcinoma.

Clinical Examination of patients should be done in a systematic manner. Start with

Inspection- 

On inspection alone certain diagnosis of respiratory system can be made. Measure respiratory rate, observe the pattern of the breathing ( abdominothoracic or thoracoabdominal), Dyspnea, use of accessory muscles of respiration, movement of the chest, any structural abnormality of the chest wall, curvature of the spine ( kyphosis, scoliosis ), any tumor of the chest, e.g., chondroma.

Palpation-

Extent of chest expansion can be measured by placing both palm across the spine and asking the patient to take deep breath.

On palpation of the chest wall cutaneous emhysema can be detected. Cutaneous emphysema is the air in the subcutaneous tissue of the chest and it feels like crepitations while compressing sknn over the chest wall. 

Vocal fremitus is examined by placing the ulnar aspect of the hand over different areas of the chest wall feeling the vibration of the sound with and while patients produces repetitive words like one, one , one. Vocal fremitus is decreased in pleural effusion but it is increased in pneumonia.

Extent of any bony tumor like chondroma of the ribs or costochondral junction can be felt by palpation.

Fracture of the ribs can be detected on palpation. Tenderness of the chest wall can be detected on palpation. Any paraspinal collection or cold abscess can also be detected on palpation which is very common in Tuberculosis.

Percussion-

Placing the middle finger of of one hand over the chest wall and tapping with index finger of other hand will commonly elicit tympanic or dull percussion over the chest wall. The normal percussion sound over the lungs is tympanic. In hemothorax the percussion will be dull. In hydropneuomathorax it will dull below and tympanic in upper part of pneumothorax. In Pneumonia ( Consolidation of the lungs ) it is dull but this is stony dull in case of pleural effusion. Tympanic sound is increased in case of emphysema of the lungs. In pneumothorax the percussion is hyperresonant.

Auscultation-

Auscultation is done with stethoscope and all doctors should own a stethoscope. The usual breath sound are either vesicular or amphoric. The breath sounds are inreased in consolidation ,i.e., in pneumonia. The breath sounds are decreased, i.e., muffled, in pleural effusion. Breath sounds will be decreased in hemothorax.

Crepts are heard in lung infection,  pulmonary edema.

Ronchi or whistle like sounds are heard in bronchoconstriction and in asthma.

So, the with clinical examination will be sufficient to make the diagnosis of  tension pneumothorax.

Pleural effusion, pneumothorax, hydropneumothorax, pneumonia, emphysema can be provisionally diagnosed on clinical examination itself. It can further be clearly diagnosed with chest X ray.

Investigations-

Chest X-Ray Postero-anterior view (PA) is very common radiological investigation. It helps in diagnosis of rib fracture, flail chest, pneumothorax, hydropneumorax, COPD, brochiectasis,  pleural effusion, Cor pulmonale, cardiomegaly, mediastinal widening, carcinoma ung, Tuberculosis, chest metastasis.

In Pnumonia, cosolidation or cavitation is seen on chest  ray depending upon type of pneumonia

       In consolidation, the lungs shadow appear radiopaque on chest x ray. 

                       Lobar consolidation is seen in pneumococcal pneumonia.

                       Bibasal consolidation is seen in Legionella pneumonia.

                       Patchy shadows- Chlamydia psittaci. If Bilateral then Mycoplasma.

     In cavitation, pneumonia is due to

                      Bilateral cavitation- Staphylococcal

                      Upper lobe cavitation- Klebsiella

    Bilateral perihilar interstitial shadowing is seen in Pneumocystis carnii pneumonia.

Tram line ang ring shadows are seen in brochiectasis. 

Spirometry can diagnose the restrictive and obstructive disease of the lungs. 

      FEV1 is helpful in the diagnosis of asthma.

V/Q scan ( Ventilation perfusion scan) 

CT scan or HRCT ( High resolution CT scan)  of the chest helps in the diagnosis of brochiectasis, and lung carcinoma.

Pulmonary angiography- clot in the 5th order pulmonary artery can be seen in Pulmoary embolism which usually occurs on 10th post operative day. 

Bronchoscopy and biopsy

Montoux test, sputum culture and sensitivity test is useful in diagnosis of Tuberculosis.

Legionella serology

Treatment of respiratory diseases

Tension pneumothorax- Tension pneumothorax is a medical emergency. Tracheal deviation is noticed in a patient who complaints of sudden shortness of breaths and neck veins are distended. Patient becomes cyanosed. So, needle thoracocentesis is done immediately.

Pneumororax oxygen, needle aspiration, chest tube drain. 

Hemothorax- chest tube drainage

Bronchogenic carcinoma- It can present with fever if there is secondary pneumonia and it requires antibiotic therapy. Surgery is for Non small cell lung cancer. Radiotherapy is treatment of choice if patient's age is more than 65 years. 

Bronchiectasis- steroid inhaler, antibiotics if there is associated infection. Postural drainage.

Pneumonia-

          Streptococcus pneumoniae- Ampicillin or cefuroxime

          Legionella- Erythromycin

          Staphylococcus- Flucloxacillin

          Pneumocystis carnii pneumonia- high dose co-trimoxazole, or pentomidine

          

Pulmonary embolism-Anticoagulant

Acute pulmonary edema- Patient develops acute breathlessness and cough productive of frothy and pink sputum. Patient cannot lie flat & on examination crackles are present both mid zones with scattered wheezes. Treat it with IV Frusemide.

Acute astham attack- young patient presents with breathlessness and becomes too breathless to speak. There is tachycardia. Chest x ray may be normal.  Treat with nebulized salbutamol.

Foreign body obstructing bronchial airway, patient is choked-Heimlich manoeuvre. Commonly observed that a person becomes suddenly breathless while eating. Person develos marked stridor, develops choking and drooling.

Pneumothorax and Pleural effusion- Needle aspiration. if recur, chest drain.

In PLAB examination, the common themes on which the questions are framed comprise of

1. Pneumonia- types of pneumonia, investigations, treatment of pnemonia

2. Hemoptysis- causes, investigations

3. Asthma- presentation, dignosis, treatment

4. Chest pain- causes, investigations, treatment

5. Breathlessness- causes, investigations

6. Pulmonary oedema- presentation, investigations, treatment

7, Cough- presentation, causes

8.Wheeze- investigation, treatment

9. Pleural effusion- presentation, investigations and treatment

     

                                                         Summary of Respiratory system 

Mechanical Ventilation ( Modes of Ventilators ) in Intensive Care Unit (ICU)

Start your understanding about the setting of ventilators. The respiratory support to a patient by mechanical means, i.e., through machines ( Ventilators) is known as Mechanical Ventilation ). There are basically 3 modes of ventilation, i.e., CMV, SIMV and CPAP. Once youunderstand this, then it is very easy to know all about mechanical ventilation in ICU.

 

ABG ( Arterial Blood Gas ) Interpretation

Doctors, Nursing staff and Paramedical staff working in emergency & ICU setting need to know the value of ABG. It helps in the diagnosis of the conditions where a patient may require a correction of the electrolyte imbalance, respirtory problems and certaion metabolic conditions and there may be requirement of mechanical ventilation.

Interpretation of ABG is very easy and one just need one page notes for interpretation of ABG. This image will make you confident of diagnosis of a patient who is on ventilator and may require some modification in the ventilator setting.