Tuberculosis Infection and Disease

      Treatment of Tuberculosis Infection and Disease

 Latent Tuberculosis Infection (TLTBI) is medication that is given to people who have latent TB infection to prevent them from developing TB disease. High-risk people should be evaluated for TLTBI if they have a positive skin test reaction, regardless of their age. Sometimes TLTBI is given to people who have a negative skin test result, such as high-risk contacts and children younger than 6 months old who have been exposed to active TB.
All patients being considered for TLTBI should receive a medical evaluation to:

• Exclude the possibility of TB disease
• Determine whether they have ever been treated for TB infection or disease
• Identify any medical problems that may complicate therapy or require more careful monitoring

People who are suspected of having TB disease or who have been documented as adequately treated for latent TB infection or disease should not be given TLTBI.
The usual regimen for TLTBI is isoniazid given daily for 9 months for all patients. Patients should be clinically evaluated every month for signs of hepatitis and other adverse reactions to isoniazid. They should also be educated about the symptoms caused by adverse reactions to isoniazid and instructed to seek medical attention immediately if these symptoms occur. In addition, people at greatest risk for hepatitis should have liver function tests before starting isoniazid. Four months of rifampin is an acceptable alternative regimen for TLTBI.
TB disease must be treated for at least 6 months; in some cases, treatment lasts even longer. The initial regimen for treating TB disease should include four drugs: isoniazid, rifampin, pyrazinamide, and ethambutol. When the drug susceptibility results are available, clinicians may change the regimen accordingly. TB disease must be treated with at least two drugs to which the bacilli are susceptible. Using only one drug to treat TB disease can create a population of tubercle bacilli that is resistant to that drug. Drug resistance can also develop when patients do not take treatment as prescribed. Thus, to prevent relapse and drug resistance, clinicians must prescribe an adequate regimen and make sure that patients adhere to treatment. The best way to ensure that patients adhere to treatment is to use directly observed therapy (DOT).
There are several options for daily and intermittent treatment. For children with certain types of extrapulmonary TB, pregnant women, and people with drug-resistant TB, treatment may last longer or involve different regimens. Treatment of drug-resistant TB should always be done daily and under the supervision of a medical expert who is familiar with the treatment of drug-resistant TB.
All patients being treated for TB disease should be educated about the symptoms caused by adverse reactions to the drugs they are taking and instructed to seek medical attention immediately if they have symptoms of a serious side effect. Patients should be seen by a clinician at least monthly during treatment and evaluated for possible adverse reactions. In addition, before starting treatment, patients may have baseline tests to help clinicians detect any abnormalities that may complicate treatment.
Patients who are not receiving directly observed therapy should be carefully monitored for adherence to treatment. However, the only way to ensure adherence to treatment is to always directly observe therapy.
To determine whether a patient is responding to treatment, clinicians should do clinical evaluations and bacteriologic evaluations during treatment. Patients should be carefully reevaluated if their:

• Symptoms do not improve during the first 2 months of treatment
• Symptoms worsen after improving initially
• Culture results have not become negative after 2 months of treatment
• Culture results become positive after being negative

In some situations, clinicians may also use X-rays to monitor a patient's response to treatment for pulmonary TB.
The treatment of TB can be complicated, especially in patients who fail to respond to treatment, who relapse, or who have drug-resistant TB or adverse reactions to medications. Clinicians who do not have experience with these situations should consult an expert. The New Jersey Medical School Global Tuberculosis Institute is qualified to assist clinicians in consultation to treat their difficult TB patients.

                                Diagnosis & Treatment

[Click image to enlarge]	Product Title
	Brief Guide on Tuberculosis Control for Primary Health Care Providers for Countries in the WHO European Region with a High and Intermediate Burden of Tuberculosis
	Caring for the Patient with Tuberculosis: What Clinicians in New Jersey Need to Know
	Designing a Drug-O-Gram: A Tool for Monitoring and Adjusting TB Therapy
	Diagnosis and Treatment of Latent Tuberculosis Infection
	Facility TB Profile for Targeted Testing and Treatment of Latent TB Infection
	Guidelines for the Diagnosis of Latent Tuberculosis Infection for the 21st Century (2nd Edition)
	Guidelines for the Diagnosis of Latent Tuberculosis Infection in the 21st Century: Online Learning Resource
	Identifying Missed Opportunities for Preventing Tuberculosis
	LTBI Card: Patient's TB Testing and Treatment Record
	Management for Latent Tuberculosis Infection in Children and Adolescents: A Guide for the Primary Care Provider
	Outpatient Infusion Therapy for Multi-drug Resistant Tuberculosis: A Practical Guide
	Tuberculosis Handbook for School Nurses
	Treatment of Tuberculosis in Adult and Adolescent Patients Co-infected with the Human Immunodeficiency Virus (HIV)
	Treatment of Tuberculosis: Standard Therapy for Active Disease in Adults & Adolescents
	Treatment of Tuberculosis: Standard Therapy for Active Disease in Children

Boost your fertility

 Inexpensive food items to boost your fertility

 

A recent piece in the Daily Mail Online, claimed that raspberries can improve fertility in men thanks to nutrients like Vitamin C and magnesium (boosts testosterone) and its high antioxidant value decreases the chance of miscarriages during conception for women. Sadly, raspberries are beyond the purchasing capacity of most Indians, not to mention very scarcely available. But you don’t need to fret while the good people of health.india.com are there; here’s a list of affordable food items that can boost fertility in men and women:

Foods that can boost fertility in men
Fresh fruits
Fruits are great thanks to the high levels of Vitamin C which ensures the potency and quality of your sperm. If you want to be a daddy, we would recommend at least two portions of fruits like lemon, sweet lime (mousambi in Hindi), oranges  and mangoes. They’re all rich packed with nutrients and antioxidants and won’t hit your wallet as hard. (Also read: A bachelor’s guide to eating healthy)
Garlic
Garlic’s health benefits are well-known but various studies have shown that it has aphrodisiac properties and also helps improve blood circulation. No wonder that Twilight fellow looked so peakish and pale! (Also read: 15 health benefits of garlic)
Fish
Rich in fatty acids, many kinds of fish can help you become fit and fertile and get your little ones swimming! Fish contains Essential Fatty Acids which helps improve circulation around the reproductive system and boosts sperm quality in the process! (Also read: Top foods for enhancing fertility)
Foods that can boost fertility in women
Meat
Meat which is packed with iron is great for reducing the risk of infertility arising during the ovulation process. It also helps boost red blood cells while reducing the threat of anaemia which can lead to severe complications during pregnancies. (Also read: Revealed – the truth about non-vegetarian food!)
 Nuts
Nuts of various varieties including almonds and walnuts which are rich in Vitamin E content heightens the female sex drive while protecting the embryos from miscarriages.  (Also read: Top 10 heart healthy foods)
Potatoes
It’s found that baked potatoes are rich in Vitamin B and E which enhances cell division, increasing the likelihood of a healthy ova being produced.
Eggs
Eggs are an extremely small power-packed nutrition source that boosts fertility. It contains Vitamin B12 and folate which minimises birth defects. In addition, it’s rich in antioxidants and cartenoids which all boost fertility in women. (Also read: Eggs – good or bad for health?)
So don’t worry if you find raspberries too expensive or frivolous, there are enough affordable food items which can boost your fertility without hitting your pocket. Oh yes and here are some things you should avoid that cause infertility.

                        Typhoid: 

     Symptoms,diagnosis,treatment &

                    prevention

 

The monsoons are here, and with water logging a common sight around every corner, cases of people suffering from typhoid are rising. So before you reach for that yummy plate of pani puri or bhel, think about the possibility of contracting the disease.

Typhoid, also known as typhoid fever is a life threatening disease that is caused due to an infection by the bacterium Salmonella typhi. According to the CDC (Center for Disease Control) almost 21.5 million people in developing countries contract typhoid each year. Here are a few common questions about the disease answered:
How is typhoid caused?
The bacterium Salmonella typhi  is present only in human beings and is transmitted through contaminated food or water. People with this infection carry the bacterium in their intestines and bloodstream, and those who have recovered from the disease could still have the bacterium in their system; they are known as ‘carriers’ of the disease. Both ill people and carriers shed Salmonella typhi in their stool. Infection is usually spread when food or water is handled by a person who is shedding the bacterium or if sewage water leaks into drinking water or food that is then consumed. That is why this disease is common in areas where proper hand washing techniques are not followed.
What are the common symptoms of typhoid?
Once the bacterium is ingested it quickly multiplies within the stomach, liver or gallbladder and finally enters the blood stream causing symptoms like fever (usually between 103⁰C- 104⁰C), rashes (flat, rose-coloured spots), vomiting, loss of appetite, headaches, general fatigue. In severe cases one may suffer from intestinal perforations or internal bleeding, diarrhoea or constipation.
One of the characteristic symptoms of typhoid is a ‘step ladder fever’. This means that the fever gradually fluctuates between very high and low fever for a short period of time, till it peaks at 103⁰C – 104⁰C. In patients without any complications the condition subsides in about three to four weeks after its onset. In about 10% of people, the condition relapses after about one week of convalescence.*
How is it diagnosed?
Usually diagnosed using a stool sample or blood sample, the presence of the bacterium is most easily visible either at the beginning or at the end of the disease.
Is there a cure?
Once diagnosed a patient is treated with antibiotics. A few years back, patients were treated using chloramphenicol. But after it showed to have severe side effects in some patients, the drug of choice has been changed to ciprofloxacin and ampicillin amongst others. Usually depending on the severity of the condition, a patient might be administered the drugs either orally or intravenously.
What care should one take during convalescence?
If someone has suffered from typhoid, they should ideally not discontinue their medication as soon as they feel better, this is because typhoid has a high rate of relapse. It is important that the patient continue his/her medication until their doctor asks them to stop. They must  also ensure that they wash their hands well with an antibacterial soap after going to the toilet and before touching any food or water.
What can one do to avoid contracting the condition?
Today, there are vaccines that can protect you from contracting typhoid. The Ty21a vaccine is administered intramuscularly (injected into a muscle) and requires the patient to take a booster shot after five years. That being said, even if a person has taken the vaccine, they should not expose themselves to possible infectious agents, because the vaccine is still not very effective. As of last year the IISc (Indian Institute of Science) was working on an improved vaccine that would be foolproof.
Apart from the vaccine, there are some basic things that one can take care of in order to avoid the condition:

• Do not eat food cooked on the road side. This is because it is very difficult to judge the water source they use and the cleanliness of the food handler.
• Do not have ice or popsicles prepared locally. Since the water source and cleanliness of the manufacturing facility is unknown, it is best avoided.
• Do not eat fruits and raw vegetables that have been precut.
• One must make sure they wash their hands well before cooking a meal or eating.
• Always drink either bottled water or boiled water. It is essential that the water is brought to a rolling boil. This means that the water reaches a boiling point and is allowed to boil for about two to three minutes.

Typhoid is a completely avoidable condition, just keep these simple tips in mind to keep the disease at bay.
 * As per Medicine net

 

Ameloblastoma and its treatment

.

                                Ameloblastoma

                               

 (from the early English word amel, meaning enamel + the Greek word blastos, meaning germ) is a rare, benign tumor of odontogenic epithelium (ameloblasts, or outside portion, of the teeth during development) much more commonly appearing in the lower jaw than the upper jaw. It was recognized in 1827 by Cusack. This type of odontogenic neoplasm was designated as an adamantinoma in 1885 by the French physician Louis-Charles Malassez. It was finally renamed to the modern name ameloblastoma in 1930 by Ivey and Churchill.
While these tumors are rarely malignant or metastatic (that is, they rarely spread to other parts of the body), and progress slowly, the resulting lesions can cause severe abnormalities of the face and jaw. Additionally, because abnormal cell growth easily infiltrates and destroys surrounding bony tissues, wide surgical excision is required to treat this disorder.

Subtypes

 There are three main clinical subtypes of ameloblastoma: unicystic, multicystic, peripheral^. The peripheral subtype composes 2% of all ameloblastomas. Of all ameloblastomas in younger patients, unicystic ameloblastomas represent 6% of the cases. A fourth subtype, malignant, has been considered by some oncologic specialists, however, this form of the tumor is rare and may be simply a manifestation of one of the three main subtypes. Ameloblastoma also occurs in long bones, and another variant is Craniopharyngioma (Rathke's pouch tumour, Pituitary Ameloblastoma.)

Clinical features

Ameloblastomas are often associated with the presence of unerupted teeth. Symptoms include painless swelling, facial deformity if severe enough, pain if the swelling impinges on other structures, loose teeth, ulcers, and periodontal (gum) disease. Lesions will occur in the mandible and maxilla,although 75% occur in the ascending ramus area and will result in extensive and grotesque deformitites of the mandible and maxilla. In the maxilla it can extend into the maxillary sinus and floor of the nose. The lesion has a tendency to expand the bony cortices because slow growth rate of the lesion allows time for periosteum to develop thin shell of bone ahead of the expanding lesion. This shell of bone cracks when palpated and this phenomenon is referred to as "Egg Shell Cracking" or crepitus, an important diagnostic feature. Ameloblastoma is tentatively diagnosed through radiographic examination and must be confirmed by histological examination (e.g., biopsy). Radiographically, it appears as a lucency in the bone of varying size and features—sometimes it is a single, well-demarcated lesion whereas it often demonstrates as a multiloculated "soap bubble" appearance. Resorption of roots of involved teeth can be seen in some cases, but is not unique to ameloblastoma. The disease is most often found in the posterior body and angle of the mandible, but can occur anywhere in either the maxilla or mandible.
Ameloblastoma is often associated with bony-impacted wisdom teeth—one of the many reasons some dentists recommend having them extracted.

Histopathology  

Histopathology will show cells that have the tendency to move the nucleus away from the basement membrane. This process is referred to as "Reverse Polarization". The follicular type will have outer arrangement of columnar or palisaded ameloblast like cells and inner zone of triangular shaped cells resembling stellate reticulum in bell stage. The central cells sometimes degenerate to form central microcysts. The plexiform type has epithelium that proliferates in a "Fish Net Pattern". The plexiform ameloblastoma shows epithelium proliferating in a 'cord like fashion', hence the name 'plexiform'. There are layers of cells in between the proliferating epithelium with a well-formed desmosomal junctions, simulating spindle cell layers.

Variants  

The six different histopathological variants of ameloblastoma are desmoplastic, granular cell, basal cell, plexiform, follicular, and acanthomatous^.
The acanthomatous variant is extremely rare.
One-third of ameloblastomas are plexiform, one-third are follicular. Other variants such as acanthomatous occur in older patients. In one center, desmoplastic ameloblastomas represented about 9% of all ameloblastomas encountered.

Treatment

While chemotherapy, radiation therapy, curettage and liquid nitrogen have been effective in some cases of ameloblastoma, surgical resection or enucleation remains the most definitive treatment for this condition. In a detailed study of 345 patients, chemotherapy and radiation therapy seemed to be contraindicated for the treatment of ameloblastomas. Thus, surgery is the most common treatment of this tumor. Because of the invasive nature of the growth, excision of normal tissue near the tumor margin is often required. Some have likened the disease to basal cell carcinoma (a skin cancer) in its tendency to spread to adjacent bony and sometimes soft tissues without metastasizing. While not a cancer that actually invades adjacent tissues, ameloblastoma is suspected to spread to adjacent areas of the jaw bone via marrow space. Thus, wide surgical margins that are clear of disease are required for a good prognosis. This is very much like surgical treatment of cancer. Often, treatment requires excision of entire portions of the jaw.
Radiation is ineffective in many cases of ameloblastoma. There have also been reports of sarcoma being induced as the result of using radiation to treat ameloblastoma.Chemotherapy is also often ineffective. However, there is some controversy regarding this and some indication that some ameloblastomas might be more responsive to radiation that previously thought.
While the Mayo Clinic recommends surgery for almost all ameloblastomas, there are situations in which a Mayo Clinic physician might recommend radiation therapy. These include malignancy, inability to completely remove the ameloblastoma, recurrence, unacceptable loss of function, and unacceptable cosmetic damageIn the case of radiotherapy, oncologists at the Mayo Clinic would use intensity-modulated radiotherapy.

Molecular biology

There is evidence that suppression of matrix metalloproteinase-2 may inhibit the local invasiveness of ameloblastoma, however, this was only demonstrated in vitro. There is also some research suggesting that α₅β₁ integrin may participate in the local invasiveness of ameloblastomas.

Recurrence

Recurrence is common, although the recurrence rates for block resection followed by bone graft are lower than those of enucleation and curettage. Follicular variants appear to recur more than plexiform variants.Unicystic tumors recur less frequently than "non-unicystic" tumors. Persistent follow-up examination is essential for managing ameloblastoma. Follow up should occur at regular intervals for at least 10 years.Follow up is important, because 50% of all recurrences occur within 5 years postoperatively.Recurrence within a bone graft (following resection of the original tumor) does occur, but is less common. Seeding to the bone graft is suspected as a cause of recurrence.The recurrences in these cases seem to stem from the soft tissues, especially the adjacent periosteum. Recurrence has been reported to occur as many as 36 years after treatment.
To reduce the likelihood of recurrence within grafted bone, meticulous surgery with attention to the adjacent soft tissues is required.

Epidemiology

The annual incidence rates per million for ameloblastomas are 1.96, 1.20, 0.18 and 0.44 for black males, black females, white males and white females respectively. Ameloblastomas account for about one percent of all oral tumors and about 18% of odontogenic tumors. Men and women tend to be equally affected, although women tend to be 4 years younger than men when tumors first occur and tumors appear to be larger in females.

The resected left half of a mandible containing an ameloblastoma, initiated at the third
 

A CT scan of a patient suffering from an ameloblastoma

Ameloblastoma
Classification and external resources
Micrograph of an ameloblastoma showing the characteristic nuclear palisading and stellate reticulum. H&E stain.
ICD-10	D16.5
ICD-9	213.1
ICD-O:	9310/0
DiseasesDB	31676

Unchalli Falls (Lushington Falls) near murdeshwar

Unchalli Falls (Lushington Falls)

Unchalli Falls (also called Lushington Falls) is perhaps one of India's most spectacular waterfalls. We were certainly impressed with this falls given its practically unchecked flow, its rather unusual shape (almost Vidfoss-like), and its dramatic scenery amongst the lush and remote forested hills of the Uttara Kannada District. I guess depending on your mood and your experience, it can be argued that this waterfall is even more impressive than a compromised Jog Falls, and this thought may be reflected by the fact that sometimes this falls is referred to as Keppa Jog. We happened to come to this 116m falls at around midday, which seemed to be a perfect time for seeing a rainbow appearing in the waterfall's rising mist.
We almost nixed the idea of coming to Unchalli Falls because we had originally thought that accessing it required a hot and sweaty 5km or 3.1-mile (each way) trek through mostly thick jungle from the village of Heggarne (some 30km south-southwest of Sirsi). In fact, we still saw some misleading signage at a turnoff just north of the town of Siddapur saying the fall's access was barely 5km from that spot (probably in reference to the old access).
Fortunately for us, there was a longer more involved road access on what were apparently newly-built roads winding through the Western Ghats past some local villages to a humble car park (more like a pulloff with a gazeebo and shack nearby) by a sharp turn. This reduced the walk to a mere 0.5km each way or 1km round trip on a fairly steep and muddy foot-traffic-only 4wd track. A lot of the infrastructure here appeared to be either new or in the process of being built so by the time you end up visiting the falls, perhaps access will be even easier and more convenient.
Near the end of the 0.5km steeply sloping muddy road, there was a flat area with benches and some latrine toilets (which were very disgusting when I was there as the rooms were caked in fecal matter on the floor). From this little rest area, it was just a few paces to an elevated sheltered lookout platform providing awesome views of the falls.
There were stairs leading down to a second sheltered platform (under construction when we were there, but the workers were kind enough to let me take photos from within the work zone) as well as an open-air third viewing spot at the end of the steps. The second platform was my personal favorite of the viewing spots due to the nicely framed foliage below the falls as well as a glimpse of its bottom. However, the last viewpoint (be careful here as there's an open side without a railing and the ground can be muddy with spray from the falls) got us even closer to eye level with Unchalli Falls. Beyond this viewpoint, it didn't seem possible to safely make it further to the bottom.
As of our visit, they didn't yet collect any fees (especially camera fees or two-tiered fees for foreigners) as the area was still not quite on the tourist radar. It seemed that pretty much the only people that knew about Unchalli Falls were locals as well as specific tour groups (we happened to meet a Yoga Group from Shimoga town somewhere near Bangalore some 300km or more away from this falls).
I'm sure this will change as this falls ought to get more attention along with the improving infrastructure (and associated cost for those things). There's also the potential to help boost the economy for the neighboring rural region, which is why I think it's only a matter of time before fees are collected for convenient access to the falls.
The British name of the falls was in honor of J.D. Lushington who was a District Collector for the British Government during their colonial rule of India and just happened to "discover" the falls in 1845.
Directions: I believe we could've gotten to Unchalli Falls directly after leaving Sirsi as I recalled seeing some signed turnoff on the way. But to be honest, Julie and I were a little disoriented as we had been driven around this part of the Western Ghats. So all we could offer up were the driving durations based on the notes we had taken.We reached this waterfall after visiting Jog Falls. It took us about 80 minutes to get from there to the trailhead for Unchalli Falls via the new road to get here.
When we left the falls, we drove a little over 2.5 hours to the beach town of Murudeshwar to the far south of Karnataka State.

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At the trailhead

The first platform

Descending to lower platforms

The second platform

View of the falls from the second platform

Heading back up to the trailhead on the muddy 4wd road

Surreal sunset at Murudeshwar with lots of fully clothed Indians in saris, lungis, or even more modern clothing enjoying the water

Nohkalikai Falls in meghayal india

   Nohkalikai Falls is one of the taller waterfalls in India. It makes a dramatic free leap from a fairly well-forested drainage into a rocky base accompanied by a pretty blue pool. While we noticed that most of the waterfalls in the Cherrapunjee area really lost their luster outside of the monsoon season, this one seemed to maintain its perforance as I've seen photos dated in January and later that still have decent flow (I suspect the relatively healthy drainage upstream of the falls helps keeps its stream flowing). In fact, we even saw a pair of light flowing companion waterfalls making similar dramatic leaps off the escarpment which made me suspect that had we seen this falls in wetter times, there could have been many more companion waterfalls flanking the main one. Nohkalikai Falls is said to be named after a story about a woman named Ka Likai who leapt off the cliff. It was certainly the waterfall highlight of our waterfalling excursion in the Meghalaya state in the country's far northeast (just east of Bangladesh), especially considering the subdued nature of its neighboring waterfalls.
Viewing Nohkalikai Falls might be a bit of a roll of the dice given the fickle nature of the weather here. That's because the area is frequently shrouded in clouds. On our visit, we just so happened to enjoy an hour or so of fairly clear (albeit hazy) skies before the fog really rolled in with a vengeance. Our guide mentioned that late morning to midday provides the highest likelihood of satisfactory viewing while the lighting (if sunny) is good at this time as well.
The Cherrapunjee town and vicinity (also spelled Cherrapunji and locally known as Sohra) has a reputation for being the wettest place on earth. But this maybe an outdated reputation from what we could tell because the area dries quickly outside the monsoon months (as evidenced by the presence of lots of brown foliage and lack of vigor in its watercourses) and there's plenty of coal mining, diversion, and deforestation around the area that may have conspired to alter the region's ability to retain the moisture or produce the quantity of precipitation the region that gave it the statistical edge that beat out places like Mt Wai'ale'ale in the Hawaiian Island of Kaua'i. In fact, the drive from Sohra town to Nohkalikai Falls meandered through a large chunk of moorish grasslands on a plateau, which our Assamese guide said was once fully covered in trees. That road is flanked by a handful of coal mounds and mine shafts nearby.
As for the height of the Nohkalikai Falls, we've seen some rather outrageous claims about this falls being the 4th highest in the world (even some Bank of India sponsored sign proclaims this at the sheltered overlook) as well as this falls being the second highest in the country according to our 2007 version of LP. So far the only number I've seen regarding its height is that it's 335m tall, which if true makes this taller than both Jog Falls and Dudhsagar Falls assuming you believe the height numbers claimed for those waterfalls as well. However, it was hard to tell if that 335m number is being generous or not based on our observations since you're looking down at the falls, and I certainly wished I employed the best-in-the-field-method-period of measuring the height of the falls.
In any case, it was pretty clear to us that this waterfall was the pride of Meghalaya tourism and there was a fairly busy car park as well as some basic infrastructure to experience the falls. In addition to the walkways and overlooks hugging the cliff edge peering down at the falls, there were also various fruit and food stands (if you've got a strong stomach) run by the local villagers.
We also noticed a series of stairs (apparently opened back in 2005) that took us to lower viewpoints of the falls (along with some distressingly high amounts of litter alongside it) though the stairs ended well before it got to the bottom. The path looked like it did continue rather steeply and with a fair bit of hazards towards the bottom, but we were hesitant to continue once we saw the stairs end. And given the little bit of graffiti we noticed on one of the big rocks near the plunge pool for the falls, I'm sure it was pretty possible to get down there if you're willing to assume the risk.
In any case, we probably spent around a half-hour total on this side excursion to get closer and lower towards the falls. I'm guessing it would've taken at least an hour or more round-trip to get right down to the base of the falls.
Directions: It's about 53km from Shillong to the town of Cherrapunjee. We were escorted here taking about 1.5 to 2 hours of driving in each direction as we were undoubtedly slowed down by plenty of lorrie (i.e. truck) traffic as well as some local buses; all of which belched out some pretty lethal and visible doses of diesel exhaust.This followed about a roughly 4-hour drive from Guwahati to Shillong.
One thing we saw while taking the road to Nohkalikai Falls was the amount of deforestation and coal mining in the area. We weren't sure if this had anything to do with the apparent lack of lush vegetation for a place that was supposedly the wettest place on earth, but I'm sure it couldn't have helped.

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The overlook area

Another look at the impressive Nohkalikai Falls

Descending some stairs for a different look at the falls

Biggest waterfall of INDIA & Biggest in ASIA - jog falls

After BDS

REGULATIONS TO THE POST GRADUATE DIPLOMA COURSE IN DENTISTRY

Eligibility:

A candidate for admission to the Diploma Course must have a degree of BDS (Bachelor of Dental Surgery) from a college and University recognized by Dental Council of India or an equivalent qualification recognized by the Dental Council of India.

Duration of the Course:

The duration of the diploma courses in various specialties of dentistry shall be of two years duration which will be further divided into four Semesters as under-

First and Second Semesters: Preclinical Work and Applied Basic Sciences.

Third and Fourth Semesters: Clinical Work.

All the candidates for the Post Graduate Diploma are required to pursue the prescribed course for at least two academic years as full time candidates in a BDS recognized and mds approved/recognized Institution under the direction of the Head of the department who has to be a recognized postgraduate teacher in that specialty.

Selection of students:

1.    Students for Post Graduate Diploma Courses shall be selected strictly on the basis of their academic merit.

2.    For determining the academic merit, the university/institution may adopt any one of the following procedures for P.G. Diploma Courses:

(i)           On the basis of merit as determined by a competitive test conducted by the State Government or by the competent authority appointed by the State Government or by the University/group of universities in the same state; or

(ii)          On the basis of merit as determined by a centralized competitive test held at the national level; or

(iii)        On the basis of the individual cumulative performance at the first, second, third  & Final b.d.s. examinations, if such examinations have been passed from the same  university; or

(iv)         Combination of (i) and (iii).

Staffing pattern:

The diploma courses shall be conducted only in postgraduate departments in a BDS recognized and MDS approved/recognized Institution by the Dental Council of India & RGUHS. For each seat of Post Graduate Diploma Course one additional reader is required.

A department, which does not have the above staff pattern, shall not start a postgraduate diploma course in that specialty.

1. Examination:

Eligibility: The following requirements should be fulfilled by every candidate to become eligible to appear for the final examination.

Attendance: Every candidate should have fulfilled the minimum attendance prescribed by Dental Council of India and RGUHS (80% of the attendance during each academic year of the diploma course).

Progress and conduct: Every candidate should have participated in seminars, journal review meetings, symposia, conferences, case presentations, clinics and didactic lectures during each year as designed by the concerned department.

Work diary and log book: Every candidate shall maintain a work diary and log book for recording his/her participation in the training programmes conducted by the department. The work diary and log book shall be verified and certified by the Head of the Department and Head of the institution. The certification of satisfactory progress is based on the work diary and log book.

2. University Examination:

There shall be one examination at the end of 2 years.

RGUHS shall hold examinations twice a .year with a minimum gap of four months between the two examinations. The university examination shall have the following components-

i)             Written

ii)           Clinical and / or Practical

iii)          Viva voce or oral examination.

Written Examination:

The written examination shall consist of three papers, out of which two shall be pertaining to the specialty; one in Applied Basic Sciences. Each paper shall be of three hours duration and shall include recent advances.

Clinical/Practical Examination:

It will aim at examining clinical skills and competence of candidates for undertaking independent work as a specialist.   The actual format of clinical examination in various specialities could be worked out by various universities making sure that the candidates is given ample opportunity to perform various clinical procedures.  The council desires that the actual format is made known to the students prior to the examination well in advance by the respective universities.

Viva voce Examination:

Viva voce examination shall aim at assessing depth of knowledge, logical reasoning, confidence and verbal communication skills.

Two examiners conduct the viva voce at a time as two teams, each team for 20 minutes. When one examiner is conducting the viva, the other examiner could make a note of the questions asked and the performance level to enable proper assessment and award of marks. Distribution of Marks at the University

Examination:

Theory:

Paper-I         100 marks

Paper-II        100 marks

Paper-III 100 marks

Total  300 marks

Clinical Examination: 200 marks
Viva-voce     : 100 marks

Examiners: There shall be at least four examiners in each subject. Out of them two shall be external examiners and two internal examiner. The qualification and teaching experience for appointment of an examiner shall be as laid down by the Dental Council of India and the RGUHS.

Valuation of answer Books: All the answer books to be valued by all the four examiners and the average marks will be computed.

Criteria for declaring pass:

A candidate is declared successful in the University Examination when he or she secure not less than 50% marks in each head of passing separately which shall include theory including viva voce and practical including clinical examination

(i.e., 50% of the total marks allotted in each of the theory paper and viva voce and 50% of the total marks in the clinical examination) and 50% in aggregate. In other words, the candidate should secure 200 out of 400 marks (300 in theory and 100, for viva voce) and 100 out of 200 in practical examination. A candidate who secures less than this shall be declared to have failed in the examination. A candidate who failed and has secured less than 50% marks has to take the whole examination (namely theory, practical and oral examination).

First Class : the candidate has to secure 65%  of the total marks in Theory, Viva Voce and Practicals combined together.

Distinction : the candidate has to secure 75% of the total marks in Theory, Viva Voce and Practicals combined together.

Ranks should be declared from among the candidates who have passed in Distinction / First Class.

Infrastructure & functional requirements:

In addition to the existing facilities for the training of postgraduate students all the postgraduate departments running diploma courses shall provide for each diploma admission an additional dental chair and unit and other such instruments, equipments as required for the clinical training.

After BDS diploma course

REGULATIONS TO THE POST GRADUATE DIPLOMA COURSE IN DENTISTRY

Eligibility:

A candidate for admission to the Diploma Course must have a degree of BDS (Bachelor of Dental Surgery) from a college and University recognized by Dental Council of India or an equivalent qualification recognized by the Dental Council of India.

Duration of the Course:

The duration of the diploma courses in various specialties of dentistry shall be of two years duration which will be further divided into four Semesters as under-

First and Second Semesters: Preclinical Work and Applied Basic Sciences.

Third and Fourth Semesters: Clinical Work.

All the candidates for the Post Graduate Diploma are required to pursue the prescribed course for at least two academic years as full time candidates in a BDS recognized and mds approved/recognized Institution under the direction of the Head of the department who has to be a recognized postgraduate teacher in that specialty.

Selection of students:

1.    Students for Post Graduate Diploma Courses shall be selected strictly on the basis of their academic merit.

2.    For determining the academic merit, the university/institution may adopt any one of the following procedures for P.G. Diploma Courses:

(i)           On the basis of merit as determined by a competitive test conducted by the State Government or by the competent authority appointed by the State Government or by the University/group of universities in the same state; or

(ii)          On the basis of merit as determined by a centralized competitive test held at the national level; or

(iii)        On the basis of the individual cumulative performance at the first, second, third  & Final b.d.s. examinations, if such examinations have been passed from the same  university; or

(iv)         Combination of (i) and (iii).

Staffing pattern:

The diploma courses shall be conducted only in postgraduate departments in a BDS recognized and MDS approved/recognized Institution by the Dental Council of India & RGUHS. For each seat of Post Graduate Diploma Course one additional reader is required.

A department, which does not have the above staff pattern, shall not start a postgraduate diploma course in that specialty.

1. Examination:

Eligibility: The following requirements should be fulfilled by every candidate to become eligible to appear for the final examination.

Attendance: Every candidate should have fulfilled the minimum attendance prescribed by Dental Council of India and RGUHS (80% of the attendance during each academic year of the diploma course).

Progress and conduct: Every candidate should have participated in seminars, journal review meetings, symposia, conferences, case presentations, clinics and didactic lectures during each year as designed by the concerned department.

Work diary and log book: Every candidate shall maintain a work diary and log book for recording his/her participation in the training programmes conducted by the department. The work diary and log book shall be verified and certified by the Head of the Department and Head of the institution. The certification of satisfactory progress is based on the work diary and log book.

2. University Examination:

There shall be one examination at the end of 2 years.

RGUHS shall hold examinations twice a .year with a minimum gap of four months between the two examinations. The university examination shall have the following components-

i)             Written

ii)           Clinical and / or Practical

iii)          Viva voce or oral examination.

Written Examination:

The written examination shall consist of three papers, out of which two shall be pertaining to the specialty; one in Applied Basic Sciences. Each paper shall be of three hours duration and shall include recent advances.

Clinical/Practical Examination:

It will aim at examining clinical skills and competence of candidates for undertaking independent work as a specialist.   The actual format of clinical examination in various specialities could be worked out by various universities making sure that the candidates is given ample opportunity to perform various clinical procedures.  The council desires that the actual format is made known to the students prior to the examination well in advance by the respective universities.

Viva voce Examination:

Viva voce examination shall aim at assessing depth of knowledge, logical reasoning, confidence and verbal communication skills.

Two examiners conduct the viva voce at a time as two teams, each team for 20 minutes. When one examiner is conducting the viva, the other examiner could make a note of the questions asked and the performance level to enable proper assessment and award of marks. Distribution of Marks at the University

Examination:

Theory:

Paper-I         100 marks

Paper-II        100 marks

Paper-III 100 marks

Total  300 marks

Clinical Examination: 200 marks
Viva-voce     : 100 marks

Examiners: There shall be at least four examiners in each subject. Out of them two shall be external examiners and two internal examiner. The qualification and teaching experience for appointment of an examiner shall be as laid down by the Dental Council of India and the RGUHS.

Valuation of answer Books: All the answer books to be valued by all the four examiners and the average marks will be computed.

Criteria for declaring pass:

A candidate is declared successful in the University Examination when he or she secure not less than 50% marks in each head of passing separately which shall include theory including viva voce and practical including clinical examination

(i.e., 50% of the total marks allotted in each of the theory paper and viva voce and 50% of the total marks in the clinical examination) and 50% in aggregate. In other words, the candidate should secure 200 out of 400 marks (300 in theory and 100, for viva voce) and 100 out of 200 in practical examination. A candidate who secures less than this shall be declared to have failed in the examination. A candidate who failed and has secured less than 50% marks has to take the whole examination (namely theory, practical and oral examination).

First Class : the candidate has to secure 65%  of the total marks in Theory, Viva Voce and Practicals combined together.

Distinction : the candidate has to secure 75% of the total marks in Theory, Viva Voce and Practicals combined together.

Ranks should be declared from among the candidates who have passed in Distinction / First Class.

Infrastructure & functional requirements:

In addition to the existing facilities for the training of postgraduate students all the postgraduate departments running diploma courses shall provide for each diploma admission an additional dental chair and unit and other such instruments, equipments as required for the clinical training.