From A Clinician's Bioscope

Is Cholesterol is Egg Yellow (yolk) Good to eat?

noreply@blogger.com (Dr Prahallad Panda) — Fri, 11 Apr 2025 08:34:00 +0530

While giving advice on diet, the dietician/doctor, most of the time, advises to discard the yellow portion of a boiled egg thinking the yellow color of the yolk to be house of all bad fats and cholesterol. This advice is mostly given to the patients suffering from hypertension, and Diabetes. The patient also, wisely enough, agrees to it, as if he knows it earlier, and the advice of discarding the yellow portion is suggestive only. And it is a popular belief to discard the yellow of the egg to stay healthy.

The egg yolk, basically, is the nucleus of the cell, and the white portion is the cytoplasm. Egg protein is considered as high-class protein or complete protein as it contains all the 9 essential amino acids and Biological value is 100%. Amino Acids are the building blocks of a protein; those amino acids not synthesized in the body and have to be taken from outside, are called essential amino acids. Egg yolks contain essential Poly-Unsaturated Fatty Acids, including linoleic acid (C18:2n-6, LA), α-linolenic acid (C18:3n-3, ALA), eicosapentaenoic acid (C20:5n-3, EPA), and docosahexaenoic acid (C22:6n-3, DHA).

According to the United States Department of Agriculture, a raw yolk from one standard, large egg provides the following;

55 calories
2.70 g of protein
4.51 g of fat
184 milligrams (mg) of cholesterol
0.61 g of carbohydrate
0.10 g of sugar
0 g of dietary fiber

Egg yolks contain at least seven essential minerals, including:

calcium
iron
magnesium
phosphorus
potassium
sodium
zinc

Egg yolks are good source of many vitamins, especially fat- and water-soluble vitamins.

One large (17 g) egg yolk contains;

Thiamin	0.030 mg
Riboflavin	0.090 mg
Niacin	0.004 mg
Vitamin B-6	0.060 mg
Vitamin B-12	0.332 micrograms (mcg)
Vitamin A	64.8 mcg
Vitamin E	0.439 mg
Vitamin D (D-2 and D-3)	0.918 mcg
Vitamin K	0.119 mcg

[ Source: Medical News Today]

Egg contains Low Density Lipoproteins (LDL) that may be a concern for those people having raised levels of the same in their blood, i.e. patients with Atherosclerosis etc.. But many researchers conclude that the bad cholesterols are synthesized in the liver, and dietary cholesterols do not per se increase bad cholesterol in the body. The liver is stimulated to make cholesterol primarily by saturated fat and trans-fat in our diet, not dietary cholesterol. A large egg contains little saturated fat, i.e. about 1.5 grams (g). [Source: Havard Health Publishing]

Hence, adding egg to the diet is a good idea, but the key is in moderation. There is nothing like an egg in the breakfast, cooked in whatever form.

ChatGPT has potential in Healthcare field, but not as Replacement of Healthcare Professional

noreply@blogger.com (Dr Prahallad Panda) — Tue, 11 Apr 2023 09:02:00 +0530

The ground breaking story of the recent days is Google's medically focused generative artificial intelligence (AI) model achieved 85% accuracy on a U.S. Medical Licensing Examination (USMLE) practice test, the highest score ever recorded by an AI model.

The AI model, known as Med-PaLM 2 (Pathways Language Model), consistently performed at an "expert" physician level on the sample of USMLE-style practice questions. It achieved 85% accuracy, beating previous record.

ChatGPT also urged healthcare professionals to stay informed about the latest developments in the technology and to remain open to the possibilities of using it to improve patient care. The chatbot itself emphasized that it is "not capable of replacing human healthcare professionals."

It is good to take suggestion from the Chatbot, but not to depend on it wholly. The suggestions on the diagnosis can be seen in the light of differential diagnosis, rather than final diagnosis. General Public should not depend on it and indulge in self-treatment. However, it is expected to improve further.

The main story appeared in MedpageToday

Coagulopathy in COVID-19 Deaths and Possible Measures

noreply@blogger.com (Dr Prahallad Panda) — Sun, 26 Apr 2020 20:33:00 +0530

SARS-CoV-2 is a new disease and the scientific community is still learning about it. COVID-19 emerged as a respiratory disease from China in the December, 2019. In recent studies on SARS-CoV-2, it has been found that there are unusual diffuse small thromboses in the lungs tissue of patients, as well as vascular damage in different tissues and organs. Evidence from post-mortem findings of occlusion and microthrombosis formation in pulmonary small vessels of deceased with critical COVID-19 has been reported. The features prompted some scientists to describe the disease as a disease of vascular system.

After, SARS-Cov infects the body, it up-regulates the expression of related genes in the coagulation pathway, leading to activation of coagulation. Studies have shown that the abnormal characteristics of blood coagulation indexes caused by SARS-CoV-2 are not the same as SARS-CoV, and it is more likely to cause multiple organ failures other than the lungs.

Dysregulated coagulation with hypercoagulability has been found to be common in COVID-19 and can progress to disseminated intravascular coagulation (DIC). A retrospective analysis of patients admitted with severe SARS-CoV-2 infection found that 71.4% of patients who ultimately died from COVID-19 developed overt DIC compared with only 0.6% of survivors. On admission, non-surviving patients presented with higher D-dimer levels and prolonged prothrombin times (PT) and activated partial thromboplastin times (aPTT) compared with surviving.

SARS-CoV-2 infection damages human immune system and results in systematic inflammatory response. Activation of monocytes produce cytokines, such as interleukin 6, tumor necrosis factor, and many more, which in turn induce activation of the endothelial cells and tissue factor that trigger the blood coagulation cascade. Activation of the vascular endothelium, platelets, and leukocytes results in dysregulated thrombin generation that occurs both systemically and locally in the lungs of patients with severe pneumonia, resulting in the deposition of fibrin with subsequent tissue damage and microangiopathic pathology. The effects of dysregulated thrombin generation are further exacerbated by an inhibition of fibrinolysis and the impairment of natural anticoagulant mechanisms. In addition, the hypoxia found in severe COVID-19 can stimulate thrombosis through not only increasing blood viscosity, but also a hypoxia-inducible transcription factor-dependent signaling pathway. All events may lead to DIC.

The activation of blood coagulation is essential in counteracting viral infections along with the immune system trapping viruses by forming a fibrin network, thus limiting their dissemination. However, a massive inflammatory and coagulative response is dangerous because it can lead to a local thrombosis in the lungs. Acute respiratory distress syndrome (ARDS) has been described in approximately 40% of 201 patients with COVID-19 pneumonia, in a study, and it was crucial in increasing the risk of death. ARDS may result from pulmonary vascular microthrombosis.

The concept of pulmonary thrombosis has been recently proposed for conditions such as pneumonia, asthma, and chronic obstructive pulmonary disease. It is known that viral diseases such as those from EBOLA and cytomegaloviruses can induce DIC. Therefore, it is not surprising that SARS-CoV-2 could be capable of doing the same.

Elevated plasmin(ogen) is a common feature in people with underlying medical conditions, including hypertension, diabetes, cardiovascular disease, cerebrovascular disease, and chronic renal illness, who are susceptible to SARS-CoV-2 infection. Plasmin enhances the virulence and infectivity of SARS-CoV-2 virus by cleaving its spike proteins. Extremely increased D-dimer in COVID-19 patients results from plasmin-associated hyperactive fibrinolysis. D-dimer and viral load are independent risk factors of disease severity and mortality. Antiproteases targeting plasmin(ogen) may be a promising approach to combat COVID-19.

Measuring D-dimers, prothrombin time and platelet count (decreasing order of importance) in all patients who present with COVID-19 infection, may help in stratifying patients who may need admission and close monitoring or not. Any underlying condition (e.g.; liver disease) or medication (e.g.; anticoagulants) which may alter should be accounted for while using the algorithm.

Measuring D-dimer had been recommended for Covid-19 patients, however, the optimal cut off for D-dimer remains to be well-established. D-dimer = 2.0 ug/ml (fourfold increase) on admission might be the optimum cut off to predict in-hospital mortality for Covid-19. The in-hospital mortality was significant higher in patients with D-dimer ≥ 2.0 ug/ml than those who had D-dimer < 2.0 ug/ml on admission. Among routine tests, D-dimer might be the best early marker to improve management of Covid-19.

According to researchers, heparin treatment has been recommended for COVID-19, however, its’ efficacy remains to be validated. The 28-day mortality between heparin users and nonusers were compared in stratified patients. The 28-day mortality of heparin users were lower than nonusers in patients with SIC score ≥4 or D-dimer > 3.0 ug/mL. Heparin treatment appears to be associated with better prognosis in severe COVID-19 patients with coagulopathy.

They suggested, based on a review of the very limited current peer-reviewed literature with low quality of evidence combined with discussions with international clinicians on the frontlines

All patients with COVID-19 should undergo coagulation studies at admission, in particular: D-dimer, prothrombin time, and platelet count.

Because of the possibility of patients to develop coagulopathy later in their hospital course, routine serial measurements of coagulation studies should be undertaken in all COVID-19 patients. The ideal interval has not yet been defined.

All patients with COVID-19 should be placed on prophylactic doses of anticoagulation, preferably with LMWH, unless there is a contraindication, such as acute kidney injury (AKI), wherein unfractionated heparin is preferred.

Therapeutic anticoagulation should be strongly considered in patients at high-risk for coagulopathy (including CRRT and ECMO), demonstrating signs of microthrombi-induced organ dysfunction, or with documented or strongly suspected macro-thromboembolism.

Determination of high-risk patients by laboratory measures of coagulopathy may include: platelet count, prothrombin time, fibrinogen, fibrinogen-degradation products, D-dimer, and TEG. Of note, some centers are therapeutically anticoagulating all patients on admission when no absolute contraindications exist.

Given the significant rate of AKI seen in COVID, intravenous contrast for imaging should be used with caution. Duplex ultrasonography, echocardiography, and clinical suspicion can play an increased role in these cases.

Some early reports support use of larger bolus-dose tPA (50mg or 100mg bolus) without holding anticoagulation in order to prevent recurrence of the suspected pulmonary microvascular thrombosis underlying COVID-19 ARDS, is worthy of consideration in COVID-19 ARDS associated exceptionally high mortality, weighed against the risks of tPA having ~1% risk of catastrophic bleeding in non-stroke patients.

Aspirin should be considered in cases with elevated troponin and cardiac dysfunction, particularly with elevated maximal amplitude on TEG.

This information has been compiled from the study of various literatures on the subject.

Credit:

1. Wiley Online Library: Covid-19: Novel Coronavirus Outbreak

2. COVID-19 complicated with DIC: 2 cases report and literatures review

Unusual Presentations of COVID-19

noreply@blogger.com (Dr Prahallad Panda) — Wed, 22 Apr 2020 15:53:00 +0530

A novel coronavirus emerged in China in 2019, named as SARS-CoV-2, become a pandemic. Scientists, Researchers and Health care professionals are still learning about it. It is an endeavor to compile the unusual/atypical symptoms, as far as possible, from different reputed sources. It will help the health care personnel to remain aware of the possibility of dealing with a COVID-19 patient, when patients present with symptoms, similar to some other disease.

Fever, Cough, Shortness of breath; these are what have become known as the classic, tell-tale COVID-19 symptoms. However, there can be additional non-specific, atypical symptoms or different, less common ones that should alert the health care profession, the possibility of the infection. Those include, Sore throat, Diarrhea, Myalgia (muscle aches, body aches), abdominal pain, loss of smell or taste, conjunctivitis, Tiredness or fatigue.

At present the definition of a COVID-19 Suspected Case:

Suspected Case Definitions
A. Symptoms + Travel History	B. Symptoms + Epidemiologic Link	C. Severe Symptoms
A patient with ALL of the following: acute respiratory illness no other etiology that fully explains the clinical presentation a history of travel to or residence in a country, area or territory that has reported local transmission of COVID-19 disease during the 14 days prior to symptom onset	A patient with ALL of the following: · any acute respiratory illness · contact of a confirmed or probable case of COVID-19 disease during the 14 days prior to the onset of symptoms	A patient with ALL of the following: · severe acute respiratory infection · requires hospitalization · no other etiology that fully explains the clinical presentation

1. Loss of smell and taste has been reported with such a frequency in COVID-19 that some medical professionals suggest to take it as a cardinal feature for diagnosis, if, associated with features of respiratory infection, even common cold or seasonal flu. According to Carol Yan, an otolaryngologist from the University of California San Diego in the US, “if, you have smell and taste loss, you are more than 10 times more likely to have COVID-19 infection than other causes of infection."

The loss of smell reported to be so profound that the patient starts nauseating just at the sight of food. He further says, while the most common first sign of a COVID-19 infection remains fever, fatigue/loss of smell and taste follow as other very common initial symptoms.

Based on the findings, UC San Diego Health has included loss of smell and taste as a screening requirement for visitors and staff, as well as a marker for testing patients who may be positive for the virus. The original article was published in The Week on April 14, 2020 15:14 IST, can be accessed here.

2. Abdominal discomfort may be the presenting symptom in as many as 20 percent of patients. Recent literature has revealed that as many as 20 percent of patients present to the hospital with a digestive symptom, such as diarrhea, vomiting, pain, accompanying their respiratory symptoms. And, roughly 5 percent show up with an abdominal complaint alone.

This is where abdominal radiologists can play an integral role, said industry experts in a recent article published in the American Journal of Roentgenology. A team, led by Abraham Dachman, M.D., professor of radiology and abdominal imaging specialist with UChicago Medicine, shared three cases where patients were referred for abdominal imaging and providers distinguished findings indicative of COVID-19 infection in the lung base.

Axial CT of abdomen and pelvis shows left basilar round airspace and ground-glass opacities (arrow). Appearance is highly compatible with atypical infection such as coronavirus disease (COVID-19) pneumonia.

The article published on April 20, 2020, can be accessed here.

3. The gastrointestinal presentation can delay the initiation of COVID-19 diagnostic workup. Notably, however, the first case of COVID-19 infection confirmed in the United States reported a 2-day history of nausea and vomiting on admission followed by loose stools in hospital on day 2, and COVID-19 viral nucleic acids of loose stool and respiratory specimens were reported positive. In a recent report from Hubei, China, 204 COVID-19-infected patients were studied, and the authors reported that digestive symptoms are not uncommon in patients with COVID-19. The original article, published in The Karger, can be accessed here.

According to the WHO, digestive issues like diarrhea and nausea may be a more common symptom than previously thought.

4. Conjuctivitis: Several reports suggest that SARS-CoV-2 can cause a mild follicular conjunctivitis otherwise indistinguishable from other viral causes, and possibly be transmitted by aerosol contact with conjunctiva. However, at this point in the COVID-19 pandemic, practically any patient seen by an ophthalmologist could be infected with SARS-CoV-2, regardless of presenting diagnosis, risk factors, indication for visit or geographic location. Updated on April 21, 2020, online by American Academy of Ophthalmology, can be accessed here. Access the Ocular manifestations of a hospitalized patient with confirmed 2019 novel coronavirus disease in The British Journal of Ophthalmology here.

5. Malaise and Confusion can be present in varied number of patients of COVID-19 are some of the atypical symptoms, according to an article published in The Lancet.

In a study, the most common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhea (one [3%] of 38). More than half of patients (22 [55%] of 40) developed dyspnoea.

6. Headaches and dizziness may also be signs of the viral infection: According to the study in The Lancet, about 8 percent of COVID-19 patients reported headaches. Dizziness has also been reported in some cases – frequent dizzy spells or very severe or abrupt bouts of dizziness could indicate a more serious health risk, according to the Cleveland Clinic.

7. Chills or muscle aches occasionally accompany COVID-19. Aches and chills can be symptoms of many illnesses, including the flu, but coronavirus patients have reported them. It's not clear how prevalent these symptoms are, but about 11 percent of people studied reported chills, and 14 percent reported muscle aches, according to the WHO report.

8. Runny nose is rarely a sign of coronavirus: It is more indicative of allergies or a cold. A minority of COVID-19 patients experience nasal congestion or a runny nose – less than 5 percent of people experience these symptoms, according to the WHO report.

9. Acute myocarditis is thought to be a possible complication associated with COVID-19. While, it is required to closely monitor such patients for the complication, medical profession should keep in mind to test for the COVID-19, whenever other symptoms or epidemiologic link is available. Laboratory testing, including troponin levels, in individuals with recent symptoms of an acute illness should be performed to guarantee appropriate identification and prompt isolation of patients at risk of COVID-19 and eventually to reduce further transmission. The article published in JAMA Network on March 27, 2020, can be accessed here.

10. Necrotizing encephalopathy: A woman who tested positive for COVID-19 developed a rare brain disease known as acute necrotizing encephalopathy, a condition that can be triggered by viral infections like influenza and herpes.

At this point, the brain damage "has yet to be demonstrated as a result of COVID-19 infection," according to a case report published March 31 in the journal Radiology. However, as the novel coronavirus continues to spread, "clinicians and radiologists should be watching for this presentation among patients presenting with COVID-19 and altered mental status," the authors wrote.

The original article published online by the Radiological Society of North America on Mar 31, 2020 can be accessed here.

11. Asymptomatic (subclinical): Now-a-days, a large number of asymptomatic (in pre-clinical/pre-symptomatic stage) patients are seen positive for COVID-19; many are also seen with mild symptoms (easily ignored). Many more asymptomatic contacts are also positive for COVID-19. It may go up to 80%. Another study suggests that the number can be between 5% and 80%.

In those mild cases, the predominant CT in Lungs can be diagnostic, with the findings of ground-glass opacification, consolidation, bilateral involvement, and peripheral and diffuse distribution. Notably, in Shi and colleagues' study, the asymptomatic (subclinical) group of patients showed early CT changes, supporting what was first observed in a familial cluster with COVID-19 pneumonia. Published on February 24^th, 2020 in The Lancet can be accessed here.

12. Atypical symptoms of COVID‑19 can be more common in immune-suppressed or immune-compromised patients. They may present with the symptoms of COVID‑19; neutropenic sepsis and pneumonitis may be difficult to differentiate at initial presentation. Medical profession has to keep in mind to screen and triage all those patients to assess, whether they are known, suspected to have COVID‑19, or have been in contact with someone with confirmed infection. In that case, COVID-19 rapid guidance from National Institute for Health & Care Excellence, updated on April 17,2020, can be followed.

Atypical symptoms in COVID-19: the many guises of a common culprit: COVID-19 exhibits a diverse range of clinical presentations. Whilst classical respiratory symptoms of a dry cough have been underscored, these may be preceded by atypical symptoms. More generally, it is important not to neglect other disease manifestations, since they may represent alternative modes of viral dissemination.

In critically ill patients, evidence of raised inflammatory markers suggests that cytokine storm syndrome occurs in COVID-19 and may underlie some atypical presentations. Notably, the elderly and those with multiple co-morbidities are severely affected by COVID-19, and atypical symptoms in these susceptible groups warrant further investigation.

2. Published on 1^st April, 2020 in The Science^Alert; Some COVID-19 Symptoms Are Turning Out to Be Atypical. Here's What We Know So Far

3. Published on 05 April 2020 in thebmj in a letter to the Editor, under caption, “Atypical symptoms in COVID-19: the many guises of a common culprit.”

4. Published on April 17^th, 2020 in Medscape: Unusual Presentations of COVID-19: 'Our Ignorance Is Profound'

(A Paradip Port Trust Hospital Document)

SARS-CoV-2 Transmission & Possible Preventive Measures

noreply@blogger.com (Dr Prahallad Panda) — Mon, 20 Apr 2020 20:09:00 +0530

A novel coronavirus emerged in China in 2019 named as SARS-CoV-2, become a pandemic. Scientists, Researchers and Health care professionals are still learning about it. It is an endeavor to compile all the possible modes of transmission of the virus from different reputed sources, so that it can help to understand the behavior of the virus and suitably modify the preventive measures practiced at present. This may change as more knowledge acquired on the virus.

1. COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2022:

During January 26–February 10, 2020, an outbreak of 2019 novel coronavirus disease in an air-conditioned restaurant in Guangzhou, China, involved 3 family clusters. The airflow direction was consistent with droplet transmission. To prevent the spread of the virus in restaurants, the researchers recommend increasing the distance between tables and improving ventilation. Reference 2. Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020

Contamination was greater in intensive care units than general wards. Virus was widely distributed on floors, computer mice, trash cans, and sickbed handrails and was detected in air ≈4 m from patients.

In this study, researchers tested surface and air samples from an intensive care unit (ICU) and a general COVID-19 ward (GW) at Huoshenshan Hospital in Wuhan, China.

The study led to 3 conclusions. First, SARS-CoV-2 was widely distributed in the air and on object surfaces in both the ICU and GW, implying a potentially high infection risk for medical staff and other close contacts. Second, the environmental contamination was greater in the ICU than in the GW; thus, stricter protective measures should be taken by medical staff working in the ICU. Third, the SARS-CoV-2 aerosol distribution characteristics in the GW indicate that the transmission distance of SARS-CoV-2 might be 4 m.

In addition, their findings suggest that home isolation of persons with suspected COVID-19 might not be a good control strategy. Family members usually do not have personal protective equipment and lack professional training, which easily leads to familial cluster infections. During the outbreak, the government of China strove to the fullest extent possible to isolate all patients with suspected COVID-19 by actions such as constructing mobile cabin hospitals in Wuhan, which ensured that all patients with suspected disease were cared for by professional medical staff and that virus transmission was effectively cut off. As of the end of March, the SARS-COV-2 epidemic in China had been well controlled. Reference

3. Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the
University of Nebraska Medical Center

SARS-CoV-2 is shed during respiration, toileting, and fomite contact, indicating
that infection may occur in both direct and indirect contact. Reference

4. The Role of Particle Size in Aerosolised Pathogen Transmission:

In a review, particle sizes generated from breathing, coughing, sneezing and talking showed healthy individuals generate particles between 0.01 and 500 μm, and individuals with infections produce particles between 0.05 and 500 μm. This indicates that expelled particles carrying pathogens do not exclusively disperse by airborne or droplet transmission, but avail of both methods simultaneously and current dichotomous infection control precautions should be updated to include measures to contain both modes of aerosolised transmission. Reference

5. Respiratory Virus RNA is Detectable in Airborne and Droplet Particles

In a study, on breathing, 58% of participants produced large particles (>5 µm) containing viral RNA and 80% produced small particles (≤5 µm) carrying viral RNA. On coughing, 57% of participants produced large particles containing viral RNA and 82% produced small particles containing viral RNA. Forty five percent of participants produced samples positive for hRV viral RNA and 26% of participants produced samples positive for viral RNA from parainfluenza viruses. Reference

6. Potential for Airborne Transmission of Infection in the Waiting Areas of Healthcare Premises: Stochastic Analysis Using a Monte Carlo Model:

The researchers have found that under normal circumstances the risk of acquiring a TB infection during a visit to a hospital waiting area is minimal. Likewise, the risks associated with the transmission of influenza, although an order of magnitude greater than those for TB, are relatively small. By comparison, the risks associated with measles are high. While the installation of air disinfection may be beneficial, when seeking to prevent the transmission of airborne viral infection, it is important to first minimize waiting times and the number of susceptible individuals present, before turning to expensive technological solutions. Reference

7. 7. COVID-19 Can Travel on Shoes:

The floor swabs also had a high rate of positive tests, potentially due to virus droplets
falling on the ground. Half of the ICU staff’s shoes also tested positive. As medical staff
walk around the ward, the virus can be tracked all over the floor, as indicated by the 100%
rate of positivity from the floor in the pharmacy, where there were no patients.

Reference
8. How COVID-19 Spreads

         COVID-19 is thought to spread mainly through close contact from person-to-person in
         respiratory droplets from someone who is infected. People who are infected often have
   symptoms of illness. Some people without symptoms may be able to spread virus.
   Spread from contact with contaminated surfaces or objects. This virus is spreading
more efficiently than influenza, but not as efficiently as measles, which is highly contagious.                                                                                                                              Reference
9. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Aerosol and fomite transmission of SARS-CoV-2 are plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculums shed.

SARS-CoV-2 remained viable in aerosols for 3 hours in experimental conditions, with a reduction in infectious titer from 10^3.5 to 10^2.7 TCID₅₀ per liter of air.

SARS-CoV-2 was more stable on plastic, viable virus was detected up to 72 hours after application to this surface, although the virus titer was greatly reduced (from 10^3.7 to 10^0.6 TCID₅₀ per milliliter of medium after 72 hours.

SARS-CoV-2 was stable on stainless steel, although the virus titer was greatly reduced from 10^3.7 to 10^0.6 TCID₅₀ per milliliter after 48 hours.

On copper, no viable SARS-CoV-2 was measured after 4 hours.

On cardboard, no viable SARS-CoV-2 was measured after 24 hours

Reference Reference
10. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations; WHO

Respiratory infections can be transmitted through droplets of different sizes: when the droplet particles are > 5-10 μm in diameter they are referred to as respiratory droplets, and when they are < 5μm in diameter, they are referred to as droplet nuclei.According to current evidence, COVID-19 virus is primarily transmitted between people through respiratory droplets and contact routes.In an analysis of 75,465 COVID-19 cases in China, airborne transmission was not reported. Reference
11. Speed of a Sneeze.

The largest droplets rapidly settle within 1 to 2 m away from the person. The smaller and evaporating droplets are trapped in the turbulent puff cloud, remain suspended, and, over the course of seconds to a few minutes, can travel the dimensions of a room and land up to 6 to 8 m away. Reference

12. Coughing and Aerosols

A maximum airspeed of 8 m per second (18 mph) has been observed by researchers, averaged during the half-second cough. The cough plume may project infectious aerosols into the surrounding air.

Reference
13. Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering

It was calculated that the original diameters of the respiratory drop lets ranged from1to 2000 micron that 95% were between 2 and 100 micron and that the most common were between 4 and 8 micron. Reference
14. Seasonality of Respiratory Viral Infections

There can be possible seasonal determinants in the epidemics of respiratory viruses as well as host factors affected by these contributing factors. These include seasonal changes in temperature, absolute humidity (AH), sunlight, vitamin status, and host behavior. Animal transmission studies with guinea pigs and ferrets have revealed that high RH (>60%) and low RH (<40%) seems to allow viability of influenza viruses in droplets, while in intermediate RH (40% to 60%) viruses become inactivated.

Since, the type II alveolar cells, where the angiotensin-converting enzyme II concentrated, are located deep in the respiratory tract, are not reachable by respiratory droplets with a diameter of more than 5 micrometers, it appears likely that at least, the severe cases of COVID-19 with viral pneumonia, are the result of air borne transmission events.

The combination of low humidity, temperature, and sunlight may trigger an impairment of the local and systemic antiviral defense mechanisms, leading to the increased host susceptibility to the respiratory viruses in winter.

In addition to vaccines and antiviral drugs, non-pharmaceutical interventions to prevent respiratory infections are gaining attention. Lifestyle (eating healthy, sleeping more than 7 h/day) and hygiene practices (washing hands, wearing facemasks) are known to increase antimicrobial resistance and prevent transmission, respectively. In addition to these measures, we might consider controlling the indoor environment to combat respiratory infections. Such interventions with humidifiers (RH~45) have been realized since the 1960s with promising results. Reference

15. Possible Preventive Measures¹:

The first and foremost message emerging out of the researches is Social Distancing:

(i) 2 meters (6 feet), instead of 1 meter, wherever possible, like market places, malls, hospital waiting areas, restaurants, and offices etc..

(ii) Quick disposal of patients and customers in commercial establishments (Malls & Restaurants)

(iii) At least, 1 meter (3 Feet) distance in Triage facility in Hospital and during home quarantine (If, no separate room is available).

(iv) Barrier (Glass) communication at Reception Counters in Acute Respiratory Infection or Fever Clinic

(v) Restriction of entry of non-essential health care staff to the ICU/Rooms of COVID-19 patients, multi-tasking.

(vi) Sanitization of footwear, like two coir mat system²; standing for 1 minute on a mat soaked with 1% Sodium Hypochlorite solution, then drying foot on 2^nd coir mat.

(vii) As health care persons (as well as some other professions, like saloon staff), who cannot maintain distancing, Correct use of PPEs (separate donning & doffing) as recommended for ICU and other places.

(viii) Healthcare supervised quarantine, in lieu of home quarantine.
2. Use of Facemasks: At least, Home-made mask for all, while going out (only to collect essential items). Standard PPEs for Hospital staff as per protocol.

3. Use of HEPA (High Efficiency particulate Air Filter) filters in Hospital settings (Acute Respiratory Infection treatment ICU/WARDS).
4. Following Good Hand Hygiene practice (Minimum 30 second, instead of 20 seconds) & Cough Etiquette.
5. Correct way of hand Sanitization (20 seconds, six steps as hand washing.
6. Maintaining healthy Lifestyle (eating healthy, sleeping more than 7 h/day), physical exercise (at least in Indoor), taking fresh fruits, and Vitamin D (Exposure to Sun is better).
7. Humidifier in Rooms to maintain RH (Relative Humidity = ~45).
8. Providing correct PPEs to patient.
9. Box-Shield Protected (as shown in NEJM video) Endotracheal Intubation/Ex-tubation/Splash generation procure.
10. Sanitization of frequently touched places, Bed-rail of patient, Door-knobs, Computer Key-board & Mouse, Lifts, stair-case rail, Hospital trolleys/stretchers/wheel-chairs, and handles of trolley/cart in Malls etc.. Sanitization of card boards (files, not required, if, not exposed; however, UV sterilizer can be used or exposed to Sun).
11. Cupper coating of steel surfaces in Hospital Settings (Like, bed-rails, bathroom door-knobs, and wheel-chairs etc.).
12. Covering the wheel-chair and stretchers with rubber mackintosh sheets that can be sanitized later.
13. Designing AIR-Conditioners with HEPA filters for hospital use, like used in Airplanes.
14. Managing laundry according to SoP (Soaking in detergent & hot water-washing/Use Hypochlorite) with correct use of PPEs.
15. Vaccination (When available).

(A Paradip Port Trust Hospital document)

Credits:

WHO

CDC

NEJM

Worldmeter Reference

WebMD

Acknowledgements

Sri Rinkesh Roy, IRTS, Chairman, Paradip Port Trust for reviewing of the article

Dr Raja Ravi Varma, Chief Medical Officer, Chennai Port Trust for use of hypochloride soaked mat

Eating how much Nuts is Safe for you?

noreply@blogger.com (Dr Prahallad Panda) — Mon, 4 Mar 2019 09:43:00 +0530

It is generally accepted that eating nuts keep heart healthy. Generally, nuts contain fats, though unsaturated (Good Fat), high in energy; consuming a lot, may not be a good idea. Let’s have an idea about the amount of nuts to be consumed safely.

Can eating nuts help heart?

A number of researches suggest that nuts are heart friendly. However, the evidences are still inconclusive. But, unless someone is allergic to nuts, it is a great idea to have nuts in snacks and include as part of heart-healthy balanced diet.
Nuts may help by mobilizing the low-density lipoproteins (LDL, or "bad") cholesterol to liver for metabolism. LDL plays a major role in the development of plaque that builds up on the blood vessels. Eating nuts has also been linked to lower levels of inflammation linked to heart disease.
Eating nuts may also reduce risk of developing blood clots in the arteries of heart by improving the inner lining (endothelium) of the coronary (heart arteries) arteries.

What's in nuts that might make them heart healthy?

Besides being packed with protein, most nuts contain at least some of these heart-healthy substances:

Unsaturated fats. It's not entirely clear why, but it's thought that the "good" fats in nuts — both monounsaturated and polyunsaturated fats, lower bad cholesterol levels. Omega-3 fatty acids is one of the polyunsaturated fatty acids, found in many kinds of fishes, but many nuts are also rich in omega-3 fatty acids.
Fiber. All nuts contain fiber, which helps lower cholesterol. Fiber, as not digested in full, makes tummy feel full and decreases appetite; hence, intake of food gets reduced. Dietary fibers also have many health benefits.
Vitamin E. Vitamin E may help stop the development of plaques in arteries, which can narrow them. Plaque development in arteries can lead coronary artery disease, leading to a heart attack.
Plant sterols. Some nuts contain plant sterols, a substance that can help lower cholesterol.
L-arginine. Nuts are also a source of l-arginine, which is a substance that may help improve the health of arterial walls by making them more flexible and less prone to blood clots that can block blood flow.

What amount of nuts is considered healthy?

As much as 80 percent of a nut is fat. Even though most of this fats are healthy, are packed with a lot of calories (One gram of fat yields 9 Calories, whereas, one gram of glucose/protein yields 4 calories) . That's why, one should eat nuts in moderation. Ideally, you should use nuts as a substitute for saturated fats, such as those found in meats, eggs and dairy products.
The American Heart Association recommends eating about four servings of unsalted nuts a week. Select raw or dry-roasted nuts, rather than those cooked in oil.
A serving is a small handful (1.5 ounces; one ounce is 28. 4 grams) of whole nuts or 2 tablespoons of nut butter. But again, do this as part of a heart-healthy diet. Just eating nuts and not cutting back on saturated fats found in many dairy and meat products won't do your heart any good.

Does it matter what kind of nuts you eat?

The type of nuts you choose to eat probably doesn't matter much. Most nuts appear to be generally healthy, though some may have more heart-healthy nutrients than others. For example, walnuts contain high amounts of omega-3 fatty acids.
Almonds, macadamia nuts, hazelnuts and pecans are other nuts that appear to be quite heart healthy. And peanuts — which are technically not a nut, but a legume, like beans — seem to be relatively healthy.

Keep in mind, you could end up canceling out the heart-healthy benefits of nuts if they're covered with chocolate, sugar or salt.
Here's some nutrition information on common types of nuts. All calorie and fat content measurements are for 1 ounce, or 28.4 grams (g), of unsalted nuts.

Type of nut	Calories	Total fat
Almonds, dry-roasted	170	14.9 g
Almonds, raw	164	14.2 g
Brazil nuts, raw	187	19 g
Cashews, dry-roasted	163	13.1 g
Chestnuts, roasted	69	0.6 g
Hazelnuts (filberts), dry-roasted	183	17.7 g
Hazelnuts (filberts), raw	178	17.2 g
Macadamia nuts, dry-roasted	204	21.6 g
Macadamia nuts, raw	204	21.5 g
Peanuts, dry-roasted	166	14.1 g
Pecans, dry-roasted	201	21.1 g
Pistachios, dry-roasted	162	13 g
Walnuts, halved	185	18.5 g

How about nut oils? Are they healthy, too?

Nut oils are also a good source of healthy nutrients, but they lack the fiber found in whole nuts. Walnut oil is the highest in omega-3s.
Consider using nut oils in homemade salad dressing or in cooking. When cooking with nut oils, remember that they respond differently to heat than do vegetable oils.
Nut oil, if overheated, can become bitter. Just like with nuts, use nut oil in moderation, as the oils are high in fat and calories.
The original article was published in MyoClinic, which can be accessed here.

Whether Aspirin or Statin in Primary Prevention or Cardiovascular Disease (CVD

noreply@blogger.com (Dr Prahallad Panda) — Thu, 17 Jan 2019 20:16:00 +0530

Aspirin, chemically acetylsalicylic acid, has been a trusted pal of health-care providers for more than 100 years by now. Many beneficial effects, including benefits in certain heart diseases & colo-rectal cancer, came to light in the recent past, adding many feathers to its’ cap.

Aspirin has been a staple of primary prevention of cardiovascular disease (CVD) in at-risk populations based on recommendations by major organizations including the American Heart Association (AHA) together with the American College of Cardiology (ACC), US Preventive Services Task Force (USPSTF) and others. Accordingly, aspirin became one of the most commonly used medications for primary prevention of CVD, and it is estimated that 40% of US adults over 50 years of age use aspirin for this purpose.

^{The
AHA Prevention Guidelines published in 1997 did not recommend aspirin
use for primary prevention, citing the need for additional research.
Major primary prevention studies completed from 1988 to 2001,
including the British Doctors Study (BDS), US Physicians' Health
Study (PHS), Thrombosis Prevention Trial (TPT), Hypertension Optimal
Treatment (HOT) and low-dose aspirin trial of the Primary Prevention
Project (PPP) trials, led the USPSTF and AHA to adopt recommendations
for aspirin (75-100 mg/day, or 325 mg every other day) for primary
prevention in 2002, particularly for high-risk individuals (5-year
CVD risk ≥3%).}

^{However,
more recent studies did not demonstrate clear benefit of aspirin,
including the Prevention of Progression of Arterial Disease and
Diabetes (POPADAD), Japanese Primary Prevention of Atherosclerosis
with Aspirin for Diabetes (JPAD), Aspirin for Asymptomatic
Atherosclerosis (AAA) and Japanese Primary Prevention Project (JPPP).
In 2016, the USPSTF Guidelines were pared back, recommending aspirin
for CVD and colorectal cancer prevention in adults aged 50 to 59 with
a 10-year ASCVD risk of at least 10% without increased risk of
bleeding and with life expectancy of at least 10 years (Grade B).
Aspirin use in adults aged 60 to 69 who have the same risk requires
an individualized approach based on a weaker recommendation (Grade
C).}

^{The
recent contribution of the ARRIVE (Aspirin to Reduce Risk of Initial
Vascular Events) , ASCEND (A Study of Cardiovascular Events in
Diabetes) and ASPREE (Aspirin in Reducing Events in the Elderly)
trials provides useful insight into the role of aspirin use for
primary prevention in the modern era, when there is decrease in
smoking, better control of cholesterol, lifestyle modification &
increased use of statins.}

^{It can be concluded that for primary prevention, in which risk is determined
largely by age and the presence or absence of diabetes, the
benefit–risk ratio for prophylactic aspirin in current practice is
exceptionally small.}

^{In contrast, for secondary prevention, in which
risk is determined largely by the extent of atherosclerotic disease,
the benefits of aspirin outweigh the risks of bleeding. Visit the NEJM here.}

^{Therefore,
beyond diet maintenance, exercise, and smoking cessation, the best
strategy for the primary prevention of cardiovascular disease may
simply be to replace aspirin with a statin.}

^{Its’
use can be narrowed to the highest-risk populations, including
individuals aged 40 to 70 years old without diabetes with 10-year
ASCVD ≥20% or patients with diabetes with ASCVD ≥10%, provided
they are not at high-risk of bleeding.See the ACC recommendation.}

USFDA Approved Tafenoquine for Radical Cure of Vivax Malaria

noreply@blogger.com (Dr Prahallad Panda) — Sat, 28 Jul 2018 19:32:00 +0530

The FDA approved tafenoquine (Krintafel, GSK) for the "radical cure" of Plasmodium vivax malaria in patients, ages ≥16 years, who are receiving anti-malarial therapy for acute infection, the manufacturer GlaxoSmithKline (GSK) announced.

Life Cycle of P. Vivax

At present, Primaquine is the only FDA approved drug prescribed for 14 days for the radical cure of Vivax Malaria. Tafenoquine 300 will be a single dose therapy for patients over 16 years.

The newly approved drug is contraindicated for patients who are allergic to tafenoquine or other 8-aminoquinoline-containing agents, as well as for those who are glucose-6-phosphate dehydrogenase (G6PD) deficient. Patients should be tested if their status is unknown.

A brief on Cancer of Cervix

noreply@blogger.com (Dr Prahallad Panda) — Sun, 1 Oct 2017 18:11:00 +0530

Observation of World Heart Day 2017 at PPT Hospital

noreply@blogger.com (Dr Prahallad Panda) — Sun, 1 Oct 2017 14:53:00 +0530

World Heart Day-2017

noreply@blogger.com (Dr Prahallad Panda) — Sun, 1 Oct 2017 10:41:00 +0530

Swine Flu

noreply@blogger.com (Dr Prahallad Panda) — Tue, 22 Aug 2017 16:08:00 +0530

Use of Alpha 1 blocker as a part of Medical Expulsive Therapy (MET) for Ureteric Stone

noreply@blogger.com (Dr Prahallad Panda) — Sun, 25 Dec 2016 12:41:00 +0530

The traditional teaching has been plenty of water, control of infection and some anti-spasmodic as an expectant treatment for small ureteric stones, i.e. around 5 mm. in diameter, to pass out; more than 10 mm, requires intervention.

In the recent days, the management of ureteric stone has been revolutionalised by introduction of Extra-Corporeal Shock Wave Lithotripsy (ESWL) and ureteroscopic surgery /other minimally invasive surgeries.

However, there is always a room for conservative management of ureteric stones, where the size of stone is around 5 mm. in diameter and is located more towards the distal part of the ureter.

Migration and increase in size of stone causes excruciating pain, only known to those, who suffer from it.

An article published in Cleveland Clinic Journal of Medicine, based on the original article published in the BMJ (British Medical Journal, Alpha Blockers & Treatment of Ureteric Stones, BMJ; ePub 2016 Dec 1; Hollingsworth, et al. December 20, 2016) recommends use of Alpha 1 blocker as a part of Medical Expulsive Therapy (MET) for ureteric stone, precisely located more distally in the ureter.

Urinary stones are common, with a prevalence of about 5% in the population. Non-contrast CT scan is the diagnostic modality of choice. When calculi are smaller than 5 mm, 90% will pass spontaneously, but as stones approach 10 mm., there is less than a 10% chance that they will pass.

Since, small stones pass spontaneously almost all of the times, alpha-blockers add little to the management of these small stones. The value of alpha-blockers is for stones of 5 mm to 10 mm in size, where the use of an alpha-blocker significantly improves the rate of passage without surgical intervention.

When conservative management of a ureteral stone is being considered and the patient has no associated signs of infection, uncontrollable pain, or renal failure, adjuvant pharmacologic intervention has proven efficacious in improving spontaneous stone passage rate and time interval, and in reducing analgesic requirements.

Many of the studies have administered the drugs in conjunction with steroids and/or NSAIDs, which may reduce ureteral edema and improve the ability for a patient to spontaneously pass a ureteral stone.

However, several of the more recent studies have shown benefit to both α-blockers and calcium channel blockers without the adjunctive use of steroids; furthermore, tamsulosin, in randomized trials, has been shown to be more efficient than nifedipine with a decreased time to expulsion and slightly higher rate of expulsion.

Alpha-1-adrenergic receptors are located throughout the human ureter. The physiologic response to antagonism of these receptors is decreased force of contraction, decreased peristaltic frequency, and increased fluid bolus volume transported down the ureter. These responses are likely, how α-blockers assist in ureteral stone passage.

Alpha-blockers, specifically α1 antagonists, are highly effective in increasing the expulsion rate of distal ureteral stones, reducing the time to stone passage, and decreasing the amount of pain medication needed during passage stones.

Alpha blockers may also be a useful adjunct in the treatment of both ureteral and renal stones after ESWL. They may also reduce the urinary symptoms and pain associated with double-J ureteral stents.

Main Points

Medical expulsion therapy is a useful adjunct to observation in the conservative management of ureteral stones.
Alpha-1 receptors are located in the human ureter, especially the distal ureter; α-blockers increase expulsion rates of distal ureteral stones, decrease time to expulsion, and decrease need for analgesia during stone passage. Moderate quality evidence was observed that alpha blockers facilitate passage of ureteric stones.
In the appropriate clinical scenario, the use of α-blockers is recommended in the conservative management of distal ureteral stones.
The greatest benefit may be among patients with larger stones (57% higher likelihood of stone passage vs controls).
Compared with controls, patients receiving alpha blockers had significantly shorter times to stone passage, fewer episodes, lower risks of surgical intervention, and lower risk of admission to hospital.

Urinary stone disease is frequently seen in the urology practice. Symptoms include flank or abdominal pain radiating to the groin or external genitalia. Although some patients with ureteral stones might remain asymptomatic, many have pain and thus commonly seek medical care. Ureteric stone and its' size are best assessed in a non-contrast CT in comparison to the ultrasound examination.

An acute episode of colic is the result of a stone entering the ureter and causing intermittent rise of pressure in the pyelocalyceal system. Spontaneous passage will occur in most of these stones.

An review article published in Cochrane Library (2nd April, 2014, Authors: Campschroer T, Zhu Y, Duijvesz D, Grobbee DE, Lock M) identified 32 studies enrolling 5864 participants. The use of alpha-blockers in patients with ureteral stones resulted in a higher stone-free rate and a shorter time to expulsion and therefore decreased the duration of symptoms and rate of complications (UTI, hydronephrosis and impairment of kidney function).

Medical expulsive therapy includes the use of oral/intravenous hydration, analgesics, and medications that promote stone passage, including alpha-1 blockers.

The most common alpha-1 blocker used to aid in the passage of ureteral stones is tamsulosin. The indicated use for tamsulosin is for treating symptoms of benign prostatic hyperplasia (BPH) (Alexander, 2010); however, off-label use has recently emerged as an efficacious and safe option for the initial management of ureteral stones (Bensalah et al., 2008)

Tamsulosin may help patients pass a kidney stone by relaxing the smooth muscle of the intramural ureters, allowing urine and stones to pass through more easily.

Tamsulosin is an antagonist of alpha1Aadrenoreceptors in smooth muscle; blocking them leads to relaxation of smooth muscle in the bladder neck causing an improvement in urine flow (Alexander, 2010).

Tamsulosin also relaxes the smooth muscle of veins and arteries, which can cause patients to feel dizzy when getting up from a sitting or lying position (orthostatic hypotension). Patients who take tamsulosin should be careful not to move too quickly when changing positions to avoid dizziness or syncopy.

Other documented side or adverse effects include blurred vision, cough, decreased sexual function, diarrhea, dizziness, drowsiness, lightheadedness, runny or stuffy nose, sinus in flam mation, trouble sleeping, and weakness (Lexi-Comp, Inc., 2011). Overdose symptoms include clammy or cold skin, rapid heartbeat, lightheadedness, extreme headache, and passing out.

Because of its sustained release formulation, the manufacturer does not recommend opening, crushing, or chewing the capsule/tablet because this can increase the medication's potential side effects (Alexander, 2010). Patients with a sulfa allergy should not use tamsulosin as a cross reactivity has been noted (Lexi-Comp, Inc., 2011)

Most adverse effects were mild of origin and did not lead to cessation of therapy, and several studies reported no adverse events in either the treatment or control group.

Alpha-blockers could be considered as first-line treatment for patients presenting with urinary stones.

All the Patients of Acute Myocardial Infarction (STEMI) may not require Oxygen therapy

noreply@blogger.com (Dr Prahallad Panda) — Fri, 23 Dec 2016 11:32:00 +0530

Oxygen therapy has been a mandatory requirement for more than 100 years unquestionably, to treat acute heart attack, i.e. Myocardial Infarction, most of the times on the basis of anecdotal evidence, expert opinion, and tradition. Recent compelling evidences have challenged this conventional thinking.

myocardial infarction - Myokardinfarkt - scheme (Photo credit: Wikipedia)

Immediate treatment with Morphine, oxygen, nitrates and antiplatelets (MONA) has become the standard treatment for acute myocardial infarction (AMI) patient. Oxygen is a lifesaving drug. Giving oxygen to patient with impending clinical emergency has become knee-jerk reflex reaction of clinician. At the same time, if not provided immediately, raises many questions from all the quarters including patient and his attendants.

Patient with AMI has compromised myocardial perfusion and event arises due to myocardial hypoxia. It appears quite logical and biologically plausible to give oxygen in such situations to improve the oxygenation of the ischemic myocardial tissue and decrease ischemic pain.
On the other side, oxygen may be harmful for its’ paradoxical effect in decreasing coronary artery blood flow and increasing coronary vascular resistance, evidenced by intra-coronary Doppler ultrasonography. This effect leads to decrease in cardiac output and stroke volume. Excess Oxygen in blood (hyperoxia) causes increase in vascular resistance and reperfusion injury due to increased oxygen free radicals.
A survey among doctors managing AMI cases had showed that oxygen supplementation was given to 96% of their patients with acute coronary syndrome. About 50% of participants believed that oxygen reduces fatality, 25% thought it is helpful in decreasing pain, and 25% thought it has no effect.
Researchers like, Nicholson, Beasley et al. and Wijesinghe et al. have suggested that efficacy and safety of high flow oxygen in MI is not substantial. The existing evidence suggests that the routine use of high flow oxygen in uncomplicated MI can cause greater infarct size and possibly increase the risk of mortality.
Cochrane systemic review by Cabello et al., did not find any conclusive evidence from randomized controlled trials (four parallel-design, randomized controlled trials reported between 1976 and 2012) to support the routine use of inhaled oxygen in patients with acute AMI.
Recently published, Air Verses Oxygen in myocardial infarction study (AVOID Study) suggested routine oxygen supplementation to AMI patients from the ambulance through to the recovery room might actually be hurting their hearts. AVOID was a randomized, controlled, multicenter trial with the aim of comparing oxygen supplementation (6–8 L/min) with no oxygen in STEMI patients with oxygen saturation in the normal range pulse oximetry saturation >94%.
The study found a significant 25% increase in creatine kinase, suggestive of increased myocardial injury and cardiac magnetic resonance imaging (cardiovascular magnetic resonance) at 6 months suggestive of larger infarction size with oxygen therapy. Although, the mortality was similar in both groups, significant increases in recurrent MI and arrhythmias were observed in the oxygen group. Even though, AVOID Study used higher oxygen flow 6–8 L/min (more than usual clinical practice) and study was not powered for hard clinical end points, AVOID trial would really question the current practice of oxygen supplementation to all patients with acute myocardial ischemia and definitely to those with normoxia.
This subject is being further studied by researchers with the Swedish Coronary Angiography and Angioplasty Registry in an open-label randomized trial DETO₂ X-AMI (with more than 5000 enrolled patients in multi centres) with mortality as the primary endpoint. Results are awaited which may have definitive conclusive evidence.
American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care recommends oxygen in patients with dyspnea, hypoxemic, or with signs of heart failure and shock, based on monitoring of oxy-hemoglobin saturation, to ≥94%. However, evidence to support oxygen use in uncomplicated acute coronary syndromes is inadequate.
Oxygen overdose is not a new, but the way we use oxygen in coronary emergency needs reconsideration. Time has come to reassess oxygen treatment in acute coronary syndrome. Clinical practice should be based on proven benefits and safety, not on tradition. Oxygen is a life-saving drug and how much you give the patients, depends on how much they need.
The question of oxygen administration to all patients of AMI remains unanswered until new strong evidence comes.
The original article can be accessed here.

A Question on "International Drug Day" Addiction a Choice or Disease?

noreply@blogger.com (Dr Prahallad Panda) — Sat, 25 Jun 2016 21:24:00 +0530

A new Bollywood film gives a rare glimpse into the exploitation and enslavement of women in India's drug trade, highlighting how the stigma surrounding women drug users leaves them vulnerable to abuse.
'Udta Punjab' (Flying Punjab), directed by Abhishek Chaubey and released on 17^th June, 2016, shows how one of India's most prosperous states has been blighted by drug use, with corrupt politicians and police complicit in the trade that largely afflicts young men.
Alongside a drug-addicted rock star, the film tells the story of a nameless young female migrant worker, who is enslaved by a gang of drug dealers, made an addict and forced to have sex with multiple men.

Addiction is defined as a chronic relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.

According to the United Nations there are more than 10 million drug addicts in India. Drug addiction has crossed all barriers of caste and class. The drug addicts in cities in India are predominantly synthetic drug users, while in rural India natural substances like ganja & hashish form the majority of usage.

What is addiction:

People feel pleasure when basic needs such as hunger, thirst and sex are satisfied. In most cases, these feelings of pleasure are caused by the release of certain chemicals in the brain. Most addictive substances cause the brain to release high levels of these same chemicals that are associated with pleasure or reward.
Over time, continued release of these chemicals causes changes in the brain systems involved in reward, motivation and memory. When these changes occur, a person may need the substance to feel normal. The individual may also experience intense desires or cravings for the addictive substance and will continue to use it despite the harmful or dangerous consequences. The person will also prefer the drug to other healthy pleasures and may lose interest in normal life activities. In the most chronic form of the disease, addiction can cause a person to stop caring about their own or other’s well-being or survival.
These changes in the brain can remain for a long time, even after the person stops using substances. It is believed that these changes may leave those with addiction vulnerable to physical and environmental cues that they associate with substance use, also known as triggers, which can increase their risk of relapse.
Short Definition of Addiction American Society of Addiction Medicine:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Reasons:
Here are some of the reasons young people have given for taking drugs:

To fit in
To escape or relax
To relieve boredom
To seem grown up
To rebel
To experiment

They think drugs are a solution. But eventually, the drugs become the problem.

Commonly Abused Drugs:

Commonly abused classes of prescription drugs include opioid painkillers, stimulants, and depressants. Opioids are usually prescribed for pain relief. Commonly prescribed opioids include hydrocodone (e.g., Vicodin^®), oxycodone (e.g., OxyContin^®), morphine, fentanyl, and codeine.

Marijuana:

Marijuana (cannabis) is the most commonly used illicit substance. This drug impairs short-term memory and learning, the ability to focus, and coordination. It also increases heart rate, can harm the lungs, and may increase the risk of psychosis in vulnerable people.

Medical Marijuana:

However, THC-based drugs to treat pain and nausea are already FDA approved and prescribed. Scientists continue to investigate the medicinal properties of cannabinoids—or the individual components of the marijuana plant (e.g., THC, CBD).

Alcohol:

People drink to socialize, celebrate, and relax. Alcohol often has a strong effect on people—and throughout history,people have struggled to understand and manage alcohol’s power. Why does alcohol cause people to act and feel differently? How much is too much? Why do some people become addicted while others do not?

Ayahuasca:

A hallucinogenic tea made in the Amazon from a DMT-containing plant (Psychotria viridis or Diplopterys cabrerana or other) along with another vine (Banisteriopsis caapi) that contains an MAO Inhibitor preventing the natural breakdown of DMT in the digestive system, thereby facilitating a prolonged hallucinatory experience.

Cocaine:

A powerfully addictive stimulant drug made from the leaves of the coca plant native to South America.

DMT:

A synthetic drug producing intense but relatively short-lived hallucinogenic experiences; also naturally occurring in some South American plants (Ayahuasca).

GHB:

A depressant approved for use in the treatment of narcolepsy, a disorder that causes daytime "sleep attacks.

Hallucinogens:

Drugs that cause profound distortions in a person’s perceptions of reality, such as ketamine, LSD, mescaline (peyote), PCP, psilocybin, salvia, DMT, and ayahuasca.

Heroin:

An opioid drug made from morphine, a natural substance extracted from the seed pod of the Asian opium poppy plant.

Inhalants:

Solvents, aerosols, and gases found in household products such as spray paints, markers, glues, and cleaning fluids; also nitrites (e.g., amyl nitrite), which are prescription medications for chest pain.

Ketamine:

A dissociative drug used as an anesthetic in veterinary practice. Dissociative drugs are hallucinogens that cause the user to feel detached from reality.

Khat:

Pronounced "cot," a shrub (Catha edulis) found in East Africa and southern Arabia; contains the psychoactive chemicals cathinone and cathine. People from African and Arabian regions (up to an estimated 20 million worldwide) have used khat for centuries as part of cultural tradition and for its stimulant-like effects.

Kratom:

A tropical deciduous tree (Mitragyna speciosa) native to Southeast Asia, with leaves that contain mitragynine, a psychoactive (mind-altering) opioid. Kratom is consumed for mood-lifting effects and pain relief and as an aphrodisiac.

LSD:

A hallucinogen manufactured from lysergic acid, which is found in ergot, a fungus that grows on rye and other grains. LSD is an abbreviation of the scientific name lysergic acid diethylamide.

Marijuana (Cannabis):

Marijuana is made from the hemp plant, Cannabis sativa. The main psychoactive (mind-altering) chemical in marijuana is delta-9-tetrahydrocannabinol, or THC.

MDMA (Ecstasy/Molly):

A synthetic, psychoactive drug that has similarities to both the stimulant amphetamine and the hallucinogen mescaline. MDMA is an abbreviation of the scientific name 3,4-methylenedioxy-methamphetamine.

Mescaline (Peyote):

A hallucinogen found in disk-shaped “buttons” in the crown of several cacti, including peyote.

Methamphetamine:

An extremely addictive stimulant amphetamine drug.

Over-the-counter Cough/Cold Medicines (Dextromethorphan or DXM):

Psychoactive when taken in higher-than-recommended amounts.

PCP:

A dissociative drug developed as an intravenous anesthetic that has been discontinued due to serious adverse effects. Dissociative drugs are hallucinogens that cause the user to feel detached from reality. PCP is an abbreviation of the scientific name, phencyclidine.

Prescription Sedatives (Tranquilizers, Depressants):

Medications that slow brain activity, which makes them useful for treating anxiety and sleep problems.
Barbiturates: pentobarbital, phenobarbital, Benzodiazepines: alprazolam, chlorodiazepoxide, diazepam, lorazepam, triazolam, Sleep Medications: eszopiclone, zaleplon, zolpidem.

Prescription Opioids:

Pain relievers with an origin similar to that of heroin. Opioids can cause euphoria and are often used nonmedically, leading to overdose deaths.
Codeine (various brand names), Fentanyl, Hydrocodone or dihydrocodeinone, Hydromorphone, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone.

^{Prescription
Stimulants:}

Medications that increase alertness, attention, energy, blood pressure, heart rate, and breathing rate.
^{Amphetamine and Methylphenidate}

^Psilocybin:

A hallucinogen in certain types of mushrooms that grow in parts of South America, Mexico, and the United States

^{Flunitrazepam:}

A benzodiazepine chemically similar to prescription sedatives such as Valium® and Xanax®. Teens and young adults tend to abuse this drug at bars, nightclubs, concerts, and parties. It has been used to commit sexual assaults due to its ability to sedate and incapacitate unsuspecting victims.

Salvia:

A dissociative drug (Salvia divinorum) that is an herb in the mint family native to southern Mexico. Dissociative drugs are hallucinogens that cause the user to feel detached from reality.

^{Steroids
(Anabolic):}

Man-made substances used to treat conditions caused by low levels of steroid hormones in the body and abused to enhance athletic and sexual performance and physical appearance.
^{Nandrolone, oxandrolone, oxymetholone,
stanozolol, testosterone cypionat.}

^{Synthetic
Cannabinoids:}

A wide variety of herbal mixtures containing man-made cannabinoid chemicals related to THC in marijuana but often much stronger and more dangerous.

^{Synthetic
Cathinones (Bath Salts):}

An emerging family of drugs containing one or more synthetic chemicals related to cathinone, a stimulant found naturally in the khat plant. Examples of such chemicals include mephedrone, methylone, and 3,4-methylenedioxypyrovalerone (MDPV).

^Tobacco:

Plant grown for its leaves, which are dried and fermented before use.
^{Cigarettes,
cigars, bidis, hookahs, smokeless tobacco (snuff, spit tobacco, chew)}

^{Burden
in India}

^{According
to Data and Analysis of 2011 by UNODC, use of cannabis among young
people in India was between 12 – 18 years of age. About 3% of
youngsters consume cannabis at least once in a year (as recorded in
2001).}

In his message on World Drug Day, the Secretary General Ban Ki-Moon said, “Drug abuse and illicit trafficking have calamitous consequences for the world’s efforts to deliver greater prosperity and equality for all. There are up to 200,000 preventable deaths each year from overdoses. Illicit drugs spawn criminal violence and weaken a state’s essential institutions.”
The Narcotics Control Bureau (NCB) of India has devised various awareness programs for school and college students as part of celebration of 'International Day against Drug Abuse and Illicit Trafficking', which falls on June 26.
Iran marked the International Day against Drug Abuse and Illicit Trafficking on Tuesday in ceremonies which were held concurrently across the country.
During a ceremony, which was held in Tehran, Interior Minister Abdolreza Rahmani Fazli said there are some 7,500 rehabilitation centers in Iran which helped about 700,000 drug users quit addiction over the past year.
Nearly 380,000 former drug addicts who are now detoxed are being trained under job training programs, Mehr news agency quoted Rahmani Fazli as saying.
“Over some 2,522 operations we succeeded in seizing 618 tons of drugs and disbanding 3,017 smuggling organizations,” he added.

Difficult as it may be to face one’s problems, the consequences of drug use are always worse than the problem one is trying to solve with them. The real answer is to get the facts and not to take drugs in the first place.

Your genes are not your destiny. The 50% of addiction that is caused by poor coping skills is where you can make a difference. Lots of people have come from addicted families but managed to overcome their family history and live happy lives.

Use this opportunity to change your life.

A Question on "International Drug Day" Addiction a Choice or Disease?

noreply@blogger.com (Dr Prahallad Panda) — Sat, 25 Jun 2016 21:24:00 +0530

To fit in
To escape or relax
To relieve boredom
To seem grown up
To rebel
To experiment

They think drugs are a solution. But eventually, the drugs become the problem.

Commonly Abused Drugs:

Marijuana:

Marijuana (cannabis) is the most commonly used illicit substance. This drug impairs short-term memory and learning, the ability to focus, and coordination. It also increases heart rate, can harm the lungs, and may increase the risk of psychosis in vulnerable people.

Medical Marijuana:

A powerfully addictive stimulant drug made from the leaves of the coca plant native to South America.

DMT:

Hallucinogens:

Drugs that cause profound distortions in a person’s perceptions of reality, such as ketamine, LSD, mescaline (peyote), PCP, psilocybin, salvia, DMT, and ayahuasca.

Heroin:

An opioid drug made from morphine, a natural substance extracted from the seed pod of the Asian opium poppy plant.

Inhalants:

Ketamine:

Kratom:

LSD:

A hallucinogen manufactured from lysergic acid, which is found in ergot, a fungus that grows on rye and other grains. LSD is an abbreviation of the scientific name lysergic acid diethylamide.

Marijuana (Cannabis):

Marijuana is made from the hemp plant, Cannabis sativa. The main psychoactive (mind-altering) chemical in marijuana is delta-9-tetrahydrocannabinol, or THC.

MDMA (Ecstasy/Molly):

Mescaline (Peyote):

A hallucinogen found in disk-shaped “buttons” in the crown of several cacti, including peyote.

Methamphetamine:

An extremely addictive stimulant amphetamine drug.

Over-the-counter Cough/Cold Medicines (Dextromethorphan or DXM):

Prescription Sedatives (Tranquilizers, Depressants):

Prescription Opioids:

^{Prescription
Stimulants:}

Medications that increase alertness, attention, energy, blood pressure, heart rate, and breathing rate.
^{Amphetamine and Methylphenidate}

^Psilocybin:

A hallucinogen in certain types of mushrooms that grow in parts of South America, Mexico, and the United States

^{Flunitrazepam:}

Salvia:

A dissociative drug (Salvia divinorum) that is an herb in the mint family native to southern Mexico. Dissociative drugs are hallucinogens that cause the user to feel detached from reality.

^{Steroids
(Anabolic):}

^{Synthetic
Cannabinoids:}

A wide variety of herbal mixtures containing man-made cannabinoid chemicals related to THC in marijuana but often much stronger and more dangerous.

^{Synthetic
Cathinones (Bath Salts):}

^Tobacco:

Use this opportunity to change your life.

How much low Salt in Diet might be Safe

noreply@blogger.com (Dr Prahallad Panda) — Sat, 28 May 2016 10:53:00 +0530

General advice to patients suffering from hypertension is to consume low salt diet. But, how much less is safe for the patient has not been clearly defined. Generally, it is advised to remain below 2.3 gms/day. Some say 1.5 gms/day.

A large worldwide study has found that, contrary to popular thought, low-salt diets may not be beneficial and may actually increase the risk of cardiovascular disease (CVD) and death compared to average salt consumption. The study suggests that the only people who need to worry about reducing sodium in their diet are those with hypertension (high blood pressure) and have high salt consumption.

The study, involving more than 130,000 people from 49 countries, was led by investigators of the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences.

Current intake of sodium in Canada is typically between 3.5 and 4 grams per day. Some guidelines suggest to consume salt below 2.3 grams per day, a level that fewer than five per cent of Canadians and people around the world consume.
Only about 10 per cent of the population in the global study had both hypertension and high sodium consumption (greater than 6 grams per day).
Low sodium intake reduces blood pressure modestly, compared to average intake, but low sodium intake also has other effects, including adverse elevations of certain hormones which may outweigh any benefits.
This new study shows that the risks associated with low-sodium intake -- less than three grams per day -- are consistent regardless of a patient's hypertension status.
"An approach that recommends salt in moderation, particularly focused on those with hypertension and high salt intake, appears more in-line with current evidence."
The study was funded from more than 50 sources, including the PHRI, the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
The article was published in the ScienceDaily, can be accessed here.

Metformin can be used to Treat certain Type II Diabetes Patients with Mild to Moderate Impaired Kidney Function

noreply@blogger.com (Dr Prahallad Panda) — Sun, 24 Apr 2016 10:48:00 +0530

Traditionally, use of metformin is contraindicated in patients with renal failure due to concern about lactic acidosis.

Metformin 500mg tablets (Photo credit: Wikipedia)

In December of 2014, a seminal paper critically looked at the evidence for the use of metformin in mild to moderate renal failure and concluded that, “Metformin levels generally remain within the therapeutic range and lactate concentrations are not substantially increased when used in patients with mild to moderate chronic kidney disease (estimated glomerular filtration rates, 30-60 mL/min per 1.73 m2).”
The paper suggested that given the benefit of metformin to patients with diabetes, of whom up to one-quarter have some degree of renal failure, and the lack of evidence of harm, metformin should be able to be used in this group.
The paper recommended dose adjustments of metformin with maximum total daily dose in patients with mild renal insufficiency (GFR 45-60) of 2000 mg per day and in patients with moderate renal insufficiency (GFR 30-35) not to initiate therapy but that one may continue metformin with maximum daily dose of 1000 mg daily.

English: Physiology of Nephron (Photo credit: Wikipedia)

Now, the US Food and Drug Administration (FDA) is requiring labeling changes regarding the recommendations for metformin-containing medicines for diabetes to expand metformin’s use in certain patients with reduced kidney function. The current labeling strongly recommends against use of metformin in some patients whose kidneys do not work normally.

After reviewing a number of medical studies, the FDA concluded that metformin can be used safely in patients with mild impairment in kidney function and in some patients with moderate impairment in kidney function and is requiring changes to the metformin labeling to reflect this new information while providing the following specific recommendations on the drug’s use in patients with mild to moderate kidney impairment:
• FDA recommends that healthcare professionals follow the latest recommendations when prescribing metformin-containing medicines to patients with impaired kidney function.
• Patients should talk to their health care professionals, if they have any questions or concerns about taking metformin.

The labeling recommendations on how and when kidney function is measured in patients receiving metformin will include the following information:

Before starting metformin, obtain the patient’s eGFR.
Metformin is contraindicated in patients with an eGFR below 30 mL/minute/1.73 m².
Starting metformin in patients with an eGFR between 30-45 mL/minute/1.73 m² is not recommended.
Obtain an eGFR at least annually in all patients taking metformin. In patients at increased risk for the development of renal impairment such as the elderly, renal function should be assessed more frequently.
In patients taking metformin whose eGFR later falls below 45 mL/minute/1.73 m², assess the benefits and risks of continuing treatment. Discontinue metformin, if the patient’s eGFR later falls below 30 mL/minute/1.73 m².
Discontinue metformin at the time of or before an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/minute/1.73 m²; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure; restart metformin, if renal function is stable.

Generally, 90-120 ml/minute/1.73 m² of eGFR is taken as normal value. Levels below 60 mL/min/1.73 m² for 3 or more months are a sign of chronic kidney disease. A GFR lower than 15 mL/min/1.73 m² is a sign of kidney failure and requires immediate medical attention.
Hence, in addition to the level of serum creatinine, it is recommended to have the eGFR estimated in patients of T2DM before starting of Metformin or metformin in combination; also periodically measure, while on the medication.
The article was published in FDA Web site, April 8, 2016. US Food and Drug Administration. Metformin-containing drugs: Drug safety communication – revised warnings for certain patients with reduced kidney function.

Acetaminophen makes it Harder to recognize Errors

noreply@blogger.com (Dr Prahallad Panda) — Wed, 13 Apr 2016 06:53:00 +0530

Dan Randles and researchers from the University of British Columbia researched in a first neurological study to look at the potential of acetaminophen to inhibit the brain response associated with making errors.

It is a well established fact that physical pain and social rejection share a neural process that can be traced to the same part of the brain..

Recent research has begun to show how exactly acetaminophen inhibits pain, while behavioural studies suggest it may also inhibit evaluative responses more generally. Randles own past research has found that people are less reactive to uncertain situations when under the effect of acetaminophen.

In the research, two groups of 30 were given a target-detection task called the Go or No Go. Participants were asked to hit a Go button every time the letter F flashed on a screen but refrain from hitting the button if an E flashed on the screen. "The trick is you're supposed to move very quickly capturing all the GOs, but hold back when you see a No Go," says Randles.

The activity of brain of person was mapped through electroencephalogram (EEG) during the experiment. The researchers were looking for a particular wave called Error Related Negativity (ERN) and Error Related Positivity (Pe). Essentially what happens is that when people are hooked up to an EEG and make an error in the task there is a robust increase in ERN and Pe.

One group, which was given 1,000 mg of acetaminophen -- the equivalent of a normal maximum dose -- showed a smaller Pe when making mistakes than those who didn't receive a dose, suggesting that acetaminophen inhibits our conscious awareness of the error.

Cognitive control is an important neurological function because people are constantly doing cognitive tasks that flow automatically like reading, walking or talking. These tasks require very little cognitive control because they are well mapped out neurological processes, notes Randles.

"Sometimes you need to interrupt your normal processes or they'll lead to a mistake, like when you're talking to a friend while crossing the street, you should still be ready to react to an erratic driver," explains Randles.

"The task we designed is meant to capture that since most of the stimuli were Go, so you end up getting into a routine of automatically hitting the Go button. When you see a No Go, that requires cognitive control because you need to interrupt the process."

The study was double blind, so neither the researcher running the study nor the participant knew whether they had been given a placebo or acetaminophen.

An unexpected and surprise finding that Randles plans to explore more closely is that those who received an acetaminophen dose appeared to miss more of the Go stimuli than they should have. He plans on expanding on the error detection aspect of the research to see whether acetaminophen is possibly causing people to "mind wander" and become distracted.

"An obvious question is if people aren't detecting these errors, are they also making errors more often when taking acetaminophen? This is the first study to address this question, so we need more work and ideally with tasks more closely related to normal daily behaviour."

The research is published in the current edition of the journal Social Cognitive and Affective Neuroscience.

The news published in the Sciencedaily can be accessed here.

Cyclodextrin for Treatment of Atherosclerosis

noreply@blogger.com (Dr Prahallad Panda) — Sun, 10 Apr 2016 11:34:00 +0530

Cardiovascular disease from atherosclerosis is one of the most common causes of death worldwide. Inflammation plays a crucial role in atherosclerosis and cholesterol crystals are considered to be main culprit.

Researchers have found out that cyclodextrin dissolves cholesterol crystals and reduces atherosclerotic plaques. This is a promising therapeutic approach for treating atherosclerosis. Their find was published in Science Translational Medicine.

Micrograph of an artery that supplies the heart with significant atherosclerosis and marked luminal narrowing. Tissue has been stained using Masson's trichrome. (Photo credit: Wikipedia)

Cyclodextrin works by reprogramming macrophages so that they do not cause such a strong inflammatory response in blood vessels that contain cholesterol crystals. The cyclodextrin also dissolves cholesterol crystals so that the cholesterol can be excreted from the body in urine. The result is prevention of plaque formation and even atherosclerotic plaque reduction in mice. Furthermore, when researchers used cyclodextrin to treat biopsies of plaques from human carotid arteries, they found similar results.

he study points to cholesterol crystals as a target for treatment of atherosclerosis, meaning that using cyclodextrin to dissolve the crystals could affect how the disease is treated.

The original idea for the test of cyclodextrin came from Chris Hempel, an American mother whose twin daughters are affected by a rare illness called Niemann-Pick Type C disease, in which cholesterol accumulates in the body. The children are being treated with cyclodextrin with promising results.

Hempel read about previous research on cholesterol crystals conducted by senior researcher Eicke Latz from the University Hospital Bonn and his colleagues from the Center of Molecular Inflammation Research (CEMIR) at the Norwegian University of Science and Technology (NTNU) in Trondheim. She contacted Dr. Latz to suggest that they test cyclodextrin as a possible treatment for atherosclerosis.

It was published in Sciencedaily, can be accessed here .

Dosing Blood Pressure Control Medicines at Bed Time Reduces the risk of Stroke and T2 Diabetes Mellitus

noreply@blogger.com (Dr Prahallad Panda) — Sat, 26 Sep 2015 21:12:00 +0530

We all prescribe medications for control of Hypertension. Most common among those are the ACE (Angiotensin Converting Enzyme) inhibitors, ARBs (Angiotensin Receptor Blocker) and Third generation β-Blocker like Nebivolol. But, seldom we advise the patients which is the preferred time to take these groups of medications. Most of the patients, conventionally, take these medicines after awakening, in the morning.

It has been observed that most susceptible people get heart attack towards dawn or early morning. One of the factors can possibly be due to the fact that blood pressure starts rising from 03 to 04 AM and gradually rises till 12 Noon.

Normally, there is a fall of systolic blood pressure more than 10% of mean day time BP reaching the zenith from 12 Mid-Night to 03-04 AM, regulated by circadian rhythm. This phenomenon is called as “Dipping.”

Alterations in these intrinsic circadian rhythms can result in the absence of the nocturnal BP decline (non-dipping). This altered pattern is commonly seen in patients with essential hypertension, several forms of secondary hypertension and disorders of the autonomic nervous system.

The clinical relevance of this phenomenon lies in the fact that non-dipping has been associated with increased frequency of hypertensive target organ damage (brain, heart and kidney), as well as cerebrovascular and cardiovascular events in hypertensive patients.

Circadian rhythms typically originate in “master oscillators” located in the suprachiasmatic nuclei (SCN) of the anterior hypothalamus. How this hypothalamic rhythm is translated into changes in blood pressure is not entirely known, but the autonomic nervous system is suspected to play a role; sympathetic activity is also modulated by hypothalamic centers, and follows a circadian pattern similar to that of blood pressure.

Patients are categorized, usually based on systolic blood pressure, as extreme dippers (night–day blood pressure ratio ≤ 0.8), dippers (0.8 < ratio ≤ 0.9), non-dippers (0.9 < ratio ≤ 1.0) and reverse dippers or risers (ratio > 1.0). Reverse dipper are particularly in the risk of developing end organ damages.

A new research article published in The Diabetologia by Ramón C. Hermida, Diana E. Ayala, Artemio Mojón and José R. Fernández of University of Vigo, Campus Universitario, Vigo, Pontevedra 36310, Spain, titled as”Bedtime ingestion of hypertension medications reduces the risk of new-onset type 2 diabetes: a randomised controlled trial” has concluded that in hypertensive patients without diabetes, ingestion of ≥1 BP-lowering medications at bedtime, mainly those modulating or blocking the effects of angiotensin-II, compared with ingestion of all such medications upon awakening, results in improved ambulatory BP (ABP) control (significant further decrease of asleep BP) and reduced risk of new-onset diabetes.

Renin angiotensin pathway or RAAS. (Photo credit: Wikipedia)

Drugs that target angiotensin include angiotensin receptor blockers (ARBs), ACE inhibitors and beta blockers. These medications act through blockade of the RAAS (Rennin-Angiotensin-Aldosterone System) in kidney that causes blood vessels to constrict and blood pressure to rise.

Angiotensin, Aldosterone and adrenaline also contribute to increased glucose (sugar) release from the liver and decreased insulin sensitivity. These factors can lead to Type 2 diabetes.

The researchers conducted a prospective, randomised, open-label, blinded endpoint trial of 2,012 hypertensive patients without diabetes, 976 men and 1,036 women, 52.7±13.6 years of age. Patients were randomised, using a computer-generated allocation table, to ingest all their prescribed hypertension medications upon awakening or the entire daily dose of ≥1 of them at bedtime.

During a median follow-up of 5.9 years, 171 participants developed type 2 diabetes. Patients in the bedtime, compared with the morning-treatment group, showed a significantly lower asleep mean BP and a greater sleep-time relative BP decline.
In the bedtime treated group, there was a lower-prevalence of a phenomenon known as 'non-dipping' -- in which patients' night time BP falls by less than 10% compared to daytime BP. Non-dipping occurred in 32% of bedtime-treated patients and 52% of those getting their treatment in the morning.
There was also a 57% decrease in the risk of developing new-onset type 2 diabetes in the bedtime-treated group after adjustment for the potential confounders of fasting glucose, waist circumference, mean asleep systolic BP, dipping classification and chronic kidney disease.
Specifically, the odds of type 2 diabetes dropped 61 percent for people taking angiotensin receptor blockers at bedtime compared to morning. For those on ACE inhibitors at night, the odds went down 69 percent. People on beta blockers reduced their odds of the blood sugar disease by 65 percent when they took their medicine at night, the researchers reported.
All three classes of medication were associated with a reduced risk of type 2 diabetes when taken at bedtime as the effect will be much more on liver/kidney in comparison to the waning effect at night when taken in the morning.
Let us remember to advise our hypertensive patients to take their anti-hypertensive medications at bed time, especially ARBs, ACE-Inhibitors and Nebovolol for better effect and delaying development of T2DM.

Can we call a Tract from Anus without External Opening as Fistula-in-Ano?

noreply@blogger.com (Dr Prahallad Panda) — Mon, 14 Sep 2015 19:48:00 +0530

Fistula-in-Ano is a completely or incompletely epithelised tract that connects the internal opening in anus to an external opening in the perianal skin.

In most of the cases, external opening can be identified; whereas in minority of cases, external opining is absent.

It happens that a firm to hard tract is palpable, ending blindly in the perineum. This is a situation, when the perineal abscess has not broken the skin, though pus can be seen coming from anal opening, on pressing from the exterior.

Hence, whether the condition can be called as Fistula-in-ano, in true sense of the term?

English: Cassia-fistula (Photo credit: Wikipedia)

In one case, a cystic swelling was noted in the posterior aspect of the scrotum, not attached to the testis; attached to it is a firm to hard tract that leads to the anal canal. A raw area can be felt in the superficial plane, in the anal canal; presumed to the internal opening of the tract. The tract could be probed.

The tract was dissected from near the base of the scrotum till the anal canal is reached, it is probed from inside and excision was completed.

The biopsy report of the tract comes as “Non-specific Chronic Inflammation.” No malignancy or Tuberculosis is seen.

Should we call it, “Anal-perineal Sinus” or “Anal-perineal blind Tract.”

Importance of Debridement and Total Contact Cast in Trophic Ulcer Healing

noreply@blogger.com (Dr Prahallad Panda) — Tue, 30 Jun 2015 19:35:00 +0530

An ulcer refusing to heal may be due to various diseases. Among all, diabetes, leprosy and cancer are most important. Those due to diabetes and leprosy are called Trophic Ulcers; Trophe=Nutrition. There is impaired nutrition to the place due to lack or less blood supply; neuropathy i.e. damage to the nerve fibre.

Deutsch: Geschwür am diabetischen Fuß (Photo credit: Wikipedia)

Lack of pain sensation, mostly in the foot, makes it vulnerable to repeated trauma; pain makes the person cautious, to use foot carefully and draws attention.

Apart from the specific disease oriented treatment, offloading of foot after debridement plays a major role in healing the ulcer.

Offloading can be achieved in various ways, among the available methods, non-removable ones are more helpful; Total Contact Cast (TCC) or plaster boot.

After through debridement of the infected and dead tissue, excision of the callous and hypertrophied skin, either TCC or plaster boot is to be applied for 21 days. After this period, the ulcer can be inspected for healing and if required, can be kept offloaded for a further period of 21 days.

Debridement of the wound helps healing by migration of platelets and thereby the growth factor; Offloading helps by saving from repetitive trauma and pressure to the part.

Formation and Accumulation of Ketone Bodies In Diabetic Ketoacidosis

noreply@blogger.com (Dr Prahallad Panda) — Thu, 2 Apr 2015 20:51:00 +0530

Finding Ketone bodies in blood and urine are hallmark of Diabetic Ketoacidosis along with clinical features.

These are three in number, namely, acetoacetate (AcAc), 3-beta-hydroxybutyrate (3HB) and the third,least abundant, acetone.

Ketones are always present in the blood in some amount and their levels increase during fasting and prolonged exercise.

Diabetes is the most common pathological cause leading to elevated blood ketones. In diabetic ketoacidosis (DKA), high levels of ketones are produced in response to low insulin levels and high levels of counter-regulatory hormones.

Acyl CoA is produced from break down of fatty acid, when cannot enter the Citric Acid Cycle (Cycle is down) due to lack of insulin sensitivity, get converted & accumulate in the form of ketone bodies.

In acute DKA, the ketone body ratio (3HB:AcAc) rises from normal (1:1) to as high as 10:1. In response to insulin therapy, 3HB levels commonly decrease long before AcAc levels.

The frequently employed nitroprusside test only detects AcAc in blood and urine. This test is inconvenient, does not assess the best indicator of ketone body levels (3HB), provides only a semiquantitative assessment of ketone levels and is associated with false-positive results.

Recently, inexpensive quantitative tests of 3HB levels have become available for use with small blood samples.

These tests offer new options for monitoring and treating diabetes and other states characterized by the abnormal metabolism of ketone bodies.

A Novel Host Immune Protein for Differentiating between Acute Bacterial and Viral Infection

noreply@blogger.com (Dr Prahallad Panda) — Sun, 22 Mar 2015 11:04:00 +0530

Can we doctors definitely say in the acute phase, whether an infectious disease is due to bacteria, virus or mixed? Is there any blood test to know it?

Answer will be no to a larger extent. Diagnosis, largely depends on the epidemiology; most of upper respiratory infections are due to viral infection. Such types of assumptions and uncertainties lead to misuse of antibiotics, antibiotic resistance and adverse effect due to antibiotic use; nontheless, the financial burden on the family.

Several bio-markers like CRP (C-Reactive Protein), procalcitonin and Interleukin-6 are used to support the diagnosis of bacterial infection. But, take the case of CRP, it is increased in cases of bacterial infection and non-infectious inflammatory diseases as well.

Recently, in a research article published in PLOS One, the researchers claim to have successfully tested for a novel Host Immune Protein that is mostly elevated in viral infection and least in bacterial infection.

In the PLOS One study, the ImmunoXpert immune signature was developed and independently validated on a cohort of 1002 patients with acute infections and yielded highly accurate results, with sensitivity and specificity greater than 90%. The best performing host-protein was TNF-related apoptosis-inducing ligand (TRAIL) to diagnose viral infection.

MeMed, Ltd., announced publication of the results of this large multicenter prospective clinical study that validates the ability of its ImmunoXpert^TMin-vitro diagnostic blood test, enrolling over 1000 patients between 2009 and 2013.

Reportedly, three host proteins are tested in ImmunoXpert kit; CRP, IP 10 and TRAIL; from swing of results, the most probable cause of infection i.e. bacterial or viral can be distinguished. TRAIL (member of the tumor necrosis factor family implicated in programmed cell death), IP-10 (IFN-gamma-inducible protein 10) small cytokine implicated in multiple cellular processes including chemotaxis and cell growth inhibition, and CRP (acute phase protein with diverse roles in tissue injury, infection and other inflammation processes).
This test will perhaps be a boon to mankind and handy to the doctors for near accurate diagnosis.

From A Clinician's Bioscope

Is Cholesterol is Egg Yellow (yolk) Good to eat?

ChatGPT has potential in Healthcare field, but not as Replacement of Healthcare Professional

Coagulopathy in COVID-19 Deaths and Possible Measures

1. Wiley Online Library: Covid-19: Novel Coronavirus Outbreak

2. COVID-19 complicated with DIC: 2 cases report and literatures review

Unusual Presentations of COVID-19

According to the WHO, digestive issues like diarrhea and nausea may be a more common symptom than previously thought.

More Readings at:

2. Published on 1st April, 2020 in The ScienceAlert; Some COVID-19 Symptoms Are Turning Out to Be Atypical. Here's What We Know So Far

3. Published on 05 April 2020 in thebmj in a letter to the Editor, under caption, “Atypical symptoms in COVID-19: the many guises of a common culprit.”

4. Published on April 17th, 2020 in Medscape: Unusual Presentations of COVID-19: 'Our Ignorance Is Profound'

(A Paradip Port Trust Hospital Document)

SARS-CoV-2 Transmission & Possible Preventive Measures

Eating how much Nuts is Safe for you?

Can eating nuts help heart?

What's in nuts that might make them heart healthy?

What amount of nuts is considered healthy?

Does it matter what kind of nuts you eat?

How about nut oils? Are they healthy, too?

Whether Aspirin or Statin in Primary Prevention or Cardiovascular Disease (CVD

USFDA Approved Tafenoquine for Radical Cure of Vivax Malaria

A brief on Cancer of Cervix

Observation of World Heart Day 2017 at PPT Hospital

World Heart Day-2017

Swine Flu

Use of Alpha 1 blocker as a part of Medical Expulsive Therapy (MET) for Ureteric Stone

All the Patients of Acute Myocardial Infarction (STEMI) may not require Oxygen therapy

A Question on "International Drug Day" Addiction a Choice or Disease?

Marijuana:

Marijuana (cannabis) is the most commonly used illicit substance. This drug impairs short-term memory and learning, the ability to focus, and coordination. It also increases heart rate, can harm the lungs, and may increase the risk of psychosis in vulnerable people.

Medical Marijuana:

DMT:

Hallucinogens:

Heroin:

Inhalants:

Ketamine:

Kratom:

LSD:

Marijuana (Cannabis):

MDMA (Ecstasy/Molly):

Mescaline (Peyote):

Methamphetamine:

Over-the-counter Cough/Cold Medicines (Dextromethorphan or DXM):

Prescription Sedatives (Tranquilizers, Depressants):

Prescription Opioids:

Prescription Stimulants:

Psilocybin:

Flunitrazepam:

Salvia:

Steroids (Anabolic):

Synthetic Cannabinoids:

Synthetic Cathinones (Bath Salts):

Tobacco:

A Question on "International Drug Day" Addiction a Choice or Disease?

Marijuana:

Marijuana (cannabis) is the most commonly used illicit substance. This drug impairs short-term memory and learning, the ability to focus, and coordination. It also increases heart rate, can harm the lungs, and may increase the risk of psychosis in vulnerable people.

Medical Marijuana:

DMT:

Hallucinogens:

Heroin:

Inhalants:

Ketamine:

Kratom:

LSD:

Marijuana (Cannabis):

MDMA (Ecstasy/Molly):

Mescaline (Peyote):

Methamphetamine:

Over-the-counter Cough/Cold Medicines (Dextromethorphan or DXM):

Prescription Sedatives (Tranquilizers, Depressants):

Prescription Opioids:

Prescription Stimulants:

Psilocybin:

Flunitrazepam:

Salvia:

Steroids (Anabolic):

Synthetic Cannabinoids:

Synthetic Cathinones (Bath Salts):

Tobacco:

2. Published on 1^st April, 2020 in The Science^Alert; Some COVID-19 Symptoms Are Turning Out to Be Atypical. Here's What We Know So Far

4. Published on April 17^th, 2020 in Medscape: Unusual Presentations of COVID-19: 'Our Ignorance Is Profound'

^{Prescription
Stimulants:}

^Psilocybin:

^{Flunitrazepam:}

^{Steroids
(Anabolic):}

^{Synthetic
Cannabinoids:}

^{Synthetic
Cathinones (Bath Salts):}

^Tobacco:

^{Prescription
Stimulants:}

^Psilocybin:

^{Flunitrazepam:}

^{Steroids
(Anabolic):}

^{Synthetic
Cannabinoids:}

^{Synthetic
Cathinones (Bath Salts):}

^Tobacco: