Yesterday

My question where is Albert, was answered by one of my friends.He has gone to kottayam.what for?was my query Friend:So didn’t you hear Albert is looking for a new car.
So he maybe at kottayam, in some car showroom, Who is with him? I lost my thoughts there. When my friend came back, he told me his story about the trip.
Santro is a good car and he has selected it, and I came back and slept.

Today

After abandoning my plan of having food from hostel after seeing the familiar food pattern in hostel mess, I was thinking about having food.
I had two options before me,either have food from Mess or go to sleep and rise in the evening

Surprise! Here comes Albert.

Alia!(friend), had food? Me:no. Let’s go out and have biriani from Floral Park. So we had our food there, and met some of our friends there,came back and he dropped me at hostel.
He went out again on his bike to buy a recharge coupon for his mobile phone( To call home,his mother had called him earlier and he had no balance to call back).

I didn’t have the thought ” Why do I see him again and again” when I met Albert after a few minutes I thought it up now. This time he was going out to buy Sports magazine.
I led him to a familiar place, where the shopkeeperwas known to both of us.Albert told me about the shopkeeper, a man who doesn’t show gratitude. I implored him to tell more about the incident, and he began to narrate
the story until we reached the front of the store. Did he hear us? I had a thought then, which I lost when I and Albert lost ourselves searching the bookstore for a sports magazine. We couldn’t find any, we were disappointed,
while scanning the books a book had caught my eye. I took the book and began reading, Albert went across the street to another bookstore.It is a car buyers guide.Albert came back and HE HAD A SMILE ON HIS FACE.
I bought the book and mounted on his bike and we rode back to the hostel.

After I settled everything, I began to lay down to sleep.I barely closed my eyes when a familiar face popped up by my side, this time it is not Albert.Who else other than Jomon.He is doing Msc outide state.
A friend of mine, and an intimate friend of Mujeeb my neighbour in hostel.His room is opposite to mine,Jomon has come in search for Ayub we couldn’t find Mujeeb in his room.He maybe in ward 24 I answered before Jomon could ask me where he might be.
I called him but he is switched off,Informed Jomon. I tried to call, but, got the same answer from the lady at the Telephone Exchange, does she get any sleep? He has another number, let me try again, great this time the phone is ringing. Why doesn’t he pick it up.
He uses this number to access internet on phone. Maybe he has left it in his room.

The Car buyers manual was by my side, I asked for Jomon’s opinion. Santro is a nice car,my car is Santro. He has come to get an appointment with a surgeon.
And I mentioned the name of one who is approachable and good at his work. I described the way to the surgeons consultation and the way to ward 24.

Albert again,this time I had my fast track magazine in my hand, and we had a detailed discussion. I came back to sleep,and while I was drifting off to sleep, a wonderful idea crossed my mind.

It was about building a simulation, with a computer keyboard
and gear system of a car. I imagined it so well that I was so happy at that time. I searched the net for models and even found a youtube video.

[youtube=http://www.youtube.com/watch?v=8QAhLHSW2IE]

I already knew something about google flight simulator,but learning more about it, I knew it will cost me a lot of money.So I started the basics
of making a simulator and have shelved the project for some years.

Since clear case definition is not possible in case of H1N1, most of the cases are categorized and isolated. Severe fever and respiratory distress in children has to be suspected to be H1N1 even if no clear history of contact with H1N1 is available.

The child to whom I was exposed was a girl, who had no history of contact or travel abroad.But the troat swab taken from the child came out strongly positive. Even though I wore a mask during my discussion with the parents and the child, I was adviced to take Oseltamivir. Since I was already taking Oseltamivir, I had to start day 1 from day 10. So now my course of Oseltamivir is extended up to Sept 19.

Adverse effects

I had mild head ache and gastric irritation on taking Oseltamivir.My headache was relieved on drinking water(psychological). Some clinical trials show that, there is increased chances of depression and self harm. I had mild depression at the start of medicine, which soon disappeared.

[nausea, vomiting, diarrhea, abdominal pain, and headache. Rare ADRs include: hepatitis and elevated liver enzymes, rash, allergic reactions including anaphylaxis, and Stevens-Johnson syndrome.Various other ADRs have been reported in postmarketing surveillance including: toxic epidermal necrolysis, cardiac arrhythmia, seizure, confusion, aggravation of diabetes, and haemorrhagic colitis.]

This has lead to a wide spread dissentment among members of KGMCTA as many of the doctors in clinical field are already heavily burdened. Some blame it on former president of KGMCTA for withdrawing strike unilaterally.

A section of doctors approve this deal because they don’t have to take any extra burden.These are the non clinical doctors who don’t have to conduct OP’s or Perform surgeries. Since their work is teaching students, they are happy to get more pay without extra effort. This has lead to a serious rift as Anaesthesiologists have also joined with the non clinical side. Meaningful discussion has to be done among the members of KGMCTA other than fight among themselves.

The private practice ban is a big loss to patients as well.There is a wide spread belief that private practice is only for money. Many of those who go to a doctors house just want to be away from the crowd in the OP’s. Not all those who go to a doctors house for consultation are rich and affluent.Some of them maybe friends, some maybe friends of friends or relatives. Though it is their right to take fees for every consultation, most of these doctors take only meagre amounts or no money at all.

Considering private service ban, most of Medical college doctors in Kerala may go looking for better options. Many private Medical Colleges are looking for experienced doctors.They are willing to pay a lot more than govt plans to give. This may lead to many doctors leaving for greener pastures. Our Medical Education system is going to be in serious trouble if this issue is not dealt with properly.

The first case gave a history of H1N1 contact. She was treated and was discharged after completion of treatment. The second case was a boy, who came from UAE. He was having very severe disease during the time of admission, he was having some co-morbid conditions(cerebral Palsy). Eventhough he was treated for 3 days, he didnt respond to treatment.

Prophylactic measures are taken by the government of India. Now our hospital has supply of the antiviral drug Oseltamivir( Fluvir).

The recommended dosage for prophylaxis is,

1 tablet of Oseltamivir(75mg) once daily for 10 days from the day of contact with a known case of H1N1.

If there are subsequent contacts with H1N1 cases, it is recommended that the person should take the medicine for 10 more days from the period of last contact.

ie If I have started taking medicine today, I have to take it for 10 days. But if I have another contact on the 5th day, I have to take day 5 as day 1 of the next course and take it for 10 more days. So the total number of days become 15.

Post exposure antiviral chemoprophylaxis with either oseltamivir or zanamivir can be considered for the following:

1. Close contacts of cases (confirmed, probable, or suspected) who are at high-risk for complications of influenza
2. Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with novel (H1N1) influenza virus infection (confirmed, probable, or suspected) during that person’s infectious period. Information on appropriate personal protective equipment is available at: Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting and might be updated frequently as additional information on transmission becomes available.

for more details visit the CDC website :

In a statement in the state Assembly, the health minister said that house-surgeons would get Rs 7,000 a month, first-year PG medicos Rs 15,000, second-year students Rs 16,000, and third-year students Rs 17,000 each.

What is HFMD?

Hand-foot-and-mouth disease (HFMD) is an acute viral illness that presents as a vesicular eruption in the mouth. HFMD can also involve the hands, feet, buttocks, and/or genitalia.

Viruses

• Coxsackievirus A type 16 (CV A16) is the etiologic agent involved in most cases of HFMD
• The illness is also associated with coxsackievirus A5, A7, A9, A10, B2, and B5 strains,
• Enterovirus 71 (EV-71)
• HFMD epidemics associated with EV-71 have been more common in south East Asian countries

Children younger than 10 years are most commonly affected.

• Initially, macular lesions appear on the buccal mucosa, tongue, and/or hard palate.
• These mucosal lesions rapidly progress to vesicles that erode and become surrounded by an erythematous halo.

Skin lesions, which present as tender macules or vesicles on an erythematous base, develop in approximately 75% of patients with hand-foot-and-mouth disease (HFMD).

• A fever of 38-39°C may be present for 24-48 hours.
  HFMD caused by coxsackievirus strains rarely presents with concomitant aseptic meningitis.
  • HFMD caused by EV-71 has a higher incidence of neurologic involvement, including a poliolike syndrome, aseptic meningitis, encephalitis, encephalomyelitis, acute cerebellar ataxia, acute transverse myelitis, Guillain-Barré syndrome, opsomyoclonus syndrome, and benign intracranial hypertension.
  • HFMD caused by coxsackievirus is generally a mild self-limited illness that resolves in 7-10 days; rarely, HFMD may recur or persist. Serious complications are also rare.

  Severe oral ulcerations can create painful stomatitis. This may interfere with oral intake and cause dehydration, the most common complication of HFMD. Rarely, aseptic meningitis accompanies coxsackievirus-induced HFMD

Atypical clinical features

How does HFMD spread

Infection generally occurs via the fecal-oral route or via contact with skin lesions and oral secretions Viremia develops, followed by invasion of the skin and mucous membranes. Widespread apoptosis likely results in the characteristic lesion formation.

Complications

HFMD-Coxakie
• HFMD caused by coxsackievirus is generally a mild self-limited illness that resolves in 7-10 days; rarely, HFMD may recur or persist. Serious complications are also rare.
• Severe oral ulcerations can create painful stomatitis. This may interfere with oral intake and cause dehydration, the most common complication of HFMD. Rarely, aseptic meningitis accompanies coxsackievirus-induced HFMD

HFMD -EV71

HFMD caused by EV-71 has a higher incidence of neurologic involvement,
Poliolike syndrome, aseptic meningitis, encephalitis, encephalomyelitis, acute cerebellar ataxia, acute transverse myelitis, Guillain-Barré syndrome, opsomyoclonus syndrome, and benign intracranial hypertension. These neurological complications have been attributed to either immunopathology or virus-induced damage to gray matter.

• cardiopulmonary complications such as myocarditis, interstitial pneumonitis, and pulmonary edema may occur. Neurologic involvement with sequelae is less likely to occur in patients with HFMD caused by coxsackievirus strains than with HFMD caused by EV-71.

Diagnosis of hand-foot-and-mouth disease (HFMD)

Diagnosis of hand-foot-and-mouth disease (HFMD) is typically based on clinical grounds. Laboratory studies are usually unnecessary

• culture and immunoassay from cutaneous lesions, mucosal lesions, or stool samples.
• Oral specimens have the highest isolation rate. In patients with vesicles, vesicle swabs are also a good source for viral collection.
• In patients without vesicles, rectal swabs can be collected.
• For viral isolation, 2 swab collections are recommended—from the throat and the other from either vesicles or the rectum.
• Serologic testing
• Polymerase chain reaction (PCR) and microarray technology are among the various ways of identifying the causative virus

Prognosis

Prognosis is excellent. The vast majority of patients are expected to recover fully.
There has been an increase in the incidence of HFMD in many parts of Kerala.The disease which was prevalent in Calicut has now spread to Kottayam district.Cases of Chikungunya and HFMD are on the rise as Monsoon has begun.Better personal hygeine and Environmental hygeine will help in reducing the number of cases and spread.

• Visceral (splanchnic) pain,
• Parietal (somatic) pain,
• referred pain.

Visceral Pain

• Visceral pain occurs when noxious stimuli affect a viscus, such as the stomach or intestines.
• Tension, stretching, and ischemia stimulate visceral pain fibers. Tissue congestion and inflammation tend to sensitize nerve endings and lower the threshold for stimuli.
• Because visceral pain fibers are bilateral and unmyelinated and enter the spinal cord at multiple levels,visceral pain usually is dull, poorly localized, and felt in the midline.

Localisation of Visceral Pain

• Pain from foregut structures (e.g., the lower esophagus and stomach) generally is felt in the epigastrium.
• Midgut structures (e.g., the small intestine) cause periumbilical pain,
• and hindgut structures (e.g., the large intestine) cause lower abdominal pain.

Parietal Pain

• Parietal pain arises from noxious stimulation of the parietal peritoneum.
• Pain resulting from ischemia, inflammation, or stretching of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal root ganglia on the same side and at the same dermatomal level as the origin of the pain.
• Parietal pain usually is sharp, intense, discrete, and localized, and coughing or movement can aggravate it

Referred Pain

• Referred pain is felt in remote areas supplied by the same dermatome as the diseased organ. It results from shared central pathways for afferent neurons from different sites

Researchers led by Dr. Zhihong Gong, of the University of California at San Francisco, report the findings in the journal Cancer.

The drug finasteride, which can help lower a man’s risk of the disease, appears unable to undo the damage of heavy drinking.

The findings come from a clinical trial of nearly 11,000 men looking at whether finasteride lowered the risk of prostate cancer over seven years. Of the men, 2,219 were diagnosed with prostate cancer, and 8,791 remained cancer-free throughout the study.

The researchers found that men who drank heavily

• four or more drinks per day,
• on at least five days out of the week

were twice as likely as non-drinkers to develop aggressive prostate tumors.

Less aggressive, slower-growing prostate tumors, finasteride cut non-drinkers’ and moderate drinkers’ risk by 43 percent.

Risk factors

Non Modifiable- older age, African-American race and family history of the disease.

Modifiable -obesity, smoking and a high intake of animal fat

Heavy drinking may need to be added to that short list

Limiting drinks to 2 or 3 per day may help men on finasteride to lower their risk for prostrate cancer.

Statins reduce significantly the incidence of coronary events,  being the most efficient hypolipidemic compounds that have

reduced the rate of mortality in coronary patients.

Decrease in LDL cholesterol>>>>antiatherosclerotic effects>>>>Prevent acute coronary syndromes.

Statins act by inhibiting HMG-CoA reductase, which is vital in Cholesterol synthesis. They can exert antiatherosclerotic effects independently of their hypolipidemic action.

Other Advantages

Mevalonate, the product of HMG CoA reductase reaction, is the precursor not

only for cholesterol, but also for many other nonsteroidal

isoprenoidic compounds, inhibition of this

key enzyme may result in pleiotropic effects.

Actions of Statins

Cholesterol Biosynthesis

• Inhibition of cholesterol biosynthesis,
• increased uptake and degradation of low density lipoproteins (LDL),
• inhibition of the secretion of lipoproteins,
• inhibition of LDL oxidation,
• inhibition of the scavenger receptorsexpression

In preventing acute coronary syndromes

• The plaque instability, manifestedas an ulceration of the fibrous cap, the rupture of the

  plaque and internal hemorrhage, are characteristics

  of the plaques with numerous lipid deposits and

  macrophages in the cap

• Statins promoste plaque stability
• statins (fluvastatin, simvastatin) can inhibit t he gelatinolytic activity ofmetalloproteases, as well as their secretion by

  human macrophages in culture.

Others

• statins interfere with events involved in bone formation and impede tumor cell growth.
• Reduction of the accumulation of esterifiedcholesterol into macrophages
• Increase of endothelialNO synthetase,
• reduction of the inflammatoryprocess,
• Increased stability of the atherosclerotic plaques,
• Restoration of platelets activity and of the coagulation process
• Human subjects treated with statins have shown a reduction in the number of bone fractures

How statins are Obtained

Some of the statins are obtained after fungal

fermentation: lovastatin , pravastatin

and simvastatin others

by synthesis: fluvastatin , atorvastatin

, and cerivastatin.

Five statins are, at this moment, in

clinical use: lovastatin, simvastatin, pravastatin,

atorvastatin and fluvastatin.

Adverse effects of statin therapy

The most important adverse effects are liver and muscle

involvement. Myopathy can occur if

cytochrom P450 or other inhibitors of statins

metabolism are co-administered with statins,

Azole antifungals

Fibrates and niacin enhance myopathy risk

Other risk factors are: liver

damage, renal insufficiency, hypothyroidism.

]]> http://drjobinmartin.com/2009/07/wider-use-of-statins-may-help-preventing-heart-attacks/feed/ http://drjobinmartin.com/2009/07/wider-use-of-statins-may-help-preventing-heart-attacks/ http://feedproxy.google.com/~r/DrJobinMartin/~3/FRZwus60r1w/ http://drjobinmartin.com/2009/07/twittering-my-thoughts/#comments Thu, 02 Jul 2009 03:27:27 +0000 drjobin http://drjobinmartin.com/?p=50 People say Twitter is growing day by day. Twitter is the best web application available etc etc.  Why do people give so much importance to twitter? I think twitter got much attention, because of the campaign held by web masters in favor of it.

When somebody says, you can increase the readership of your blog, just by posting a tweet, won’t you do it? I would take up such an opportunity, because there is nothing to lose. It is free and easy to use. What I don’t understand is, why people send so many tweets a day. Some have more than 1000 tweets a day. When ever they have a thought or feeling, they just feel amused and posts it in twitter. It is a new for of addiction. In India, twitter is not much a favorite. The favorite here is Orkut. I too was an orkut addict, I spent many hours trying to figure out how to browse orkut, from our college, where orkut is blocked. But once I had my own internet connection and no body to block me from browsing Orkut, I lost the thrill and Orkut is no longer an adiction in my case.

Some say, twitter helps in getting close to friends, read new posts from bloggers and so on. But What I think is , twitter is clutterng our thoughts. Being so simple, we are lured to twitter. If twitter helps an introvert to open his mind, or a marketer to get his idea acroos his customers it is doing something worthwhile.But one shouldn’t be adicted to anything, however tempting it maybe.