Clinician On Net

Eight Measures that may Increase Your Longevity by about Six Years

drppanda@gmail.com (Dr.Prahallad Panda) — Fri, 10 Nov 2023 09:05:00 +0530

Aging can be Chronological, and Biological. Chronological age is the age in years, as one grows older after birth. Biological aging is the aging at cellular and molecular level. Chronological age and Biological age can be well different depending on the different habits (food, physical activity, and accompanied diseases etc.).

Aging is accompanied by gradual changes in most body systems. Research on the biology of aging focuses on understanding the cellular and molecular processes underlying these changes as well as those accompanying the onset of age-related diseases.

Gradual loss of the length of Telomeres, the highly repetitive DNA sequences located at the end of chromosomes, is associated with cell aging (biological aging). As cells divide, telomere length gets progressively shorter until eventually, proliferation stops entirely. Such cells, which have ceased dividing, are called senescent.

New research shows that the following eight simple health measures can help in slowing down ageing. According to researchers, following the American Heart Association's Life's Essential 8 can help slow down biological ageing by six years.

The identified health measures are

1. Eating Healthy,

2. Exercising Regularly,

3. Not Smoking,

4. Getting Enough Sleep,

5. Maintaining Low Cholesterol Levels,

6. Healthy Blood Pressure,

7. Healthy Sugar Levels and

8. Staying Slim.

Experts believe that these eight measures can improve good heart health, which eventually helps to slow the pace of biological ageing. Researchers at Columbia University in New York looked at data from more than 6,500 Americans, aged 47, on average. They determined their phenotypic age by using an experimental gauge of biological age, which relies on the outcomes of nine biomarkers. These biomarkers encompass measurements related to metabolism, inflammation, and organ function.

The scientists then assigned each participant a cardiovascular score—categorized as high, moderate, or low—depending on their adherence to the Life Essential 8 checklist.

Factors that could skew the results, income, education and ethnicity, were accounted for.

People who had high cardiovascular health were associated with a lower biological age. This means that such participants were younger than expected physiologically. For example, the average actual age of those with high cardiovascular health was 41, yet their average biological age was 36.

On the other hand, people who had low cardiovascular health had a positive phenotypic age acceleration. This meant that they were older than expected biologically. An example of this is, the average actual age of those with low cardiovascular health was 53, while their biological age was 57.

A further analysis showed that having the highest healthy score was linked to being six years younger, biologically.

The researchers found that higher cardiovascular health is associated with decelerated biological ageing, as measured by phenotypic age. They also found a dose-dependent association — as heart health goes up, biological ageing goes down. That means the greater the adherence to all Life's Essential 8 metrics the more slow down body's ageing process and a lot of benefits down the line.

“Reduced biologic ageing is not just associated with lower risk of chronic disease such as heart disease; it is also associated with longer life and lower risk of death.”

“Everyone wants to live longer, yet more importantly, we want to live healthier longer so we can really enjoy and have good quality of life for as many years as possible.”

The original publication can be accessed here.

Survival of SARS-CoV-2 on different surfaces

drppanda@gmail.com (Dr.Prahallad Panda) — Wed, 14 Oct 2020 07:52:00 +0530

The data presented in a study demonstrates that infectious SARS-CoV-2 can be recovered from non-porous surfaces for at least 28 days at ambient temperature and humidity (20 °C and 50% RH). Increasing the temperature, while maintaining humidity, drastically reduced the survivability of the virus to as little as 24 h at 40 °C. SARS-CoV-2 survivability on hospital PPE observed viable virus up to 21 days post inoculation on both plastic and N95 mask material when held at room temperature.

(Reference:)

Common Surfaces tested in the study:

Polymer bank notes, de-monetised paper bank notes, surfaces including brushed stainless steel, glass, vinyl and cotton cloth. Stainless steel is used in kitchen areas and public facilities; Glass prevalent in public areas, including hospital waiting rooms, public transport windows and shopping centres; high contact surfaces such as mobile phone screens, ATMs and self-serve check-out machines; Vinyl used in social settings, tables, flooring, grab handles on public transport, as well as mobile phone screen protector material; Cotton in clothing, bedding and household fabrics.

Result:

The data presented in this study demonstrates that infectious SARS-CoV-2 can be recovered from non-porous surfaces for at least 28 days at ambient temperature and humidity (20 °C and 50% RH). The persistence of both SARS and SARS-CoV-2 on cotton has been demonstrated to be significantly shorter than on non-porous surfaces. The data presented in the study also shows a significant decrease in titre of recovered virus after just 1 h drying at room temperature (20 °C) the amount of virus recovered from cotton swatches was approximately 99% less than for comparable virus recovery time points for non-porous material. SARS-CoV-2 persists on both paper notes and polymer notes to at least 28 days at 20 °C, albeit with a faster rate of inactivation on polymer notes.

Is Coagulopathy the Real Culprit in COVID-19 Deaths?

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 26 Apr 2020 20:31:00 +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

Atypical Symptoms of COVID-19

drppanda@gmail.com (Dr.Prahallad Panda) — Wed, 22 Apr 2020 15:57:00 +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 in Hospital Setting

drppanda@gmail.com (Dr.Prahallad Panda) — Mon, 20 Apr 2020 20:24:00 +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.
COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2022:

1. 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 mouse, 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. 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:

1. 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)

Credit:

WHO

CDC

NEJM

Worldmeter Reference

WebMD

Acknowledgements

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

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

Myths vs Safety on New Coronavirus-2019-China

drppanda@gmail.com (Dr.Prahallad Panda) — Mon, 3 Feb 2020 14:55:00 +0530

Sunehere Yaade-2019

drppanda@gmail.com (Dr.Prahallad Panda) — Tue, 31 Dec 2019 08:19:00 +0530

Sodium and Potassium Dietary Reference Intake Values Updated in New Report

drppanda@gmail.com (Dr.Prahallad Panda) — Sat, 9 Mar 2019 20:26:00 +0530

The Adequate Intake (AI), Dietary Reference Intakes (DRIs) range for Sodium and Potassium has been revised by the National Academies of Sciences, Engineering, and Medicine.

The report reaffirms the sodium AI for individuals ages 14-50, decreases the sodium AIs for children age 1-13, increases the sodium AIs for adults ages 51 and older, and decreases the potassium AIs for individuals age 1 and older.

The report also uses guidance from a 2017 National Academies report to introduce the first DRI specific to chronic disease risk reduction.

Sodium and potassium are interrelated, essential nutrients that play vital functional roles in the body, including being important for nerve signal transmission, muscle contraction, and fluid balance.
The excess intake of both the nutrients have been linked to risk of chronic disease, particularly cardiovascular disease, the report says. Therefore, the committee established a Chronic Disease Risk Reduction Intake (CDRR) for sodium using evidence of the beneficial effect of reducing sodium intake on cardiovascular disease risk, hypertension risk, systolic blood pressure, and diastolic blood pressure. Reductions in intakes that exceed the sodium CDRR are expected to reduce chronic disease risk within the apparently healthy population.
Sodium
The updated sodium AIs are;

Infants 0-6 months 110 mg daily
Infants 7-12 months 370 mg daily
Children ages 1-3 800 mg daily
Ages 4-8 1,000 mg daily
Ages 9-13 1,200 mg daily
Ages 14 and older 1,500 mg daily
For individuals ages 14 and older, the CDRR recommendation is to reduce sodium intakes if above 2,300 mg per day. The committee also established a sodium CDRR for children ages 1-13. The effect of sodium intake on blood pressure that was used to inform the sodium tolerable upper intake level (UL) established in the 2005 DRI report is part of the evidence base that informed the CDRR.

Most U.S. and Canadian populations consume sodium above both the AI and CDRR values. There is no concern of sodium inadequacy in the population, the report says. Reducing sodium intake has a greater effect on adults with hypertension than on adults with normal blood pressure, but the benefits of reducing sodium intake toward the sodium CDRR or below apply to both groups.

Potassium

The updated potassium AIs are

Infants 0-6 months 400 mg daily
Infants 7-12 months 860 mg daily
Children ages 1-3 2,000 mg daily
Ages 4-8 2,300 mg daily
Other age groups range from 2,300 to 3,400 mg per day
The potassium AIs in this report are lower than those established in 2005. This difference is due, in part, to the expansion of the DRI model in which consideration of chronic disease risk reduction was separate from consideration of adequacy.

This report reaffirms that there is insufficient evidence to establish a potassium UL for apparently healthy individuals. The absence of a potassium UL does not mean that there is no risk from excessive supplemental potassium intake, either overall or for segments of the population. Caution against high intake through supplemental potassium is warranted for certain population groups, particularly those with or at high risk for compromised kidney function.

The original article was published in The National Academies News, that can be accessed here.

Cyst in Penile Prepuce?

drppanda@gmail.com (Dr.Prahallad Panda) — Fri, 15 Feb 2019 11:46:00 +0530

Sometimes, I get male children referred to me for cyst in prepuce. Some doctors also would have already advised antibiotics, by that time.

On examination of the male children around 3-5 years, a fixed small swelling of about 3-4 millimeter with hard consistency, situated mostly towards the corona of glans penis would be noticed. Mostly, the mucosa of prepuce would be found adherent to the glans penis; the prepuce would not be reduced easily.

This occurs mostly after mild inflammation of the prepuce, so that the inner layer of prepuce becomes adherent to the glans penis. The smegma cannot come out and solidify to from concretion. This smegma concretion feels like a small hard mass, when palpated over the prepuce.

In these cases, we apply a little surface anesthetic and gentle pull the foreskin down and clean the smega, apply some local antibiotic ointment and advice parents to gentle clean it regularly.

So, these are not the cysts.

World Diabetes Day-2017

drppanda@gmail.com (Dr.Prahallad Panda) — Sat, 11 Nov 2017 10:34:00 +0530

Influenza (Swine Flu)

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 1 Oct 2017 18:14:00 +0530

Observation of World Heart Day 2017 at PPT Hospital

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 1 Oct 2017 14:13:00 +0530

World Heart Day-2017

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 1 Oct 2017 10:39:00 +0530

World Heart Day observed in Paradip Port Hospital

drppanda@gmail.com (Dr.Prahallad Panda) — Fri, 29 Sep 2017 08:05:00 +0530

Treatment of Type II Diabetes Mellitus (T2DM) with Metformin in a nutshell

drppanda@gmail.com (Dr.Prahallad Panda) — Sat, 14 Jan 2017 12:05:00 +0530

Metformin is a Biuagnide. It was derived from the herb Galega officinalis (French lilac, also known as Goat’s Rue or Italian Fitch)

and has been used as a traditional botanical (tea infusion) for over 3,000 years to relieve polyuria (frequent urination) and halitosis (sweet odor on the breath), both are now well known symptoms of diabetes.

It was approved for the treatment of hyperglycemia in Britain since the late 1950’s, Canada in the 1970’s and U.S. in 1995.

Metformin is the most widely prescribed anti-diabetes drug (over 120 million prescriptions filled yearly worldwide).

Mechanism of action

• Lowers both basal and postprandial plasma glucose.

• It decreases hepatic glucose production by inhibiting gluconeogenesis and glycogenolysis. Enhances secretion of GLP-1 and peptide YY, which in turn affect systemic mechanisms including reducing hepatic glucose production through glucagon suppression and enhanced glucose-dependent insulin secretion

• Delays intestinal absorption of glucose

• Enhances insulin sensitivity by increasing peripheral glucose uptake and utilization.

• Some other unclear pathway

What is the Waiting Time to Show Effect?

• Usually, dose is gradually increased from 500 mg-1000 mg-1500 mg-1700 mg-2000 mg-2550 mg

• Gradual Increment lessens GI side effects

• May take days together to show its’ full effect, if prescribed in this manner.

• Mostly, effect is seen after 1500 mg/day dose is reached.

Whether Extended Release or Plain tablet?

Extended Release is better tolerated-Maximum dose 2000 mg/day. Metformin should be taken with meals to help reduce stomach or bowel side effects that may occur during the first few weeks of treatment. Swallow the extended-release tablet whole with a full glass of water. Do not crush, break, or chew it.
Plain tablet-maximum dose-2550 Mg

What are the types of technology of manufacture?

• Dissolution/erosion controlled release

• Diffusion controlled release

• Osmotic controlled release

When to be taken?

If in single dose

Morning!

Evening!

If, taken in the evening, it works better by suppressing hepatic neoglucogenesis that occurs towards dawn.

What is passing in Stool? What is Ghost Pill?

Some patient see passing out of tablet in stool. They apprehend, the medicine might not be working. Why is passing out in stool?

It is the technology for delayed release of the ingredients and un digested portion comes out in feces.

Important Side Effects!

• Vomiting (Gastritis) and Diarrhea!

• Headache

• Lactic Acidosis

• Sometimes B12 deficiency: vitamin B-12 concentrations of ≤ 150 pmol/l; Dietary calcium or Vit. B12 supplementation

The mechanism of vitamin B12 deficiency with metformin is undoubtedly due to malabsorption of vitamin B12 at its absorption site in the terminal ileum. Absorption of the vitamin B12-intrinsic factor complex is calcium dependent and metformin interferes with its’ effect on calcium-dependent membrane action in the terminal ileum.

In support of this hypothesis is evidence that dietary calcium supplementation reverses metformin-induced vitamin B12 malabsorption.

Can it be prescribed to Patients of Impaired Kidney Function?

What is Impaired Kidney Function

• Generally, 90-120 ml/minute/1.73 m²of 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 (creatinine levels reach 1.4 mg per dL {120 μmol per L) in women or 1.5 mg per dL (130 μmol per L) in men}.

Labeling Change Recommendation-FDA: FDA concluded, from the review of studies published in the medical literature, that metformin can be used safely in patients with mild impairment in kidney function and in some patients with moderate impairment in kidney function.

• eGFR below 30 mL/minute/1.73 m²: Metformin is contraindicated

• eGFR between 30-45 mL/minute/1.73 m²: Starting metformin is not recommended.

• 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.

Precautions:

Before starting metformin, obtain the patient’s eGFR (glomerular filtration rate estimating equation).
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.

• 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.

• 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.

Other Uses!

• PCOS (Polycystic Ovary Syndrome)

• Cancer (Breast, Colon, Lung, Pancreas and Prostate)!

It is believed that systemic effect of metformin manifested by the reduction of circulating level of insulin and insulin-like growth factor 1 (IGF-1) might be associated with anticancer action.

Old is Gold

After supper walk a mile to burn more Fat!

drppanda@gmail.com (Dr.Prahallad Panda) — Sat, 24 Dec 2016 20:23:00 +0530

The old saying, “after lunch rest a while, after supper walk a mile’ may hold good; a recent research, published in the Science Daily, suggests.
The use of lipids/fats and glucose in muscle depends on the circadian rhythm and may have a role in metabolic disorders like obesity and diabetes.

The research team performed a number of functional genomics studies that established the link between HDAC3 (Histone Deacetylase3) and the circadian clock.

In normal mice, when the mouse is awake, the clock in the muscle anticipates a feeding cycle and uses HDAC3 to turn off many metabolic genes. This leads the muscles to use more carbohydrate. When the animal is about to go to sleep and anticipates a fasting cycle, the clock removes HDAC3. This leads the muscles to use more lipid.

Although these studies were done in mice, the researchers speculate that human muscles most likely will follow the same cycle. The study opens the possibility of promoting body fat burning by increasing exercise activity during the periods in which muscles use lipid, which is at night for people.

The master clock in the SCN (Suprachiasmatic Nucleus in Hypothalamus) drives circadian rhythms of behavior including the sleep-wake cycle and feeding patterns.

Overview of biological circadian clock in humans. Biological clock affects the daily rhythm of many physiological processes. This diagram depicts the circadian patterns typical of someone who rises early in morning, eats lunch around noon, and sleeps at night (10 p.m.). Although circadian rhythms tend to be synchronized with cycles of light and dark, other factors - such as ambient temperature, meal times, stress and exercise - can influence the timing as well. (Photo credit: Wikipedia)

Circadian rhythms are generated at the cellular level by a self-sustained molecular clock. Exposure to alternating cycles of light and darkness synchronizes the SCN clock, thereby aligning behavior with the solar cycle.

The SCN regulates rhythmic synthesis of endocrine factors, including the release of glucocorticoids, which can potentially synchronize peripheral clocks. Through its effects on feeding cycles, the SCN can also coordinate the timing of peripheral cellular oscillators.

In general, the primary function of clock control of processes is to prepare the cell/tissue for a predictable event before its onset; through regulation of metabolism, circadian clocks likely allow anticipation of daily fluctuations in energy demand and/or nutrient availability (e.g. increased physical activity during the awake phase).

Common behavioral/environmental risk factors for cardiometabolic diseases (e.g. food intake, physical activity, lighting, etc.) are known to influence circadian clocks in a tissue-specific manner, leading to the suggestion that circadian misalignment contributes toward obesity, diabetes mellitus, and cardiovascular disease.

Losing body fat would be easier by exercising lightly and fasting at night. "It's not a bad idea to take a walk after dinner."

Endometriosis of the Cesarean Section scar

drppanda@gmail.com (Dr.Prahallad Panda) — Mon, 19 Dec 2016 19:20:00 +0530

A young lady and mother of a child complained of pain in the right side of lower abdomen for more than 7 years. Apparently, it began about 1 year after the cesarean section delivery of her child. It has nothing to do with the timing of food, and her bowel and bladder habits were normal.

She was examined by many experts and her ultrasonogram of abdomen was showing a cyst in the ovary (Right). She was examined by me. I inquired about the suture materials used during the previous cesarean se4ction. I presumed it to be due to the use of non-absorbable suture material, like polypropelene, the knot of which sometimes gives rise to pain. However, as she could not exactly say about the use of the suture material, I too suspected it to be due to the ovarian cyst.

English: localisation of endometriosis Deutsch: Lokalisation der Endometriose (Photo credit: Wikipedia)

The cyst along with the innocent appendix was removed in a higher centre. But, she continued to experience the same pain and approached me again. This time, I could make out a tender sub-cutaneous nodule in the right lower abdominal wall. Again, I thought it to be a foreign body granuloma arising out of use of some non-absorbable suture material. Ultrasound was ordered for the abdominal wall. It suggested that there is a well defined solid sub-cutaneous nodule. I thought it to be some benign tumour of the fascia or again foreign body granuloma. The nodule was subjected to FNAC examination. It came out to be non-specific inflammation. It was presumed to be a foreign body granuloma.

It was planned for excisional biopsy. Intra-operatively, it was found that the nodule was a part and partial of the rectus sheath. The nodule was excised and fascial defect repaired. The HP study came out to be endometriosis.

Though, endometriosis is rare after a cesarean section, is a reality. This happens due to implantation of endometrial tissue from uterus during the cesarean section. Typically, endometriosis becomes painful, towards the time of periods, but this feature was not there in the present case.

Hence, painful and tender sub-cutaneous nodule in the scar of previous cesarean section should be suspected to be endometriosis.

Dengue (DEEngee) in Nutshell

drppanda@gmail.com (Dr.Prahallad Panda) — Mon, 22 Aug 2016 06:48:00 +0530

Once Daily Combination Drug Linagliptin and Metformin approved by FDA for T2DM

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 19 Jun 2016 09:12:00 +0530

The FDA has approved once-daily Jentadueto XR (linagliptin and metformin hydrochloride extended-release) tablets from Eli Lilly and Boehringer Ingelheim for the treatment of type 2 diabetes (T2D) in adults.

English: The blue circle is the global symbol for diabetes, introduced by the International Diabetes Federation with the aim of giving diabetes a common identity, supporting existing efforts to raise awareness of diabetes and placing the diabetes epidemic firmly in the public spotlight. (Photo credit: Wikipedia)

Indications: Jentadueto XR is a dipeptidyl peptidase-4 (DPP-4) inhibitor and biguanide combination product indicated as an adjunct to diet and exercise to improve glycemic control in adults with T2D mellitus when treatment with both linagliptin and metformin is appropriate.

Dosage and administration: Individualize the starting dose of Jentadueto XR based on the patient’s current regimen. Do not exceed a total daily dose of linagliptin 5 mg and metformin 2000 mg. Give once daily with a meal.

Adverse reactions: The most common side effects include stuffy or runny nose, sore throat, and diarrhoea.

2016 American Diabetes Association (ADA) Guideline for Primary Care of Diabetes

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 8 May 2016 10:06:00 +0530

The American Diabetes Association (ADA) published the 2016 Standards of Medical Care in Diabetes (Standards) to provide clinicians, patients, researchers, payers, and other interested parties with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The ADA Professional Practice Committee revised recommendations based on new evidence to include 8 key areas important to primary care providers, including:

• Diagnosis –

1. remains an A_1c >6.5%,

2. fasting plasma glucose >126; or

3. an oral glucose tolerance 2 hr. result >200 mg/dL, or

4. a random glucose >200mg/dL and classic symptoms of hyperglycemia.

English: Overview of the most significant possible symptoms of diabetes. See Wikipedia:Diabetes#Signs_and_symptoms for references. Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)

• Glycemic targets - The HbA_1c goal for most non-pregnant adults is less than 7%; more stringent HbA_1c goals (such as <6.5%) may be recommended for patients without co-morbidities and who have a short duration of diabetes, and less stringent A1c goals are appropriate for older patients with significant comorbid illness.

• Hypoglycemia – severe or frequent hypoglycemia is an indication to modify treatment regimens.

• Medical management – intervention should always include lifestyle modification with diet and exercise. If lifestyle modification is not sufficient to reach target A1c goals, then metformin should be added at or soon after diagnosis. If A_1c is over target for longer than 3 months, then a second agent should be added. The second agent could be from the class of: sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, sodium–glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, or basal insulin.

• Cardiovascular risk factor management - blood pressure treatment goal is <140/90 mm Hg, and an ACE or an ARB should be used as part of BP management. Statins are recommended for most persons with diabetes age 40 or older.

These recommendations highlight individualized care to manage the disease, prevent, or delay complications, and improve outcomes.

Citation: Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A. Diagnosis and management of diabetes: Synopsis of the 2016 American Diabetes Association standards of medical care in diabetes. Ann Inter Med. 2016;164:542-552. doi:10.7326/M15-3016.

MammaPrint Assay Reduces use of Chemotherapy in Breast Cancer Patients

drppanda@gmail.com (Dr.Prahallad Panda) — Sat, 23 Apr 2016 19:14:00 +0530

In the American Association for Cancer Research (AACR) meeting 2016, Martine Piccart, MD, PhD, of the Jules Bordet Institute in Brussels, Belgium said that use of the gene assay was associated with a 46% reduction in prescriptions for chemotherapy among the 3,348 high-risk patients and 14% reduction for all 6,648 patients in the study. The meeting coverage was published in the Medpage Today on 22.04.2016.

English: Validation chart for Agendia's MammaPrint Assay, part of the Symphony Breast Cancer Suite (Photo credit: Wikipedia)

Patients at high clinical/pathologic risk but low risk by the 70-gene MammaPrint assay had a 5-year distant metastasis-free survival (DMFS) of 94.4% without chemotherapy versus 95.9% with chemotherapy, a difference that did not reach statistical significance (HR 0.78, 95% CI 0.50-1.21).
In patients with a low clinical risk but high genetic risk, the 5-year DMFS was 95% to 96% with or without chemotherapy.
As compared to standard clincopathological classification, MammaPrint re-stratified 20% of Clinical High Risk patients to Low risk. 97% of this Low Risk patient group which primarily chose to forgo chemotherapy, were disease free at 5 years.
The first ever prospective clinical study for a breast cancer recurrence assay, RASTER (MicroarRAy PrognoSTics in Breast CancER) was published in 2013.
"The MammaPrint FFPE (Formalin Fixed Paraffin Embedded) tissue test has been approved by the FDA."
It confirmed the utility of the MammaPrint (Agendia) 70-gene signature to identify those breast cancer patients that may safely forgo chemotherapy.

DPP-4 Inhibitora like Saxagliptin and Alogliptin may increase the Risk of Heart Failure

drppanda@gmail.com (Dr.Prahallad Panda) — Tue, 12 Apr 2016 09:37:00 +0530

Diabetes drugs containing saxagliptin (Onglyza) and alogliptin (Nesina) may increase the risk of heart failure, the US FDA announced on 5^th April, 2016.

A U.S. Food and Drug Administration (FDA) safety review has found that type 2 diabetes medicines containing saxagliptin and alogliptin may increase the risk of heart failure, particularly in patients who already have heart or kidney disease.

Heart failure can result in the heart not being able to pump enough blood to meet the body’s needs. As a result, a new warning is being added to the drug labels about this safety issue.

Saxagliptin and Alogliptin are part of the class of dipeptidyl peptidase-4 (DPP-4) inhibitor drugs, which are used with diet and exercise to lower blood sugar in adults with type 2 diabetes.

Patients taking these medicines should contact their health care professionals right away, if they develop signs and symptoms of heart failure such as:

Unusual shortness of breath during daily activities
Trouble breathing when lying down
Tiredness, weakness, or fatigue
Weight gain with swelling in the ankles, feet, legs, or abdomen

Patients should not stop taking their medicine without first talking to their health care professionals.

Health care professionals should consider discontinuing the medicine in patients who develop heart failure and monitor their diabetes control. If a patient’s blood sugar level is not well-controlled with their current treatment, other diabetes medicines may be required.

The original article can be accessed here.

LAMA and LABA combination Treatment for COPD is more Effective than Monotherapy

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 10 Apr 2016 11:13:00 +0530

Treatment of chronic obstructive pulmonary disease (COPD) has always been a challenge to the physician.

According to a publication, [Published online ahead of print March 3, 2016]. Chest. doi:10.1016/j.chest.2016.02.646, “A systematic review with meta-analysis of dual bronchodilation with LAMA/LABA for the treatment of stable chronic obstructive pulmonary disease” by Calzetta L, Rogliani P, Matera MG, Cazzola M., dual bronchodilation with Long-acting Muscarinic Antagonists/Long-acting Beta Agonists (LAMA/LABA) for the treatment of stable chronic obstructive pulmonary disease (COPD) is more effective than a LAMA or a LABA alone

Dual bronchodilation with Long-acting Muscarinic Antagonists/Long-acting Beta Agonists (LAMA/LABA) for the treatment of stable chronic obstructive pulmonary disease (COPD) is more effective than a LAMA or a LABA alone, regardless of the drugs used.

Enlarged view of lung tissue showing the difference between healthy lung and COPD (Photo credit: Wikipedia)

This according to a review and meta-analysis of 23,168 COPD patients (combinations n=10,328; monocomponents n=12,840) who participated in trials that lasted at least 3 months. Researchers found:

• All LAMA/LABA combinations were always more effective than the LAMA or LABA alone in terms of improvement in trough FEV1.

• There was a gradient of effectiveness among the currently available LAMA/LABA fixed-dose combinations, although there was not a significant difference among them.

• LAMA/LABA combinations also improved both quality of life scores, and did not increase the cardiovascular risk when compared with monocomponents.

There are currently 3 FDA approved LABA/LAMA combination inhalers:

• Umeclidinium bromide and vilanterol (Anoro-GSK).

• Glycopyrronium bromide and indacaterol (Ultibro-Novartis).

• Tiotropium and olodaterol (Stiolto Respimat-Boehringer Ingelheim Pharmaceuticals).

Better Prevention be the goal than the Treatment of Drug Resistant Gonorrhoea

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 20 Sep 2015 12:50:00 +0530

It has been published in The Guardian that a multi-drug resistant Gonorrhoea strain has been detected in 15 cases by Public Health England since March; the British Association for Sexual Health and HIV reported. It has triggered an unprecedented national public health alert in England.

Gonorrhoea is caused by a bacterium called Neisseria gonorrhoeae. It has become resistant to penicillin, tetracycline, quinolones and many more groups of drugs, finally is being treated with Ceftrixone in combination with azithromycin.

Neisseria Gonorrhoeae

Now, it has been reported that several cases are not responding to azithromycin and some cases have become resistant to ceftrixone too.

News of the British cases comes less than a day after the European Centre for Disease Prevention and Control (ECDC) reported gonorrhoea rates in Europe had gone up by 79% since 2008, particularly among men. The UK reported 61% of all cases in Europe. It has risen by 19 per cent in 2014 amongst heterosexuals and a whopping 32 per cent in gay men.

There were almost 35,000 cases of gonorrhoea reported in England last year. It is the second most common bacterial sexually transmitted infection in the UK after Chlamydia, with the bacteria transmitted through discharge from the penis and vagina.

It’s a clever little bug that doesn’t always show symptoms and patients carry the infection without even realizing it, called carriers.
The main causes of resistance to the antibiotics are inadequate/inappropriate treatment and emergence of mutated strains of bacteria.
Hence, it is better to emphasize on prevention than to go for treatment of Drug Resistant Gonorrhoea.

Gonorrhea: Protect Yourself- According to the recommendations of CDC:

It is critical that individuals protect themselves against infection.

Prevention strategies include:

(1) Abstinence or mutual monogamy— The surest way to avoid transmission of gonorrhea is to abstain from sexual intercourse, or to be in a long-term, mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

(2) Condoms— When used consistently and correctly, condoms can reduce the risk of transmission of gonorrhea.

(3) Regular screening— Screening for those at greatest risk is critical. CDC recommends that sexually active gay and bisexual men and high-risk sexually active women be tested for gonorrhea at least once a year.

(4) Prompt and effective treatment— Anyone who becomes infected should get treated with a ceftriaxone injection and either azithromycin or doxycycline right away to cure the infection and prevent transmission to others. Patients receiving a treatment other than dual therapy that includes ceftriaxone should be tested one week after completing treatment to confirm that the infection has been cured.

Prevention is better than cure, “A stitch in time prevents none.”

DPP-4 Inhibitors Used to Treat Type 2 Diabetes Mellitus may cause Joint Pain

drppanda@gmail.com (Dr.Prahallad Panda) — Sun, 13 Sep 2015 09:16:00 +0530

FDA Issues Warning for DPP-4 Inhibitors; published in ClevelanD Clinic on 08.09.2015, drugs like sitagliptin, saxagliptin, linagliptin, and alogliptin, used to treat Type 2 Diabetes Mellitus, may cause joint pain that can be severe and disabling. Nevertheless, FDA has not advised to stop the medications.