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Sunday, December 15, 2013

Prognostic scores in alcoholic hepatitis

1. Maddrey (modified) Discriminant Function score of greater or equal to 32 indicates a high risk (30-50%) risk of mortality at 30 days. The risk is even higher is there are signs of hepatic encephalopathy. Scores should be repeated at day 7.

2. MELD stands for Model for End stage Liver Disease. It is used to estimate 90 days mortality. Poor prognosis if score is greater than 18. Score should be repeated at day 7.

Sunday, October 6, 2013

Effect of weather on COPD

Exacerbations of COPD are more commonly seen during the winter season (nearly 1.6 times more frequently). The main cause of these exacerbations is infection with the respiratory virus, rhinovirus.
Frequent exacerbations have been shown to lead to a faster decline in the lung function, poorer quality of life and increased mortality.
A recent study showed that COPD exacerbations in colder periods of the year take longer to recover from and are more likely to involve cough or coryzal symptoms. The exacerbations in the cold seasons also have a greater impact on daily activity, with patients spending more time indoors and being more likely to be hospitalized with respiratory viral infection.

Monday, August 5, 2013

X ray spina bifida occulta

It is the case of a 16-yr old female who came to the emergency department with complaints of low back ache for the past week. She has had similar symptoms in the past but now the intensity is increasing.
There is no associated numbness or weakness of extremities. She did not have any weight loss. There was neither urinary nor fecal incontinence.

On examination she had an obvious limp.
Lumbar spines: mild tenderness lower lumbar spines, no deformity, range of motion was normal, no stigma of spina bifida.
Lower limbs length showed a discrepancy of 1.5cm being shorter by 1.5cm on the left side.
Left ankle in inversion and with hyperlaxity while left ankle was stiff and with restricted inversion.

X-ray of Lumbar Spines showed a spina bifida.

Impression of Spina Bifida occulta was made.

Sunday, June 2, 2013

Diabetes - 7 keys messages to the patients

1. Diabetes is self-managed.

Caring for diabetes is more than just taking a daily pill or doing your insulin injection. It may feel like a burden but the decisions you make about physical activity, what and when you will eat will affect both how you feel today and your future health and well-being.

2. Take diabetes seriously.

It is a multi-systemic disorder and indeed needs a lot of care. Since the symptoms and complications take time to appear you may think that it is a simple disease but it is not in reality!!!

3. Learn everything about the disease.

Since most of diabetes care is  about self-care, the more you know about it, the better you will be able to manage it. You can control your diabetes rather than letting your diabetes control you. If possible, try to get updated with latest developments in the field and read to drive away myths about the disease.

4. Your treatment will change over time.

Treatment of diabetes will eventually change over time. Changes in treatment do not mean that you have failed or that your diabetes is worse. It simply means that your body needs more help to keep your blood glucose level on target. Insulin therapy is part of the treatment and not a punishment.

5. Negative emotions are common.

It can be difficult to live with diabetes and researchers have shown that patients are about twice as likely to become depressed. Let your doctor know if your emotions are getting in the way of managing diabetes or enjoying your daily life. Do not hesitate to go for a psychological evaluation.

6. Step by step is the motto.

Diabetes often involves making changes in your food, exercise and other habits. It can quickly become too hard if you try to do it all at once. Start by choosing one thing that is important to you. Try to make small changes each day. It is likely that you will try different things along the way. Use what you learn about what does and does not work as a guide. Perfection is not the goal. It is what you do most of the time that counts.

7. Complications don't always happen.

You may have seen the toll of long-term complications on others. The good news is that these can be delayed or prevented by keeping your blood glucose and blood pressure levels in the target ranges. There are no guarantees, but you can greatly reduce your risk.

Living with diabetes is not easy. But with the help of your health care team and your family and friends, you can do it.

Thursday, May 2, 2013

Mediterranean diet and cognitive decline

A Mediterranean diet is one which comprises of fresh vegetables, fruits, beans, whole grains, nuts, olives, and olive oil along with some cheese, yogurt, fish, poultry, eggs, and wine.
A recent study has shown that this diet if adopted and followed leads to a slower decline in the cognitive function. The two main hypotheses are that it has a lot of anti-oxidants which prevent cell death in the brain and secondly it has a protective effect on the vasculature of the brain and thus prevents vascular dementia. Thus, the Mediterranean diet not only improve your looks and protects your cardiovascular system but also your brain cells benefit from it.

Wednesday, May 1, 2013

Highest prevalence of Diabetes Mellitus

Figures till November 2012 show that the top 5 countries with the highest prevalence of Diabetes Mellitus are from the pacific islands. They may be the smallest islands but the epidemic of diabetes is one of the worst there. More than a third of adults in some of these countries have diabetes and the combined toll of complications, deaths and loss of income make diabetes a real threat not just to the individuals experiencing the disease but also to the economies of the countries themselves.

Above is an image showing the locations of the pacific islands.

Top 10 countries with Diabetes Mellitus 2012

Data till November 2012 showed that together, these 10 countries make up 75% of the total prevalence of diabetes in the world.  Urbanisation and the accompanying changes in lifestyle are the main drivers of the epidemic in addition to changes in population structure where more people are living longer.

Friday, April 19, 2013

Anemia in diabetic patients - Erythropoietin treatment?

If you encounter a normochromic and normocytic anemia in a diabetic patient, do not forget that it may be a case of erythropoietin deficiency. This deficiency can occur early in diabetic nephropathy (well before stage 5 of chronic kidney disease).

In adults, about 85-90% of the erythropoietin comes from the kidneys and 10-15% from the liver. It is produced by interstitial cells in the peritubular capillary bed of the kidneys and by perivenous hepatocytes in the liver. In cases of decreased renal mass, the level of erythropoietin falls and does not increase much in response to hypoxia (anemia). This occurs even if the liver is normal as the latter cannot compensate for the kidney's loss of function.

Since the availability of recombinant human erythropoietin to patients in 1989, anemia and transfusion requirements have become relatively  rare in patients on hemodialysis.
After adequate treatment with erythropoietin, studies have demonstrated that there is an:
1) enhanced exercise capability, presumably partly because of improved cardiac function with reduction in ventricular hypertrophy,
2) improved quality of life with improved physical performance, work capacity and cognitive capacity,
3) improved sexual function,
4) reduced rates of hepatitis and iron overload because of fewer transfusions.

All of the erythropoietin preparations are now referred to collectively as erythropoiesis stimulating-agents (ESAs). So far, intravenous route has been the sole route of administration and is given during hemodialysis but investigations are going on about the possibility of subcutaneous administrations.

With subcutaneous administration, peak serum concentrations of about 4% to 10% of an equivalent IV dose are obtained at around 12 hours, and thereafter they decay slowly such that concentrations greater than baseline are still present at 4 days.
The bioavailability of subcutaneous epoetin is around 20% to 25%. Nevertheless, subcutaneous application
is more efficient than IV application, allowing an approximately 30% dose reduction to maintain the same hemoglobin concentration.
Presumably, the early peak concentrations of epoetin after IV injection are inefficient, but the more prolonged elevation of hormone concentrations after subcutaneous application allows a more sustained stimulation of red cells production. Thrice-weekly administration has remained the most popular dosage frequency for both IV and subcutaneous administration, although once-weekly, twice-weekly and
seven-times-weekly (once-daily) dosing have all been used.

The hemoglobin target should be in the range of 11-12 g/dL and should not be greater than 13 g/dL.

Above is a diagram showing the change in hemoglobin level (blue line) with respect to different dosage of erythropoietin from 1991 till 2009 in an attempt to keep the hemoglobin in the target range. Hemoglobin level should be tested at least once monthly. 

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