Attention to patients on valproate

Sodium valproate is a drug used for seizure. It is a broad spectrum drug for seizure. It is used since 1960.

Uses of valproate

1. Control of seizure

2. Treatment of psychiatric illness

Following are the adverse effect of valproate.

Loss of appetite

Vomiting

Drowsiness

Ataxia and tremor

Alopecia (loss of hair)

Curling of hair

Increased blood ammonia

Rash

Low platelet count.

A serious but rare complication is severe liver damage. Those who have preexisting liver disease and who are on other drugs producing liver damage are at risk for valproate induced liver disease. If used in pregnancy it produce neurological disease in offspring. So it should be avoided.

Drug interactions

Special precaution should be taken in people on  the following drugs.

1. Phenytoin

2. Phenobarbitone

3. Carbamazepine 

4. Clonazepam.

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Risk factors and Types of gall stone

It is the most common disorder of biliary tree. Overall prevalence of gall stone is 11%, 7% in men and 15% women. In people below 40 yrs sex ratio is 3:1. People with gall stone may be asymptomatic or present with recurrent upper abdominal pain. Some stones are detected on ultra sound scanning of abdomen.

Types of gall stone.

They are classified as cholesterol stones, pigment stones and mixed stones. Mixed stones are the most common types. Cholesterol stones are common in developed countries, whereas pigment stone occur in developing countries.

Different types of gall stone are pure cholesterol (white), mixed, bile salt predominant (black) stones. Cholesterol or cholesterol predominant (mixed) stones constitute 80% of gall stones. They are formed due to supersaturation of bile with cholesterol. Decreased gallbladder motility also aid the stone formation. Pigment stones occur following infection of  biliary system, usually due to Escherichia coli and Klebsiella spp, 

Risk factors associated with formation of cholesterol gall stones

Increased Cholesterol secretion seen in 

* Age > 40 years

* Female sex (twice the risk in men)

* Genetic or ethnic variation highest Prevalence in North American Indians, Chilean Indians

* Pregnancy (risk increases with number of pregnancies

* High fat, low fibre diet

* Obesity

* Hyperlipidaemia

* Bile salt loss (ileal disease or resection)

* Diabetes mellitus

* Cystic fibrosis

* Antihyperlipidaemic drugs (clofibrate)

Impaired gallbladder emptying condition associated are

* Pregnancy

* Gallbladder stasis

* Prolonged Fasting

* Total parenteral nutrition

* Spinal cord injury

Pigment Stones cause are the following

* Demographic/genetic factors: Asia, rural setting

* Chronic hemolysis

* Alcoholic cirrhosis

* Pernicious anemia

* Cystic fibrosis

* Chronic biliary tract infection, parasite infections

* Increasing age

* Ileal disease, ileal resection or bypass

Factors that decreases gall stone formation.

* A low-carbohydrate diet

* Physical activity.

* Intake  of caffeinated coffee help to reduce gall stone risk  in women,

* High polyunsaturated and monounsaturated fats intake decreases the risk of gallstones in men.

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Role of vitamin C in the body and its deficiency disorders

Vitamin C is also called Ascorbic acid, which is an important dietary antioxidant. It is required for collagen synthesis in the body. Traditional cooking method destroy it as vitamin C is very heat sensitive.

Actions of vitamin C include

1.Antioxidant activity.

2.Help the absorption of non heme iron .

3.Carnitine biosynthesis.

4.Required for the conversion of dopamine to norepinephrine.

5.Help the production of  of peptide hormones.

6.Vitamin C is important  for collagen synthesis .

7.It is a part of many drug-metabolizing enzyme systems.

Significance of vitamin C in  the body

1. During stress and hospital admission and disease need of vitamin c increases. It may be due to decreased  absorption  or increased catabolism.

2. Need of vitamin c is increased during trauma and surgery for  extra collagen synthesis.

3. Vitamin C supplementation (e.g., 1–2 g/d) may slightly reduce.

 the symptoms and duration of common cold .

4.Vitamin C supplementation is also useful in Chédiak-Higashi syndrome and osteogenesis imperfecta.

5. It is proposed that high dose of vitamin C intake will increase the anti oxidant property of body. So it will delay the development of degenerative disease such as cataract and  atherosclerosis

6. High vitamin C will help to prevent certain cancers especially stomach cancer and esophageal cancers. It may be because vitamin C prevent the conversion of nitrites and secondary amines to carcinogenic nitrosamines..

7. Parenteral ascorbic acid  is also tried in the treatment of advanced cancers.

8. Those people with past history of kidney stone  and chronic kidney disease should not use high dose of vitamin C ,because  in these patients.plasma Vitamin C  can reach  to levels above the normal range.

9. Absorption of Vitamin C enhances the non-haem iron absorption that is taken at the same time. Thus help to prevent iron deficiency anemia.

Clinical  features of vitamin deficiency

Vitamin C deficiency produce the following clinical features 

1. Scurvy.

2. Bleeding around the hair follicle (Perifollicular petechiae).

3. Bleeding gums-Swollen spongy gum with bleeding ,loosening of teeth.

4. Follicular hyperkeratosis ( Thickening of skin around the  hair follicle )

5. Delayed wound healing.

6. Infection.

7. Anemia.

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Treatment of Osteoarthritis

Goals of osteoarthritis treatment are the following

1. Control of pain.

2. Functional improvement.

3. Decrease the handicape due to osteoarthritis.

4. Improve the quality of life.

5. Educate the patient about the disease.

6. Decrease the drug related side effects.

Number of modalities are available to achieve these goals. The main problem of the patient is pain and physical handicap due to osteoarthritis. Cause and treatment of it require special attention.

Given below are the treatment modalities 

1. Counselling.

2. Patient education.

3. Physical therapy.

4. Occupational therapy.

5. Drugs.

6. Complementary medicine.

7. Surgery.

Reduction of pain  and stiffness of joint with following drugs

1. Analgesics.

2. Intermittent/regular analgesics (acetaminophen).

3. Topical NSAIDs.

4. Topical capsaicin.

5. Oral NSAIDs.

6. Oral glucosamine sulfate.

7. Peri- and intra-articular corticosteroid injection.

8. Hyaluronic acid injection.

9. TENS and nerve blocks for severe pain.

Reduction of the impact of pain and disability

Due to the pain and disability of osteoarthritis patients experience depression, anxiety, fibromyalgia. Treatment of these aspects is also advised

Modification of  patient environment to reduce handicap

Surgery is reserved for those patients with severe pain and disability.

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What is sudden cardiac death and its management

Sudden cardiac death is defined as Natural death due to cardiac causes, heralded by abrupt loss of consciousness, within 1 hour of the onset of a/c symptoms. Preexisting heart disease may or may not have been known to be present, but the time and mode of death are unexpected. It is due to direct consequence of cardiac arrest

Risk factors of  sudden cardiac death

Age.elderly at risk.

Male Gender.

Familial factors.Positive family history may be present.

Structural and functional factors.

Heart attack and chest pain - 80%.

Cardiomyopathies - 10 to 15%.

Other causes - 5 to 10 %.

Management of sudden cardiac arrest

Confirm cardiac arrest.

Call for help.

Give Chest compression.

Maintain airway –with  head tilt , chin lift, clear passage.

Look, listen and feel   the breathing.

Hospitalize the patient as early as possible. 

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What are the risk factors for osteoarthritis

Osteoarthritis is very common in the community and there are certain factors that place the patient at high risk for osteoarthritis. These factors act in two ways

1. They may increase the joint susceptibility to development of  osteoarthritis.

2. They increase the load on the joint

3. Combination of above mechanism

Following are the risk factors for osteoarthritis.

1. Age is the most potent risk factor for osteoarthritis,as age advances the risk also increases.

2. Gender, females are at increased risk for osteoarthritis. The role of sex hormone is indicated by increased risk after menopause.

3. Heritability, osteoarthritis is a heritable disease. Heretability varies depending on the joint. This is high in hip osteoarthritis.

4. Local factors in the joint. This will lead to uneven distribution of weight and increased focal stress example malalignment across the joint, increased mobility of joints, congenital joint abnormality.

5. Obesity increases the load across the joint.

6. Repeated use of joints and injury will cause osteoarthritis especially in sportsmen.

7. Fracture and trauma increases the risk.

8. Cigarette smoking.

9. Occupation - Certain occupation is at risk for this condition. 

   (a) Miners - osteoarthritis of hip, knee, shoulder.

   (b) Cotton workers - hand osteoarthritis.

   (c) Farmer - hip osteoarthritis

10. Osteo arthritis can  also develop secondary to certain disease.

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Management of irritable bowel syndrome

IBS (Irritable bowel syndrome) is characterized by recurrent abdominal pain and alteration in bowel habits. After the diagnosis is made most important step is reassurance of the patient, because many patient will have a fear of colonic malignancy because of this symptom. In mild cases there is only symptoms at the time of stress, these people need not be treated. Those with severe  symptoms should receive treatment. All the symptoms will not be controlled with medication.

1. Patient counselling - This is done to reasssure the patient./

2. Lifestyle Changes - Since stress is part of normal life, in this modern era try to avoid stress as possible, you should spend time to relax, enjoy the life. Adequate sleep at night and regular exercise are also helpful. Patient should avoid tobacco, excessive use of caffeine and alcohol.

3. Diet  - Certain dietary recommendations are advised in people with IBS. Small frequent meals will help to reduce the symptoms. Food with low fat and high carbohydrate such as rice, cereals, vegetables and food with low fat and high protein (fish, skimmed milk and low fat cheese) may be advised. In patient with loosestools, fruits, fruit juices and dairy products are NOT advised. 

        

Certain patients have aggravation of symptoms after taking coffee, legumes, cabbage, disaccharide. Such patients should avoid these things. Excessive fructose and artificial sweeteners (sorbitol, mannitol) may produce loose stool, abdominal cramp and flatulence(feeling of fullness in abdomen) . Four week of very low carbohydrate  that is20 grams per day reduce symptoms in many patients.   

Medication used in the treatment of IBS.

1. Stool-Bulking Agents.

High fiber diet ,bulking agents such as hydrophyllic colloid help in relieving symptoms. It will increase the stool weight, decrease in colonic transit time ,improve constipation. It is also useful in diarrhea prone patients.

2. Agents to reduce abdominal pain(Antispasmodics).

These are given to reduce the abdominal pain. Majority experience pain shortly after food intake. So these drugs are given 30 minutes before food intake. Anticholinergic such as dicyclomine is beneficial.

3. Agents that reduce diarrhea(loose stools).

Antidiarrheal agents used to treat are loperamide, opiate, cholestyramine. Agents such as loperamide is useful especially in stressful situation.

4. Antidepressant Drugs.

Effect of anti depressant in IBS is independent of its antidepressant action. Abdominal pain also improves with anti depressants. Tricyclic anti depressants are used. Examples are desipramine, SSRI (Selective serotonin reuptake inhibitor) are also useful. mainly in IBS C patients.

5. Agent that reduce the flatulence

Patients are advised to eat slowly, avoid chewing gum and carbonated drinks. Antibiotics and pancreatic enzyme may be tried.

6. Modulation of Gut Flora.  

Antibiotic is used to treat a subset of people with IBS. The agent used is rifaximin. 

7. Serotonin Receptor Agonist and Antagonists

These agents are also tried in IBS. Chloride Channel Activators Lubiprostone is tried.

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How will you care heart attack patient ?

Heart attack is a common problem in the community, but majority of the people don’t know what are the precautions we should take after a major heart attack. Understanding of which is very important because it will help us to avoid further attack, and improve the quality of life. Patients and their relatives should take special attention in understanding this aspect. Millions of people are living with heart disease,but it is not easy to live with heart attack.Following are the tip for caregivers and patients.

1.Healthy food - Patient should take a balanced food.Predominantly vegetarian food is preferred,food should be rich in antioxidants.

2.Exercise - Daily exercise will help to protect the heart,only safe exercise is advised.

3.Stop smoking and heavy alcohol intake.

4.Ensure adequate sleep.

5.Patient should not stop drugs without doctors advise.

6.Patients can  take part in cardiac rehabilitation program  after dicussing with the treating doctor.

7.Caregivers should understand the psychological ,cultural and spiritual aspect of health and disease.

8.Avoid mental and physical stress.

9.CPR - Cardio pulmonary resuscitation  is called as chain of survival,it is important that care givers should learn it for their loved one.

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Why obesity lead to osteoarthritis ?

Obesity or overweight is a common problem in community. It will lead to a variety of health problem. One of the important health problem in obese individual is osteoarthritis. Three to six times body weight is transmitted across the knee during single-leg stance. Any increase in weight may be multiplied by this factor to reveal the excess force across the knee in overweight persons during walking. Obesity’s effect on the development and progression of disease is mediated mostly through the increased loading in weight-bearing joints that occurs in overweight persons. 

1. Obesity is closely associated with knee osteoarthritis,  in those who have body weight more than 50 per cent above their ideal body weight when compared to those people with ideal body weight. The risk is more in women than men Risk ratio is of  9.0 for women and  4.5 for men.

2. One of the interesting factor noticed is that obesity does not seem to be  a strong risk factor for  hip osteoarthritis, compared to knee osteoarthritis.

3. At the knee joint, obesity is a predisposing factor for development of disease than it follows knee osteoarthritis.

4. In some people osteoarthritis at knee may or may not be associated with symptoms, but it produce radiographic change.

5. Once the obese people develop knee osteoarthritis the painful knee also lead to sedentary lifestyle. The same thing happens with obesity.

6. For a given damage to knee joint obesity increases the pain. Obesity also increases the severity of disease.

7. Malalignment (varus/valgus knee alignment) increases the risk for osteoarthritis.

There are  two types of limb malalignment in knee joint in the frontal plane,
  1.Varus deformity in which the stress is placed across the medial compartment of the knee joint.
  2.Valgus deformity which places excess stress across the lateral compartment of the knee.

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What is polycythemia ?

The term polycythemia means there is an elevation of hemoglobin above the normal level. Blood contain cellular components and fliud compartment .One of the cellular component is RBC (red cell corpuscles )and the fluid compartment is called plasma. Hemoglobin elevation can be absolute or relative. The term relative means elevation in hemoglobin is secondary to decrease in plasma volume that is fluid part of blood. RBC cell mass is measured as PCV (packed cell volume )or hematocrit. It is a disease of middle  aged people or elderly

Criteria for diagnosis of polycythemia are given below

Hemoglobin level - more than 17 g/dLfor men.

Hemoglobin level - more than 15 g/dL for women.

Hematocrit levels > 50% in men.

Hematocrit levels > 45% in women may be abnormal.

Hematocrits > 60% in men and >55% in women  is definitely associated with Elevated RBC mass.

Elevated PCV in a patient with true polycythaemia due to congenital cyanotic heart disease (left) compared to a blood sample taken from a person with a normal PCV (right ). Dark part represent the RBC mass, yellow part the plasma. In the first one there is a rise in RBC mass representing polycythemia.It is very important to identify whether the polycythemia is true or apparent. True polycythemia can be  primary or secondary.

Apparent or spurious polycythaemia

In apparent or relative polycythaemia RBC mass is not elevated and the increased packed cell volume is secondary to a fall in the plasma volume. It may be associated with dehydration  smoking,  excess alcohol intake, obesity, diuretics, and hypertension.

True polycythemia

Polycythaemia vera is the term given to Primary polucythemia. Exact cause not known, genetic factors play a significant role.

Secondary polycythaemia

Here the rise in hemoglobin is secondary to definite cause. There are a variety of secondary causes of polycythemia most common is decreased oxygen content of blood and disease of kidney, cigarette smoking. Other causes are given in the table below.

Relative polycythaemias

Hemoconcentration secondary to dehydration, diuretics, ethanol abuse, androgens or tobacco abuse

Causes of Absolute polycythaemias are the following

1.Hypoxia is seen in 

Carbon monoxide intoxication

High oxygen-affinity hemoglobin

High altitude

Pulmonary disease

Right to left cardiac or vascular shunts

Sleep apnea syndrome

2.Renal Disease

Renal artery stenosis

Focal sclerosing or membranous glomerulonephritis

Postrenal transplantation

Renal cysts

3.Tumors

Hypernephroma

Hepatoma

Cerebellar hemangioblastoma

Uterine myoma

Adrenal tumors

Meningioma

Pheochromocytoma

4.Drugs

Androgens

Recombinant erythropoietin

Detection of polycythemia is important irrespective of the cause because when there is a rise in hemoglobin or RBC mass it increase the the whole blood viscosity. As a result of rise in viscosity there can be reduction of  blood supply to the organ and reduced oxygen supply which in turn lead to a variety of clinical symptoms. 

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Screening for gestational diabetes mellitus - Glucose challenge test and glucose tolerance test

Gestational diabetes means diabetes first detected during the present pregnancy. Usually occur during the later half of pregnancy. Its detection and treatment is important because this can result in increased birth weight of fetus and complication during delivery.

Screening for diabetes during pregnancy.

Glucose challenge test (GCT)

How it is done ?

Patient is given 50 gms of oral glucose, as sugar syrup (dissolved in about 150 ml of water) to drink. This test is done without regard to time or last meals.

Usually done between 24 to 28 week of pregnancy.

A plasma glucose value 140 mg% or whole blood value 130 mg% is considered as cut off value and indication for  Glucose tolerance test.

Glucose tolerance test or (GTT)

Glucose tolerance test is done after taking 100 gm oral glucose (75 gm glucose as per WHO recommendation). Fasting blood sugar and blood sugar first ,second and third hour after 100 gm glucose is taken. If done after intake of 75 gms of oral glucose, fasting and 2 hour blood sugar  is taken.

Interpretation of GTT

Criteria for diagnosis of gestational diabetes with 100 gm oral glucose tolerance test.

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Use turmeric to get fair and beautiful skin

Natural treatment for skin gives long lasting effect, turmeric is a herb known as curcuma longa. It has many beauty benefits.
How turmeric will help you to get a fair beautiful skin?
1. Turmeric  lightens your facial hair.
2. Enhances your skin tone.
3. Turmeric has anti inflammatory action  that reduces skin pigmentation and tanning.
4. It has anti bacterial action so cure pimples and skin breakouts thus help you to get a glowing skin.
5. Turmeric can lighten stretch mark.
6. It has moisturizing effect that is good for dry skin.
7. It can reduce the wrinkles and fine lines.
8. Turmeric has exfoliating effect that remove dead cells and gives glow to skin.
9. Turmeric remove the facial hair.

How to make turmeric fairness face pack for oily skin?
Make a paste mixing the following.
1. ½ tablespoons of sandalwood powder (Act as astringent).
2. A pinch of ground turmeric (Controls the sebum oily substance in the face).
3. Tablespoons of orange juice (ource of vitamin C ,reduces blemishes).
Apply this paste on the face, wash with warm water after 15 minutes.

How to make turmeric fairness face pack for dry skin?
If you have dry skin make a face pack with
1. Egg white.
2. Drops of olive oil.
3. Fresh lemon juice.
4  Rose water.
5. A pinch of turmeric.
This is applied in the dry areas, allow to dry and wash with lukewarm water.

To reduce pigmentation.
1. Make a paste with turmeric powder and cucumber juice or lemon juice.
2. To use as body scrub make a paste with turmeric powder, gram flour, rose water. 

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Hot oil massage for hair fall

Thick beautiful shiny hair is a dream of every women. But hair loss is a cause of  headache to many of them. There are several methods to prevent hair loss. One of the most effective method is hot oil massage. Good massage with essential oils will help you to get thick beautiful hair. It is the first step to prevent hair fall.

How to do hot oil massage?

Hair oil that are effective are the following

Coconut oil - Prevent hair fall, strengthens your hair.

Almond oil - This is a source of vitamin E  which help to reduce hair fall, and promote hair growth and make it shiny.

Olive oil - Destroys the bacteria in the scalp reduce dandruff and promote hair growth.

Wheat germ oil.

Castor oil.

Amla oil.

Jojoba oil.

Mustard oil.

Lavender oil.

If you add a few drops of rosemary to your oil you will get faster and more effective results.

How often it is done?

Do this once or twice a week for better result.

Right way to do oil massage.

You will get maximum benefit if the oil massage is done in specific method.

1. Apply the oil   at least 1 to 2 hour before  washing your hair or for better result  apply the oil  overnight. 

2. Take lukewarm oil in your hand. Oil should not be very hot.

3. It should be applied on your scalp(not on the hair) with tip of your finger.

4. Do not apply over pressure, should be done gently with light pressure.

How does massaging help to prevent hair fall?

1. Massaging increases  the blood flow to the hair follicle, which gives nutrition to hair.

2. Strengthen your hair root.

3. Decrease the stress and gives relaxation.

4. Oil promote hair growth.

5. Oil reduces the damage to hair because of the lubricating effect.

6. Removes dandruff.

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Common causes of foot pain

Foot pain  is a common complaint, it is important because it will interfere with mobility. There are a variety of causes for foot pain. Common  causes are given here.

1. Ankle or foot injury - It is very common after sudden twisting of ankle. This is associated with pain and swelling in the foot. Differentiation between ankle sprain and fracture is difficult.

2. Achilles tendinitis - Achilles tendon is situated in the back of ankle, inflammation may be associated with overuse or spondyloarthropathy.It present as painful swelling of tendon.

3. Rupture of Achilles tendon - There will be sudden pain in the back of ankle joint during activity,Patient walk with a limb.Patient cannot raise the heel from floor.

4. Plantar fasciitis - Present as pain under the foot, it is a common cause of foot pain. Patient experience maximum pain immediately after getting up from the bed. It usually resolves in 6 weeks.

5. Tender heel pad - Present as throbbing sensation in the foot. This is seen a few months after truma to heel.

6. Flat foot - Common in children,this can be painful or painless, treatment is required only if it produce pain.

7. High arched foot.

8. Forefoot pain - Is secondary to fracture, synovitis, or mechanical dysfunction.

9. Toe fracture - Due to fall of heavy weight object on the toe.

10. Arthritis of joints of foot.

11. Ingrowing of toe nail - As a  result of ill fitting shoes and poor nail cutting cause the nail to grow in to toe skin.

12. Hammer toe, clawing of toe or hallus valgus.

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How sports injuries are managed?

Sports injuries are so common nowadays. It may be in the form of injury to muscle, joints, ligaments and bones. Immediate attention is required for early recovery. Principles of  management of sports injuries are given here.

• First aid - Here we assess whether the patient has breathing difficulty,or low blood pressure.
• RICE (Rest,Ice,Compression,Elevation)
  (a) Rest - Relative rest of the injured part with activities to maintain the overall fitness.
  (b) Ice and analgesic - Done immediately after injury,ice is wrapped in a towel use for 10 minutes at a time.
  (c) Compression - Strapping or taping to prevent acute sprain.
  (d) Elevation of affected part  will help to reduce the swelling and edema.
• Detailed examination and x-ray if required.
• Early treatment as per the cause,should not be delayed.
• Rehabilitation -include measures to regain fitness ,strength and flexibility.
• Correction of cause of injury such as poor technique or equipment.
• Team of sports physician,sports physiotherapists and coach  is essential in deciding most appropriate treatment.
• Graded return to activity after discussion with coach.
• Prevention of further injuries,this require suitable preparations and training .That is suitable footwear,safety equipment,warm up exercise.

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Common cold and its complications

Common cold is one of the most common disease in the community. that is caused by virus. It affect any age group and both sex. Affected patients usually present with the following.

1. Headache

2. Running nose

3. Sneezing

4. Sorethroat

5. Heaviness of head

6. Earpain

7. Malaise

8. Tiredness

9. Fever

10. Cough

11. Bodypain

Spread of infection

Spread of infection is through contaminated secretions on the hand, towels, droplets or through air. There is high risk of transmission from one person to other. Practice of good personal hygiene is very important to prevent spread of infection. Affected persons may use nasal mask to prevent spread of infection.

Management

1. Patient should take adequate rest.

2. Plenty of water intake should be advised.

3. Frequent steam inhalation to relieve congestion in nose and throat.

4. Paracetamol(acetaminophen) for symptomatic relief.

5. Antihistamineto reduce congestion.

Symptoms usually resolve in 4 to 10 days

Complication of common cold.

1. Asthmatic and COPD patients  experience exacerbation of symptoms.

2. Pneumonia.

3. Tonsillitis.

4. Sinusitis.

5. Infection and discharge from ear (otitis media)

6. Infection of eye(conjunctivitis) and redness of eye.

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Significance of testing platelet count

What is platelet?

Platelet is a component of blood. When there is bleeding platelet will help to control bleeding. Platelet are produced from bone marrow. Adequate number and normal functioning of platelets are required for control of bleeding. When there is elevation or reduction in platelet count it will lead to various clinical manifestations.

Platelet count

Normal value - 0.15 to 0.4 million.

Platelet count if less than 20000 there is high risk of bleeding.

Low platelet count is called as thrombocytopenia.

High platelet count is called thrombocytosis.

Method of testing

Flow cytometry

Conditions associated with low platelet count 1.Low platelet  count due to decreased  production is seen in 

 Bone marrow suppression by chemotherapeutic agents or drugs ,ethanol

2.Low platelet count due to increased destruction is seen in following sitautions

a.Drugs that decrease platelet count - Clopidogrel, heparin, cephalosporin, quinidine

b.Antibody to platelet - Immune thrombocytopenia (ITP)

c.Infections that reduce platelet count - Dengue fever, viral fever, leptospirosis.

d.Following blood transfusion platelet count may be reducred
e.Cirrhosis and enlarged spleen,
f.DIC (disseminated intravascular coagulation)

Increased platelet count is seen in the following conditions

1. Following bleeding

2. Iron deficiency anemia

3. Chronic inflammatory conditions.

4. Following removal of spleen.

5.Myeloproliferative conditions such as polycythemia,essential thrombocytosis,Chronic myeloid luekemia.

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Why obesity predispose to heart attack?

Obesity is an important risk factor for heart attack, because it contribute a number of other factors that predispose to heart attack. Obesity is measured in terms of BMI or body mass index. That is body weight divided by height squared. There are 3 levels of obesity.

1. Level 1 - More than 30

2. Level 2 - More than 34.9 less than 40

3. Level 3 - More than 40

Morbid  obesity means more than 50% of ideal body weight.

The risk of heart attack attributed to obesity is very high if the body mass index is more than 40.

Obesity is associated with 

1. Increased calories in the diet.

2. High fat intake.

3. High saturated fat intake.

4. Physical inactivity.

Heart attack risk factors that are influenced by obesity are given below.

1. Metabolic syndrome and insulin resistance.

2. Diabetes mellitus.

3. Hypertension.

4. Increased triglycerides.

5. Low HDL cholesterol.

6. Increased fibrinogen.

7. Increased C-reactive protein.

8. Alteration in blood vessel wall function leading to clot formation.

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Smoking cessation for the prevention of heart attack.

Smoking cessation is one of the important step in prevention of heart attack. Smoking  has several effect on the risk factors for heart attack. Smoking increases the heart attack risk 6 fold in women and 3 fold in men. It is the most important modifiable heart attack risk factor and a preventable cause of death due to heart attack.

Adverse effect due to smoking is

1. Dose dependent.

2. More for high tar than low tar cigarettes

Effects of smoking on coronary risk factors are given below.

1. Smoking causes increase in blood pressure

2. It decreases the good cholesterol that is HDL cholesterol. HDL cholesterol will protect from heart attack.

3. Smoking predispose the blood clotting which is the  key factor in  heart attack.

4. Reduce the effective lysis or removal of clot.

5. Increase the fibrinogen and C-reactive protein both of them are risk factors of heart attack.

6. Smoking change the function of wall of blood vessel thus predispose to clot formation.

7. Smoking  causes spasm of blood vessels and thus reduce the blood supply.

8. It causes increase in heart rate.

9. There is increased risk of  recurrent infection of oral cavity and lungs.

Following cessation of smoking, there will be immediate beneficial effect in people of all age groups. Smoking cessation thus help to reduce the heart attack  incidence. But the problem is that smoking cessation is very difficult.

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Skin manifestations of diabetes

In diabetes various skin manifestations are seen. The altered carbohydrate-lipid metabolism, lesions in the small blood vessels and, neural involvement all these may be associated with skin lesions. The common  skin manifestations are given below.

Infection

Most common skin manifestations in diabetes is delayed woud healing and skin ulceration. Chronic bacterial infection of the skin occur, especially in uncontrolled diabetes. There is increased chance of infection with staphylococcus, coliform, and pseudomonal infection.

Candidal infection (fungal) is more common in diabetic patients. It cause redness and edema in the area below breast, between fingers and in axilla. In uncontrolled diabetes candidal vulvovaginitis is commom. It produce pruritus.

Hypertriglyceridemia can produce Eruptive xanthomas if the glycemic control is poor.

Xerosis (dryness of skin ) and pruritus is common in diabetes, and moisturizers are used to relieve them.

Vitiligo (area of hypopigmentation ) is more common in type 1 diabetes.

Acanthosis nigricans (hyperpigmented velvety lesions seen in the neck, axilla, or extensor

surfaces) is a feature of insulin resistance

Specific skin lesions of diabetes

Diabetic dermopathy

Also called as Shin spots or diabetic skin spots They are seen in the legs over the shin and rarely on the thighs and forearms. More common in elderly men with a sex ratio 2:1, start as red area which later becomes circular hyperpigmented lesion. This  lesions is due to  minor mechanical trauma in the shin region

Granuloma annulare

They are circular raised lesion seen in the hands and feet. Other areas affected are elbow  knee and ankle. They start as raised area later fuse to form the circular lesion may be single or multiple. More common in women below 30 yrs. It may be associated with insulin dependent diabetes mellitus. This is a self limiting condition that clears over 2-3 yrs.

Necrobiosis lipoidica diabeticorum

An unusual lesion over the legs or ankle. Shin region is the most common site. It is an oval or irregular plaque with distinct bordes and glistening yellow surface. More common in women. These lesions rarely resolve.

Necrobiosis lipoidica diabeticorum

Diabetic bullae (bullosis diabeticorum seen  in longstanding diabetes  with diabetic neuropathy. They have rapid  origin seen in the toes, foot, and fingers. The blisters are tense, and the content may be serous and sometimes haemorrhagic fluid.

Lipoatrophy and lipohypertrophy may be seen at insulin injection sites but  now a days incidence is low with the use of human insulin. 

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Management of fibromyalgia

Fibromyalgia is a chronic pain syndrome. Patients have neuropsychiatric manifestation such as fatigue, depression, anxiety, sleep disturbances, apart from widespread pain. Basic abnormality is, altered pain processing in the brain

Laboratory investigations required in fibromyalgia are the following

1. Routine test.

2. Full blood count is done to  look for Anaemia and lymphopenia of SLE.

3. Erythrocyte sedimentation rate(ESR), C-reactive protein  elevated in Inflammatory disease.

4. Thyroid function to rule out Hypothyroidism.

5. Calcium, alkaline phosphatase  to search for Hyperparathyroidism, osteomalacia

Following investigations are done based on clinical history and physical examination

Antinuclear antibodies -SLE

Anti-SSA (anti-Sjögren’s syndrome A) and anti-SSB

Rheumatoid factor and anticyclic citrullinated peptide (anti-CCP)

Creatine phosphokinase (CPK)

Viral and bacterial serologies

Spine and joint radiographs

In about 20% of cases associated rheumatologic disorders such a systemic lupus erythematosus, sjogrens syndrome, rheumatoid arthritis may be seen. Decreased serum calcium, low thyroid hormone, raised parathyroid hormone, infectious and inflammatory process all produce widespread musculoskeletal pain. Laboratory investigations will help to rule out the above mentioned conditions. Laboratory test are done after detailed clinical history and physical examination.

Treatment

The aims of treatment  are

1. To educate the patient about the disease,

2. Adequate  pain control

3. Improve sleep.

4. Improve the quality of life

As fibromyalgia adversely affect the quality of life treatment has to be planed according to individual patient. Both pharmacological and non pharmacological treatment are used to improve the outcome.

Behavioral therapy

Patients should be educated about the expectation for treatment. Excessive anxiety should be relieved. Illness behavior should be discouraged and behavior that improve the outcome should be encouraged. It is also aimed at maintaining normal sleep.

Exercise

One of the treatment strategy is physical conditioning. Aerobic exercise is started at low levels and consistently advanced. Relaxation with yoga or and Tai Chi may be helpful. Exercise programs are useful to reduce the pain and to improve the self eficasy.

Pharmacologic approaches

It is important to treat the triggers such as inflammation Steroids, and NSAIDS  may be useful for that. These are not effective in managing fibromyalgia symptoms.

Pharmacologic Agents Effective for treatment of Fibromyalgia

Antidepressants: (balanced serotonin:norepinephrine reuptake inhibition)

Amitryptiline

Duloxetine *

Milnacipran *

Anticonvulsants

Gabapentin

Pregabalina

*Approved for fibromyalgia by the U.S. Food and Drug Administration.

Utilisation of single drug to treat multiple symptom domain is strongly recommended

Example 1. If pain and sleep disturbances are the prominent symptoms. Agent that reduce pain and promote sleep is advised such as sedating antidepressants such as amitriptyline, gabapentin and pregabalin

Example 2. Pain with fatigue, anxiety, or depression. Agents that have both analgesic and antidepressant/anxiolytic effects, such as duloxetine or milnacipran, are  the best choice.

Drugs that should be avoided

Opioid analgesics should be avoided in fibromyalgia,because opoid induced hyperalgesia(increased pain )will worsen the symptoms.

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Inhaler in the treatment of bronchial asthma.

Inhaler is the best way to prevent recurrent attack of asthma and to terminate the acute asthma attack. Inhaler deliver the precise amount of drug into the lung. The striking advantage of inhaler is that the maximum effect of drug is achieved by avoiding its side effects. Effect of drug is fully obtained, at the same time it is safe. It has rapid onset of action, acts within 1 minute.

Types of inhalers

They are mainly of 3 types

1. Spray or metered dose inhaler.

Medicine is delivered to lung in the sprayform. It is very effective and correct amount of drug is delivered even at single use hence called as metered dose inhaler.

2. Powder inhaler.

Drug is delivered in powder form.

3. Nebulizer 

They are used to terminate an acute severe asthmatic attack rapidly. Nebulizer can deliver large amount of drug  rapidly to the lung.

Drugs used in inhaler

They are of two types

1. Drugs that prevent asthma.

These drugs reduce the oedema in the airways and helps to open them, thus reduces recurrent attack of asthma. These drugs should be used for prolonged periods. These are steroid group of drugs.

Beclomethasone.

Budesonide.

Fluticasone.

2. Drugs that treat an acute attack of asthma.

They reduce oedema in the airways and rapidly open them thus terminate the acute attack, but they cannot prevent recurrent attack. Example include salbutamol group of drugs.

Tablets that contain both the above type of drugs are available they should be taken after doctors advice. Inhaler with baby masks are available for use in children.

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Clinical features of depression

Depression is a common clinical problem. Many of us at sometime or other experience sadness, fed up or down in dumps. It is called as depressive illness when such symptoms become qualitatively different and interfere with normal functioning. It can vary in severity may be mild, moderate or severe. Symptoms can be transient or persistent. Patients usually experience disturbance of mood , speech, energy and ideas. Some patients describe symptoms in physical terms. Two most common physical symptoms are fatigue and headache. If symptoms  are severe patients require hospitalization.

Many patients describe the world looking grey and they are devoid of pleasure and interest in life (anhedonia). Anxiety and phobic disorders are common in these patients. Symptoms usually last for at least 2 weeks. In severe forms of the disease diurnal variation in mood can be seen. Such people feel worse in the morning after awaking. One of the major risk is suicide, risk is 5%in out patients and 15% in those whose symptoms are severe enough to require hospital admission.

The following changes are noted in depression.

Mood - May be depressed, miserable or irritable.

Talk - Slow, monotonous.

Energy - Low energy and lethargic.

Ideas - Feeling of futility, guilt, self unworthiness, hypochondriacal preoccupation, worrying, suicidal thoughts, delusions of guilt and persecution.

Cognition - There can be impaired learning and pseudodementia in elderly patients .

Behavior - Retardation or agitation ,poverty of movements and expression.

Hallucination - Auditory ,often hostile and critical

Physical - Early waking, poor appetite ,constipation, loss of libido, erectile dysfunction, fatigue, bodily aches and pains.

Other psychiatric disorder associated with depression

1. Misuse of alcohol

2. Amphetamine and derivatives misuse and withdrawal

3. Dementia

4. Delerium

5. Schizophrenia

Other medical illness associated with depression

1. Cushing syndrome

2. Thyroid disorders

3. Increased parathyroid hormone

4. Steroid treatment

5. Brain tumours

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Lithium toxicity neurologic manifestations - mood stabilizing drug

Lithium is a mood stabilizing drug. It is used as a prophylaxis in bipolar disease. Thus it will help to reduce the suicidal tendency. Lithium is rapidly absorbed from the gastro intestinal tract, 95% is excreted through kidney. Small amounts are seen in sweat, saliva and breast milk. Clearance of lithium decrease in renal failure.

Lithium intoxication

No magic serum concentration below which intoxication never occurs or above which it is inevitable.

Severe toxicity is described in patients with serum concentration within the therapeutic range of 0.5 - 1.5 meq/l

Factors leading to lithium toxicity

1. Accidental ingestion in children

2. Mistakes on the quantities of ingested tablets

3. Elevation of lithium blood level due to diuretic therapy

4. Dehydration

5. Renal impairment

6. Thyroid dysfunction

7. Intoxication in manic patients following chaotic self-administration of lithium

Early manifestations include 

1. Dysarthria(difficuty in speech)

2. Ataxia (difficulty in walking and swaying)

3. Coarse tremor

SILENT - The syndrome of irreversible lithium-effectuated neurotoxicity.

The typical profile of silent neurotoxicity is - persisting cerebellar dysfunction which is manifested as ataxia. Monitoring of treatment and early detection are measures to decrease the incidence of this potentially serious condition. No definitive treatment is available

Ominous findings include

1. Fasciculations(Abnormal twitching in the body)

2. Myoclonus (sudden shock  like jerky movements)

3. Convulsions

4. Coma.

       

Lithium-induced confusional states : non convulsive status epilepticus, encephalopathy.

Lithium therapy can cause a confusion state by direct toxicity, precipitation of nonconvulsive status epilepticus, or by interplay with other neuroleptic medications to produce neuroleptic malignant syndrome or serotonin syndrome. These conditions resemble each other clinically, but EEG may help differentiate among them. Dural sinus thrombosis with severe hypernatremia may develop in a patient on long-term lithium therapy

Lithium toxicity-is a risk factor for neuroleptic malignant syndrome.

Lithium may cause NMS independent of other neuroleptic agents.
Feaures of NMS are the following
 High fever
 Tachypnea (increased respiratory rate)
 Muscle rigidity
 Rhabdomyolysis
 Acute renal insufficiency
 Mental confusion
 Obtundation
 High creatine kinase level
 Abnormal renal function tests 

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Look at your belly and assess the health risk

Abdominal (belly) obesity is a very common problem in males and females. Main cause of it is intake of fatty and sweet foods and lack of exercise. After 30 years abdominal obesity is very common in men. Obese person with increased abdominal circumference has high risk for disease than an obese person without increased abdominal circumference. It is not only the weight but also where it is concentrated is also important in assessment of disease risk.

Why it is important?

Abdominal obesity is considered to be one of the early indicator of heart attack and diabetes mellitus in the future.

How will you measure abdominal circumference?

Take a tape ,hold it at the level of umbilicus,then take the measurement circumferentially.

Abdominal circumference in males 

Below 94 cm -Healthy

94 to102 cm - Moderate risk

More than 102 cm - High risk

Abdominal circumference in females

Below 80 cm - Healthy

80 to 88 cm - Moderate risk

More than 88 cm  -High risk. 

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Glow like sun with Galvanic spa - remove wrinkles,reduce ageing

Everybody like radiant glowing and fresh skin, which improve your confidence and give you an attractive personality. Spa beauty treatment will give your skin good glow and freshness. As age advances your skin start showing signs of aging, which can be treated with galvanic spa. Galvanic spa is the newest wonderful one in the spa beauty treatment and is done with galvanic machine. This article is aimed to give you information about  advantages ,method and precautions after galvanic spa.

Why Galvanic spa?

Following are the benefits of galvanic spa facial.

1. It improves skin complexion gives glow to your skin and make it baby soft.

2. Removes the wrinkles, tightens the skin and reduce the signs of ageing.

3. Removes impurities from skin thus cleanses exfoliates skin .

3. This fades away scars and wrinkles.

4. Massaging help to regain the muscle tone , improve the blood circulation nourishes the skin  and make the skin firm and tight. 

5. Can be done on any  part of the body face,hands and legs or bull body spa.

6. Its antibacterial cleansing action fights with acne and blemishes. 

7. Lightens dark under eye circles

8. It has anti-inflammatory action and helps in skin repair.

How it is done?

This  beauty treatment is done after assessing the skin type with skin tester.
.First, with cleanser skin is cleaned, for dry skin creamy cleanser is used. Apply galvanic gel to desired body part. With flat surface of galvanic machine massaging is given to skin for 5 minutes.

Galvanic gel 

The key ingredients in galvanic gel include:

1. Magnesium improve cellular energy

2. Arginine helps the recovery from daily stress

3. Aspartate balances pH of your skin

4. Vitamin E is an antioxidant which moisturizes skin.

Next step is to give cool compression to skin. While doing galvanic spa there is increased blood circulation which may appear as redness in face. Cool compression will prevent it. This is done with a cold mask, then galvanic pack is applied. Clean the face after 20 minutes and apply moisturizer. Usually one or two sitting in 15 days is required.

Precautions after galvanic spa

1. Reduce the sun exposure after galvanic spa, if going out use sun protection cream.

2. If exposed to sunlight after one hour of spa clean the face and use sun protection cream.

3. Avoid soap for 2 days after galvanic spa.

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