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.

Read More

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.

Read More

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.

Read More

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. 

Read More

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.

Read More

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.

Read More