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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