News and Views (Dr G M Singh)
Management of the patient with statin intolerance
Strategies for managing statin intolerance include changing statins, intermittent dosing, intensification of lifestyle modifications, and using other LDL–C–lowering agents such as ezetimibe, bile acid sequestrants, and LDL apheresis in suitable patients. More controversial approaches include red yeast rice, coenzyme Q10, and vitamin D supplementation. New therapies to lower LDL–C are in development.
Phototherapy for chronic musculoskeletal pain
Prolotherapy is an injection–based complementary and alternative medical therapy for chronic musculoskeletal pain. Prolotherapy techniques and injected solutions vary by condition, clinical severity, and practitioner preferences; over several treatment sessions, a fairly small volume of an irritant or sclerosing solution is injected at sites on painful ligament and tendon insertions and in adjacent joint space during several treatment sessions. Prolotherapy is becoming increasingly popular in the United States and internationally and is actively used in clinical practice. Prolotherapy has been assessed as a treatment for various painful chronic musculoskeletal conditions that are refractory to ‘standard of care’ therapies. Although anecdotal clinical success guides the use of prolotherapy for many conditions, clinical trial literature supporting evidence–based decision–making for the use of prolotherapy exists for low back pain, several tendinopathies, and osteoarthritis.
Conference on Retroviruses and Opportunistic Infections (as reported by medpage)
Antiretroviral treatment is highly effective at reducing risk of HIV transmission to uninfected partners, prospective data has affirmed. The 92% reduction in risk of transmission dropped the incidence of in–couple transmission from 2.23% to 0.39%, according to Deborah Donnell, PhD, of the Fred Hutchinson Cancer Research Center in Seattle.
Four years of clinical data indicate that patients infected with human immunodeficiency virus and treated with the integrase inhibitor raltegravir fare as well as patients treated with efavirenz. There is no difference between these patients in efficacy after 192 weeks, but the side effects on lipids favor raltegravir, said Eduardo Gotuzzo, MD, director of infectious diseases, Hospital Nacionale Cayetano Heredia, Lima, Peru.
HIV-positive people can markedly reduce their risk of heart attack and forms of cardiovascular disease if they stop smoking. In a large international cohort study, HIV patients who smoked had a significantly elevated risk of cardiac events, according to Kathy Petoumenos, University of New South Wales Sydney, Australia.
Women may be highly vulnerable to HIV during pregnancy, suggesting the need for repeat testing during perinatal care in high prevalence areas. Two studies in sub-Saharan Africa showed that 2.6-4.4% of women who were HIV–negative during prenatal care tested positive at or within weeks after delivery.
Once–daily dosing of the protease inhibitor darunavir appeared to be at least as effective as twice–a–day regimens among treatment–experienced patients with no darunavir-associated resistance mutations. (Dr Pedro Cahn, Medical Director, Fundación Huesped, Buenos Aires.)
For people with both HIV and Hepatitis C, a poor response to hepatitis therapy markedly increased the risk of HIV progression and death. Previous research had shown that such patients were at increased risk of liver–related complications and death, according to Dr Juan Berenguer, Gregorio Marañon University Hospital in Madrid.
Among injection drug users, the type of needle used and the temperature it’s stored at can substantially affect the risk of transmitting hepatitis C virus. Syringes with detachable needles appeared by far to be the most likely to transmit the virus, Dr Elijah Paintsil, of Yale, and colleagues showed in a laboratory study.
HIVV infection did not make the H1N1 pandemic flu more dangerous, and catching the pandemic flu did not worsen the progression of HIV, according to Dr Esteban Martinez, Hospital Clinic, Barcelona.
People with HIV are at increased risk from fragility fractures in the hip or backbone. In a large cohort of more than 119,000 veterans, HIV was associated with a 38% increase in the risk of such fractures, even after adjustment for other risk factors, according to Julie Womack, PhD, VA Connecticut Healthcare System, West Haven, Conn.
A potent capsaicin patch, recently approved to ease neuropathic pain from shingles, burned hopes for similar efficacy in HIV–associated distal sensory polyneuropathy.The patch reduced pain scores by 29.5% to 32.8% in affected HIV patients, Dr David Clifford,of Washington University in St. Louis, Mo., and colleagues found in a nearly 500–patient clinical trial.
Prostate CA prevention affirmed for BPH drug
For men with benign prostatic hyperplasia (BPH), dutasteride both prevents prostate cancer and boosts the predictive power of prostate specific antigen. The drug was associated with 40% lower incidence of prostate cancer diagnosis than the BPH drug tamsulosin in at–risk men, according Dr Leonard G. Gomella, of the Kimmel Cancer Center at Thomas Jefferson University in Philadelphia. There was less frequent biopsy in the dutasteride group. Also, the number of cancers confirmed when biopsy was performed –– largely driven by rising PSA –– tended to be higher on dutasteride. Being on dutasteride or another 5–alpha reductase inhibitor appears to transform PSA into a highly specific tool.
PSA threshhold > 20 ng/ml
Most commonly–used methods to determine when to start prostate cancer treatment for men on watchful waiting have a high ‘false trigger' rate. Only the PSA threshold of 20 ng/mL had a low false trigger rate of 14% among men who didn’t need treatment, Dr D. Andrew Loblaw, a radiation oncologist at the Sunnybrook Health Sciences Centre at the University of Toronto, reported at the Genitourinary Cancers Symposium. PSA doubling time and PSA velocity would have triggered treatment for 39% to 84% of the same cohort of men
Basic Life Support (BLS) Provider Course (Target Audience – All Healthcare Personnel & General Public). Date: March 25, 2010 . Venue: V Block, No: 70 (Old No: 89) Fifth Avenue Anna Nagar, Chennai, Tamil Nadu.
Psychiatry: weight gain
A systematic review of second–generation antidepressants found that mirtazapine and paroxetine were associated with more weight gain than fluoxetine, sertraline, trazodone, and venlafaxine.
Quote of the Day
I believe in prayer. It’s the best way we have to draw strength from heaven. (Josephine Baker)
Amylin effect: Insulin reduces sugar and glucagon increases sugar. Food leads to secretion of amylin, which reduces glucagon and gastric emptying effect. Pramlinitide (amylin analog) reduces glucagon levels. Newer drug. Inj. form
Public Forum (Press Release)
Diabetic or hypertensive: get your albumin tested
Microalbuminuria or presence of albumin in the urine in micro amounts indicates an early kidney damage, early vascular endothelial dysfunction and/or earely atherosclerosis with risk of major cardio or cerebrovascular events and death.
Current guidelines advocate annual screening in patients with diabetes and wherever possible also in non–diabetic patients with hypertension, said Dr. K K Aggarwal, President, Heart Care Foundation of India and Editor eMedinewS.
Early detection of high–risk patients allows selection of aggressive treatment to slow progression of disease.
Antihypertensive agents that provide angiotensin II blockade are recommended for the treatment of hypertensive patients with microalbuminuria, regardless of diabetes and/or early or overt nephropathy. Treatment with these drugs provides effective reduction of microalbuminuria and blood pressure, and long–term prevention of cardiovascular events beyond blood pressure reduction.
Even very low levels of microalbuminuria strongly correlate with cardiovascular risk. Albumin excretion rates as low as 4.8 µg/min, well below the microalbuminuria thresholds are associated with increased risk of cardiovascular and cerebrovascular disease, independent of the presence of other risk factors.
Question of the day
How do you manage a case of multiple disseminated intra–abdominal hydatidosis with spontaneous intrabiliary rupture?
Echinococcal infection constitutes most of the cystic lesions of liver and only 5–10% are distributed along the peripheral arterial system. The most common complication of hydatid cyst is spontaneous rupture into the biliary tract. Hydatid disease (liquid tumor) is a zoonosis caused by larval or cyst stage of Echinococcus granulosus and humans act as accidental and abortive intermediate hosts. Hydatid cysts occur at all ages, in both sexes and anywhere in the body. In unilocular variety, cysts are usually superficial, grow slowly by expansion and internal pressure of cyst may reach upto 300–900 mm of water. Daughter and even grand daughter cysts develop by restructuring and fragmentation of the germinal layer. Intraperitoneal rupture results in explosive showering of viable reproductive elements, which initiates secondary echinococcosis of the peritoneum. Splenic localization is usually due to retrograde invasion via valveless hepatoportal circulation during bouts of increased intra–abdominal pressure.
Endoscopic sphincterotomy, including removal of daughter cysts and hydatid debris (for rupture cyst in CBD) and PAIR technique (for non–communicating hydatid cysts) with antihelminthic chemoprophylaxis is the mainstay of treatment. During the follow–up period, ultrasonography and laboratory investigations are mandatory to assess effective and complete response to treatment. Ultrasonography and CT are complementary tools for diagnosis of hepatic echinococcosis, with endoscopic retrograde cholangiography being the "gold standard" in confirming rupture into the biliary system. Laboratory results are usually nonspecific. Anti–helminthic treatment,should be continued for 1 year. The traditional treatment of biliary cystic fistula is surgery and recently endoscopic sphincterotomy.
Suggested reading z
McGreevy PB and Nelson GS. Larval cestode infections. In: Hunter’s Tropical Medicine Strickland GT (Ed.), WB Saunders, Toronto, Canada 1984:771.
Zargar SA, Khuroo MS, Khan BA, et al. Intrabiliary rupture of hepatic hydatid cyst: Sonographic and cholangiographic appearances. Gastrointest Radiol 1922;17(1):41–5.
Akkis H, Akinoglu A, Colakoglu S, et al. Endoscopic management of biliary hydatid disease. Can J Surg 1996;39(4):287–92.
Filice C, Brunetti E. Use of PAIR in human cystic echinococcosis. Acta Tropica1997;64:95–107.
eMedinewS Try this it Works
Home made saline nasal spray
Saline solution sprayed into the nose removes irritants, allergens, and excessive mucus. Patients can avoid the expense of repeatedly purchasing saline solution by putting homemade solution into an empty commercial spray bottle. The solution is made by mixing 1/2 tsp of table salt with 8 oz of warm water.
Dr Good Dr Bad
Situation: An elderly female diabetic on pioglitazone developed fractures
Dr Bad: Its not related.
Dr Good: It may be due to pioglitazone.
Lesson: Patients with diabetes using thiazolidinediones, regardless of type, had higher proportions of distal upper and lower limb fractures compared with those not using thiazolidinediones. Fracture proportions do not differ by thiazolidinedione type. Fracture proportions are higher among women and increased with age. (Source: Am J Manag Care 2009;15(8):491-6.)
A 28–year–old male presents with increased frequency and occasional blood in urine. Examination of urine shows sterile pyuria.
Oh my God! Why didn’t you check for TB?
Make Sure to rule out TB in patients with frequency, dysuria, haematuria. Sterile pyuria is the first clue to diagnosis.
Medi Finance Indirect Tax; Budget 2010
Boost to SME Sector, and Infrastructure Sector with special emphasis on Road Infrastructure
Scope of cases which may be admitted by the Settlement Commission expanded to include proceedings related to search and seizure cases pending for assessment. Scope of Settlement Commission also expanded in respect of Central Excise and Customs to include certain categories of cases that hitherto fell outside its jurisdiction.