Vol. 11, No. 11, November 2011
ISSN 0971-880X
Single Copy Rs. 100/-
Pages 12
Dr KK Aggarwal Gr. Editor-in-Chief, IJCP Group
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Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http//twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)
Member The Indian Newspaper Society
Official Voice of Doctors of India
Biggest Ever Study Shows no Link between Mobile Phone Use and Tumors: Is the Study Applicable to India? There is no link between long-term use of mobiles and brain tumors finds new research published online in the British Medical Journal. In this largest study on the subject to date, Danish researchers found no evidence that the risk of brain tumors was raised among 3,58,403 mobile phone subscribers over an 18-year period. The International Agency for Research on Cancer recently classified radio frequency electromagnetic fields, as emitted by mobile phones, as possibly carcinogenic to humans.
The only cohort study investigating mobile phone use and cancer to date is a Danish nationwide study comparing cancer risk of all 4,20,095 Danish mobile phone subscribers from 1982 until 1995, with the corresponding risk in the rest of the adult population with follow-up to 1996 and then 2002. This study found no evidence of any increased risk of brain or nervous system tumors or any cancer among mobile phone subscribers. The researchers, led by the Institute of Cancer Epidemiology in Copenhagen, continued this study upto 2007. Overall, 10,729 central nervous system tumors occurred in the study period 1990-2007. When the figures were restricted to people with the longest mobile phone use - 13 years or more - cancer rates were almost the same in both long-term users and nonsubscribers of mobile phones. In my view the implications would be different in India as passive mobile radiation rate is very high. The study also did not take into account the number of hours of usage per day and the same would be much higher in Indians. Most people are studying the effect of mobiles on brain cancer but what about all types of cancers. We are seeing a substantial increase in the number and types of cancers in India. Apart from mobile radiations, one must also study the additional effects of microwave radiations, X-ray radiations, active and passive smoking, etc. to explain the high occurrence of cancers.
Thomas A Edison
FDA Approves Device for Nonsurgical Aortic Valve Repair The FDA approved the Sapien Transcatheter Heart Valve for treatment of patients too sick to undergo open-heart surgery to repair calcified aortic valves. The Sapien valve, from Edwards Lifesciences, is a replacement valve that doesn’t require major surgery. The Sapien valve is approved for patients who are not eligible for open-heart surgery for replacement of their aortic valve and have a calcified aortic annulus. The product label advises that a heart surgeon should be involved in determining if the Sapien valve is an appropriate treatment for the patient. It is not approved for patients who can be treated by open-heart surgery. (Source: Medpage Today)
Make Sure
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During Medical Practice A patient of jaundice with fever developed complications. Oh my God! Why were other causes of jaundice not suspected?
©IJCP Academy
“The three great essentials to achieve anything worth while are, first, hard work; second, stick-to-itiveness; third, common sense.”
Make sure that in a patient with jaundice and fever, causes other than viral hepatitis are looked into. In viral hepatitis, jaundice appears after the fever subsides. KK Aggarwal
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Case Report
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News & Views
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Fitness Update
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Photo Quiz
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Legal Column
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Expert’s Opinion
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Research Review
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Case Report A Rare Case of Chorangiosis of Placenta: An Important Placental Sign of Neonatal Morbidity and Mortality Sandhya Mittal, Anupama Goel, Krishna Bal Taneja, Meenu Puri
Abstract Chorangiosis is a placental vascular lesion diagnosed histologically; involving terminal villi and is associated with a number of fetomaternal and placental conditions. It is a rare but ominous condition resulting in higher incidence of perinatal morbidity and mortality though the ultimate mechanism by which chorangiosis is involved in adverse perinatal outcomes is unknown. We report a case with this unusual condition in association with major congenital malformations and perinatal mortality; thus re-emphasizing the need of complete placental examination including histopathological examination in all cases of perinatal mortality.
Introduction Pathological examination of placenta is probably the most underutilized pathologic assessment of any human tissue. The placenta provides a wealth of information retrospectively about the fetus and prospectively regarding the infant; often gives useful insight for the diagnosis and treatment of sick newborns and reflects the impact of maternal disorders on pregnancy. The normal chorionic villi should not contain more than five vascular channels even when the same vessel is present in more than one plane of section. Chorangiosis is a placental change characterized by hypervascular terminal chorionic villi without stromal hypercellularity.1 It is an important sign of placental malperfusion and long-standing fetal hypoxia. The reported associated perinatal mortality and major congenital malformation have been as high as 42% and 39%, respectively.2 We report an unusual case of chorangiosis of placenta associated with major congenital malformations in fetus and its bearing on the subsequent pregnancy.
Case Report A 26-year-old G2P1L0 presented in the OPD at 29 weeks of gestation for antenatal check-up. She had a previous history of stillbirth delivered at home. Her general condition was good, vitals were stable, obstetric examination was normal for gestational age. Routine investigations were within normal limits. However, obstetric USG showed single, live intrauterine pregnancy of 27 weeks of gestation with bilateral renal agenesis and oligohydramnios. Placenta was fundoanterior with Grade II maturity. Fetal Echo showed findings suggestive of Tetralogy of Fallot. Guarded fetal prognosis was explained to the patient and pregnancy was continued. She had a full-term vaginal delivery; however, the baby was congenitally malformed and died within few hours of birth. Placenta was grossly unremarkable and weighed 640 g. Bystanders refused to give consent for autopsy; however, placenta was sent for histopathological examination which revealed chorangiosis of placenta. She conceived spontaneously after six months and underwent regular antenatal check-up. Her antenatal period was uneventful and she was taken-up for elective cesarean section at 37 weeks of gestation and delivered a healthy baby weighing 3.4 kg with an Apgar
score 8 and 9 at 1 and 5 minutes, respectively. Histopathology of placenta revealed no abnormality. Postnatal period was uneventful.
Discussion The placenta is the largest organ of fetal origin and pivotal for not only the proper fetal development but also both maternal and fetal functions. Therefore, histological examination of the placenta provides useful information in cases of poor obstetric outcome. Three benign, inter-related vascular lesions have been identified in the placenta: Chorangiosis, chorangiomatosis and chorangioma. Gestational age distribution is different for these vascular lesions with chorangioma and chorangiomatosis usually occurring before 32 weeks of gestation and chorangiosis more commonly seen after 37 weeks of gestation. Pathogenesis of these vascular lesions is unclear and the histological features especially those of chorangiosis and chorangiomatosis frequently overlap. Placental chorangiosis is a vascular hyperplasia in the terminal chorionic villi, diagnosed histologically using the criteria described by Altshuler in 1984 as the presence of a minimum of 10 villi, each with ≥10 vascular channels in ≥10 areas of ≥3 random noninfarcted placental areas when using 10 times magnification.2 Chorangiosis has been reported in 5-7% of placenta from infants who required admission to a newborn intensive care unit but the clinical importance of this pathological finding has not been studied extensively.3 The true etiology is unknown but it has been proposed to result from hypoxia-related angiogenesis due to various maternal, fetal and placental disorders.1-4 The incidence of chorangiosis is higher in women living in high altitudes and thus a hypoxic stimulus may well lead to an extensive villous capillary and to connective tissue proliferative activity. The associated maternal conditions include pre-eclampsia, eclampsia, diabetes mellitus, drug ingestion, urinary tract infection, severe anemia and syphilis. Placental conditions associated with chorangiosis include umbilical cord anomalies, single umbilical artery, abruption placenta, placenta previa, amnion nodosum and villitis (rubella virus, cytomegalovirus, syphilis and bartonella species are known (Cont’d on page 4...)
News & Views Risk Factors for Progression of Glaucoma Confirmed
Lupron Label Updated with Added Puberty Data
Patients with glaucoma and elevated intraocular pressure (IOP) and splinter-type disc hemorrhage are more apt to experience progressive worsening of their condition. The confirmation of these risk factors could be valuable in designing interventions to help reduce progression of glaucoma in these patients, Spanish researchers announced at the American Academy for Ophthalmology (AAO) 2011 Annual Meeting. (Source: Medscape Medical News)
The FDA has approved an updated label - including 18 years of data - for a drug that delays the onset of early puberty. The Abbott drug, leuprolide acetate for depot suspension (Lupron Depot-PED), is already approved to treat central precocious puberty (CPP), a condition which causes children to enter puberty too soon (in girls, before the age of eight and in boys, before the age of 9). CPP results in early breast development in females and early genital development in both females and males, and can lead to diminished adult height. (Source: Medpage Today)
An Egg a Day Raises Risk of Diabetes People who eat eggs every day may substantially increase their risk of type 2 diabetes. Men with the highest level of egg consumption - at seven or more per week - were 58% more likely to develop type 2 diabetes than those who did not eat eggs, and women were 77% more likely to become diabetic if they ate at least an egg a day, Luc DjoussĂŠ, M.D., D.Sc., of Brigham and Womenâ&#x20AC;&#x2122;s Hospital and Harvard, and colleagues reported online in Diabetes Care. Levels of egg intake above one a week also incrementally increased diabetes risk in both men and women (both p<0.0001 for trend), the researchers said. (Source: Medpage Today) (...Contâ&#x20AC;&#x2122;d from page 3)
to infect and induce proliferation of endothelial cells). An abnormal placenta could decompensate acutely leading to a catastrophic outcome.5 The fetal factors commonly associated with chorangiosis are the presence of major congenital anomalies, intrauterine growth retardation, intrauterine death and Apgar <5 at birth. The rate of recurrence of this lesion and its effect on the future pregnancies is unknown. In the above case, chorangiosis of placenta is associated with major congenital malformation and adverse perinatal outcome but without any effect on the future pregnancy. Thus, we conclude that though the clinical significance of this pathological finding has not been reported extensively, it should be considered as a placental sign of potential clinical significance and should be mentioned in the pathology report of the patient.
References 1. 2. 3.
4.
5.
De La Ossa MM. Cahello-Inchausti B, Robinson MJ. Placental chorangiosis. Arch Path Lab Med 2001;125(4):1258-8. Altshuler G. Chorangiosis: an important placental sign of neonatal morbidity and mortality. Arch Path Lab Med 1984;108:71-4. Ogino S, Redline RW. Villous capillary lesions of the placenta: distinction between chorangioma, chorangiomatosis and chorangiosis. Hum Path 2000;31:945-54. Gupta R, Nigam S, Arora P, et al. Clinicopathological profile of twelve cases of chorangiosis. Arch Gynaecol Obstet 2006; 274:50-3. Benirschke K, Franciosi R. Placental pathology casebook. J Perinatol 1999;19:393-4.
Alcohol Link to Breast Cancer Reaffirmed Breast cancer risk increased modestly but significantly in women who reported a history of moderate alcohol consumption, investigators reported, confirming results of previous studies. Women who averaged 3-6 drinks a week had a 15% higher risk of invasive breast cancer compared with nondrinkers. The excess risk increased to 50% in women who averaged more than 30 drinks a week. (Source: Medpage Today)
FDA Update Generic Version of Zyprexa The FDA has approved a generic version of atypical antipsychotic drug olanzapine (Zyprexa) to treat schizophrenia and bipolar disorder. The approval paves the way for more people with the mental illnesses to receive treatment with the drug. For many, brand-name olanzapine, which costs upwards of several hundred dollars per month, is too expensive. (Source: Medpage Today)
Xarelto for Stroke Prevention The FDA has approved rivaroxaban (Xarelto) for prevention of stroke in patients with nonvalvular atrial fibrillation, making it the first oral direct factor Xa inhibitor win an indication for stroke prevention. The drug had already been approved for prevention of deep vein thrombosis in patients undergoing joint replacement surgery at a dose of 10 mg once a day. (Source: Medpage Today)
Ezetimibe-simvastatin Combination Pill Okay for Some Kidney Disease Patients An FDA advisory committee has recommended that the ezetimibe-simvastatin combination pill be approved for prevention of cardiovascular disease in chronic kidney disease patients who are not on dialysis. (Source: Medpage Today)
Fitness Update 12 Indian Foods that Cut Fat You donâ&#x20AC;&#x2122;t have to acquire a taste for olive oil, seaweed or soya to maintain a low-fat, healthy diet. Indian cuisine can be healthy too, if itâ&#x20AC;&#x2122;s cooked with oil and ingredients that take care of your heart and health. Ayurveda suggests you include all tastes - sweet, sour, salty, pungent, bitter and astringent in at least one meal each day, to help balance unnatural cravings.
Turmeric
Moong Dal
Curcumin, the active component of turmeric, is an object of research owing to its properties that suggest it may help to turn off certain genes that cause scarring and enlargement of the heart. Regular intake may help reduce low-density lipoprotein (LDL) or bad cholesterol and high blood pressure, increase blood circulation and prevent blood clotting, helping to prevent heart attack.
Bean sprouts are rich in vitamin A, B, C and E and many minerals, such as calcium, iron and potassium. It is recommended as a food replacement in many slimming programs, as it has a very low-fat content. It is a rich source of protein and fiber, which helps lower blood cholesterol level. The high fiber content yields complex carbohydrates, which aid digestion, are effective in stabilizing blood sugar and prevent its rapid rise after meal consumption.
An effective fat-burning food, garlic contains the sulfur compound allicin, which has anti-bacterial effects and helps reduce cholesterol and unhealthy fats.
Cardamom This is a thermogenic herb that increases metabolism and helps burn body fat. Cardamom is considered one of the best digestive aids and is believed to soothe the digestive system and help the body process other foods more efficiently.
Chillies Foods containing chillies are said to be foods that burn fat. Chillies contain capsaicin that helps in increasing the metabolism. Capsaicin is a thermogenic food, so it causes the body to burn calories for 20 minutes after you eat the chillies.
Curry Leaves Incorporating curry leaves into your daily diet can help you lose weight. These leaves flush out fat and toxins, reducing fat deposits that are stored in the body, as well as reducing bad cholesterol levels. If you are overweight, incorporate eight to 10 curry leaves into your diet daily. Chop them finely and mix them into a drink, or sprinkle them over a meal.
Honey It is a home remedy for obesity. It mobilizes the extra-fat deposits in the body allowing it to be utilized as energy for normal functions. One should start with about 10 g or a tablespoon, taken with hot water early in the morning.
Buttermilk It is the somewhat sour, residual fluid that is left after butter is churned. The probiotic food contains just 2.2 grams of fat and about 99 calories, as compared to whole milk that contains 8.9 g fat and 157 calories. Regular intake provides the body with all essential nutrients and does not add fats and calories to the body. It is thus helpful in weight loss.
Millets Fiber-rich foods such as millets - jowar, bajra, ragi, etc.absorb cholesterol and help increase the secretion of the bile that emulsifies fats.
Cinnamon and Cloves Used extensively in Indian cooking, these spices have been found to improve the function of insulin and to lower glucose, total cholesterol, LDL and triglycerides in people with type 2 diabetes. â&#x20AC;&#x201D;Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com
Mustard Oil Mustard oil contains low saturated fat compared to other cooking oils. It has fatty acid, oleic acid, erucic acid and linoleic acid. It contains antioxidants, essential vitamins and reduces cholesterol, which is good for the heart.
Cabbage Raw or cooked cabbage inhibits the conversion of sugar and other carbohydrates into fat. Hence, it is of great value in weight reduction.
Mind Teaser little LARGE little LARGE little little little LARGE Answer: A little on the large side
Garlic
Photo Quiz Rash at the Site of a Tattoo
A
34-year-old man with no significant medical history presented with a rash on his arms (Figure 1) and posterior neck (Figure 2). The rash began on his left arm two years earlier after he got a tattoo. The eruption was composed of scattered papules and plaques measuring 1 to 2 cm in size. It occasionally itched, but was usually asymptomatic.
Figure 1.
Question Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis? A. Contact dermatitis. B. Cutaneous sarcoidosis. C. Discoid lupus erythematosus.
Figure 2.
D. Tattoo granuloma.
(For Answer and Discussion, see page 10...)
An Inspirational Story Promise Yourself
To be so strong that nothing can disturb your peace of mind. To talk health, happiness and prosperity to every person you meet. To make all your friends feel that there is something in them. To look at the sunny side of everything and make your optimism come true. To think only the best, to work only for the best and to expect only the best. To be just as enthusiastic about the success of others as you are about your own. To forget the mistakes of the past and press on to the greater achievements of the future. To wear a cheerful countenance at all times and give every living creature you meet a smile. To give so much time to the improvement of yourself that you have no time to criticize others. To be too large for worry, too noble for anger, too strong for fear; and too happy to permit the presence of trouble. To think well of yourself and to proclaim this fact to the world, not in loud words, but in great deeds. To live in the faith that the whole world is on your side so long as you are true to the best that is in you. —Ms. Ritu Sinha
Laugh a While! The Lawyer’s Dog A butcher was minding his store one day, when a dog ran in and stole a cut of meat off his counter. The butcher recognized the dog as belonging to his neighbor who was a lawyer. He called up his neighbor and said, “Your dog stole meat from my store. I believe you owe me for the meat.” The lawyer said “You are correct. How much was the meat?” The butcher told him that it cost $4.50, the lawyer replied that the butcher should receive a check for that amount in the mail the next day. The next day, the check arrived in the mail for $4.50, with a bill attached for $150 “for legal consultation.”
Idioms
Turn a blind eye: Refuse to acknowledge something you know is real or legit. Till the cows come home: A long time. The last straw: When one small burden after another creates an unbearable situation, the last straw is the last small burden that one can take. Explore all avenues: Try out every possibility in order to obtain a result or find a solution. Run out of steam: To be completely out of energy. A chip on your shoulder: Being upset for something that happened in the past.
Legal Column Legal Question I am an Indian citizen. I graduated in medicine from China. I have been offered a scholarship to pursue postgraduation in Orthopedics in China without paying any fees. The university is recognized by WHO but not by the Medical Council of India (MCI). Will I face any problem if I work in the private sector in India as an orthopedician? Can I get a diploma in orthopedics from India while I am working for my postgraduate (PG) degree in China? Please give me career guidance. Ans. The question of your practicing medicine in India does not arise unless you are registered with the MCI. If you want to work in India as a doctor, this is a must. You should get in touch with the MCI to find if there is a way to get registered.
If you don’t get a licence to practice medicine in India, the only option to pursue medical career for you is to get your PG degree in China and work there or in some other country that may allow you to work there.
If you get an Indian licence and, after getting it, you still want to get your PG degree from China because
it is free, you may do so and, afterwards, do one of the two things: EITHER come back and try to get diploma in orthopedics, MS or DNB in India; OR, go to USA, Canada, UK, Australia or New Zealand and get a degree in ortho from any of these five countries because it would be recognized in India, if it is recognized by the medical council of the country concerned.
If you are not a registered medical practitioner in India on the basis of medical graduation, it is doubtful that you would be permanently registered with the MCI on the basis of a PG degree from the five countries as mentioned above.
It is possible that even if you do not get registered with the MCI and obtain a PG degree from any one of the five countries, and if you want to work in India as a medical teacher or researcher or a doctor working in a charitable institution, then, as per the MCI Act, 1956, you can be given temporary registration in India. —Dr MC Gupta, Advocate
Police/Magistrate is Empowered by Law in India to Order a Designated Doctor to Perform a Forensic Autopsy
A medicolegal autopsy means an examination of the body after death, which is conducted in cases where the circumstances of the death suggest that the death was caused by homicide, suicide or accident or is suspicious in nature, where criminal investigation is instituted. Designated area Police/Magistrate is empowered by law in India to request/order the designated doctor to perform a Forensic/medicolegal autopsy, hence no consent from the family/legal heir is required for forensic autopsy. Autopsia cadaverum or an autopsy is the postmortem examination of corpse by a registered doctor. It is a specialized surgical procedure that consists of a thorough examination of a corpse to determine the identity of corpse, the cause and manner of death and to evaluate any disease or injury that may be present. The autopsy must be performed by a specialized experienced medical doctor; however, if possible it should preferably be done only by forensic medicine qualified/experienced doctor. The autopsy ideally includes a thorough external examination of the body and a probing examination of the internal organs of the body. During the external examination, the doctor searches for wounds and injuries, noting deformities, absence of limbs, state of nutrition and unusual features.
The doctor should examine the hands, fingers, fingernails, feet, teeth, scalp, tattoos, scars, hair, skeleton remains, hair fibers, jewelry and clothing.
The doctor conducting the internal examination, the autopsy surgeon should remove the deceased’s chest plate, lungs, heart, liver, intestines, etc. and, with the use of a scalpel, examine these organs for wounds, disease and deformities.
There should be an arrangement to videotape the autopsy and the doctor must release a report detailing the findings, including the cause of death to the police as early as possible. It is best and most transparent if postmortem report is handed over along with dead body only.
Autopsies, as well as the reports released by the medical examiner, vary in quality. Some medical examiners take little care in their work. A small percentage is outright incompetent.
Once an autopsy is complete the body must be wellreconstituted by sewing/suturing it back together with cosmetic care of deceased body. Suture from chin to pubic prominence should be masked by resembling skin color paste. —Dr Sudhir Gupta, Additional Professor, Forensic Medicine & Toxicology, AIIMS.
Expert’s Opinion Malaria Update What the National Drug Policy of India Says
Medicine Update How is a case of hepatitis C diagnosed?
A screening antibody test such as an enzyme immunoassay (EIA) or other immunoassay is initially performed and real-time polymerase chain reaction (RT-PCR) for RNA is used to confirm active infection. In HIV- positive patients with a low CD4 count (<200 cells/mm3), the EIA may occasionally be negative and an RT-PCR may be needed for definitive diagnosis.
An antibody test may not become positive for ≥3 months after acute hepatitis C virus (HCV) infection but a test for HCV-RNA will be positive after only two weeks.
Chronic infection is confirmed if an HCV-RNA assay is positive six months after the first positive test. Patients with low-level viremia may require HCV-RNA levels testing on ≥2 occasions to confirm infection.
All patients being considered for therapy should have a viral RNA test to confirm viremia and be genotyped. A positive antibody test with persistently negative RNA test indicates resolved infection.
How to report cases of malaria? Malaria is currently not a notifiable disease in India, but it important that private providers inform the Government malaria services about malaria cases seen every fortnight. Suitable formats for this can be obtained from district malaria officers or block medical officers. Whenever a private provider observes an increase in the number of suspected or confirmed malaria cases, this should be intimated urgently to local health authorities.
What are the criteria for referral to a referral hospital?
Cerebral malaria patients not responding to initial antimalarial treatment. Severe anemia warranting blood transfusion Bleeding and clotting disorder Hemoglobinuria Pulmonary edema Cerebral malaria complicating pregnancy Oliguria not responding after correction of fluid deficit and diuretics Fluid, electrolyte and acid-base disturbance
What are the symptoms for immediate referral of a malaria case to a higher level healthcare facility? The management of severe malaria requires immediate administration of life-saving drugs. Therefore, essential requirements for management of severe malaria are as follows:
Persistence of fever after 48 hours of initial treatment Continuous vomiting and inability to retain oral drugs Headache continues to increase Severe dehydration – dry, parched skin, sunken face Too weak to walk in the absence of any other obvious reason Change in sensorium e.g. confusion, drowsiness, blurring of vision, photophobia, disorientation Convulsions or muscle twitching Bleeding and clotting disorders Suspicion of severe anemia Jaundice Hypothermia —AC Dhariwal, Hitendrasinh G Thakor, Directorate of NVBDCP, New Delhi
How can asthmatic medications be delivered to a child? In pediatric asthma, inhaled treatment is the cornerstone of asthma management. Inhaler devices currently used broadly fall into the following four categories:
Pressurized metered dose inhaler (pMDI): Propellant used to dispense medication when canister is pressed manually.
Dry powder inhaler (DPI): Does not require handbreath coordination to operate.
Breath-actuated pMDI: Propellant used to dispense medication when patient inhales.
Nebulized solution devices
In pediatrics, the inhaler device must be chosen on the basis of age, cost, safety, convenience and efficacy of drug delivery.
The preferred device for children younger than four years is a pMDI with spacer and age-appropriate mask.
Children aged 4-6 years should use a pMDI plus a valved holding chamber or spacer.
Children older than six years can use either a pMDI, a DPI, or a breath-actuated pMDI.
For all three groups, a nebulizer with a valved holding chamber (and mask in children younger than 4 years) is recommended as alternate therapy. —Dr Neelam Mohan, Director, Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta - The Medicity
Research Review Comorbidities in Gouty Arthritis Background: Gouty arthritis is increasing in prevalence in men and women, particularly in older age groups. Methods: A PubMed search was conducted to identify common comorbidities associated with gouty arthritis, their impact on quality-of-life and strategies to manage gouty arthritis and its associated comorbidities. Results: Gouty arthritis is associated with numerous comorbidities that are increasing in prevalence (chronic kidney disease [CKD], hypertension, obesity, diabetes, metabolic syndrome and cardiovascular disease) and that negatively impact long-term prognosis and quality-oflife. Therefore, certain considerations and precautions are necessary when treating gouty arthritis in these patients. For example, nonsteroidal anti-inflammatory drugs can cause acute renal toxicity or worsen CKD and should be avoided in this population. Dosage adjustments are recommended when using colchicine and urate-lowering therapy in patients with CKD, which may limit efficacy. Febuxostat may be used in patients with mild-to-moderate renal impairment, but insufficient information is available for use in patients with creatinine clearance of <30 ml/ min. Numerous drug-drug interactions in patients with gouty arthritis and comorbidities may alter serum uric acid levels. Several interleukin 1β inhibitors, which target the underlying inflammatory mechanism of gouty arthritis and many of its comorbidities, are in development and may provide an option for patients not adequately managed with other treatments. Conclusions: Gouty arthritis is associated with renal, metabolic and cardiovascular comorbidities that negatively impact overall health. The management of gouty arthritis in the presence of comorbidities is particularly challenging because of contraindications, the need for dosage adjustments and polypharmacy. Marwah RK. J Investig Med. 2011 Nov 4. [Epub ahead of print]
Closed-loop Insulin Delivery for Treatment of Type 1 Diabetes Type 1 diabetes is one of the most common endocrine problems in childhood and adolescence, and remains a serious chronic disorder with increased morbidity and mortality, and reduced quality-of-life. Technological innovations positively affect the management of type 1 diabetes. Closed-loop insulin delivery (artificial pancreas) is a recent medical innovation, aiming to reduce the risk of hypoglycemia while achieving tight control of glucose.
Characterized by real-time glucose-responsive insulin administration, closed-loop systems combine glucosesensing and insulin-delivery components. In the most viable and researched configuration, a disposable sensor measures interstitial glucose levels, which are fed into a control algorithm controlling delivery of a rapid acting insulin analog into the subcutaneous tissue by an insulin pump. Research progress builds on an increasing use of insulin pumps and availability of glucose monitors. We review the current status of insulin delivery, focusing on clinical evaluations of closed-loop systems. Future goals are outlined, and benefits and limitations of closed-loop therapy contrasted. The clinical utility of these systems is constrained by inaccuracies in glucose sensing, inter- and intra-patient variability, and delays due to absorption of insulin from the subcutaneous tissue, all of which are being gradually addressed. Elleri D, Dunger DB, Hovorka R. BMC Med 2011;9(1):120.
The Impact of Comorbidities on Stroke Prophylaxis Strategies in Atrial Fibrillation Patients Arial fibrillation (AF) is the most commonly occurring sustained arrhythmia in the United States and is associated with increased mortality. AF is a risk factor for ischemic stroke, and risk factors for AF include co-morbid conditions such as congestive heart failure, diabetes mellitus, older age, hypertension, diabetes, pulmonary disease and history of stroke, transient ischemic attack or heart failure. Risk stratification for ischemic stroke in AF patients is based on scoring a group of risk factors that allows for the appropriate tailoring of antithrombotic therapy. The vitamin K antagonists are effective at reducing ischemic stroke rates in medium-risk to high-risk patients and are therefore generally recommended for this group. However, a large proportion of these patients are not treated with vitamin K antagonists because of the potential for adverse outcomes, particularly in elderly patients. New direct thrombin inhibitors and direct Factor Xa inhibitors in development offer the possibility of simplifying treatment and management although offering similar or better efficacy and safety profiles to warfarin. In light of these potential new treatments, the importance and improvement of risk stratification methods and the resulting recommendations in thromboprophylaxis become even more paramount as they make it more likely that medium-risk to high-risk patients can be treated safely. Somberg JC. Am J Ther 2011;18(6):510-7.
“Many of life’s failures are people who did not realize how close they were to success when they gave up.”
Thomas A Edison
(...Cont’d from page 6)
Discussion
Summary Table
The answer is B: cutaneous sarcoidosis.
Condition
Characteristics
Sarcoidosis is a systemic granulomatous disease that may involve the skin alone (25 percent of cases1) or other tissue or internal organs. Flesh-colored papules are the most common presentation, but many other forms exist, including lupus pernio and annular, hypopigmented, ulcerative, subcutaneous, and ichthyosiform sarcoidosis. On histologic examination, sarcoidosis often displays the classic “naked granuloma” within the dermis.
Contact dermatitis
Exudative, extremely pruritic papules or plaques in a linear or geometric-appearing distribution; histologic examination shows epidermal spongiosis
Cutaneous sarcoidosis
Lesions typically appear as flesh-colored papules; may demonstrate koebnerization; histologic examination demonstrates “naked granulomas”
Discoid lupus erythematosus
Pink to red papules and plaques that become hyperpigmented or hypopigmented and atrophy; tends to affect the face, scalp, and ears; histologic examination demonstrates atrophy with an interface dermatitis involving the basal layer of the epidermis
Tattoo granuloma
Lesions occurring only at the site of a tattoo; histologic examination demonstrates granulomas with pigment-laden macrophages
The development of numerous sarcoidal lesions in tattooed areas is a classic example of an isomorphic response, or Koebner phenomenon (i.e., the appearance of identical lesions at sites of previous trauma).1 The Koebner phenomenon may occur in a variety of other cutaneous diseases, including psoriasis, vitiligo, and lichen planus.2 Studies have suggested that increases in proinflammatory cytokines, such as tumor necrosis factor α and interleukin 1, after traumatic insult play a role in the Koebner phenomenon.3 First-line therapy for cutaneous sarcoidosis is mid- to high-potency topical corticosteroids. Additional treatment modalities include intralesional corticosteroid injection and hydroxychloroquine. Systemic sarcoidosis commonly requires long-term therapy with hydroxychloroquine and oral steroids. Contact dermatitis manifests as exudative, extremely pruritic papules or plaques. The presence of linear or geometricappearing eruptions suggests an external exposure or insult. For example, allergic contact dermatitis from poison ivy often exhibits linearly distributed vesicles that correspond to the sites of contact with the plant leaves. These reactions demonstrate epidermal spongiosis on biopsy rather than the granulomatous reaction seen in sarcoidosis.4 Discoid lupus erythematosus is a form of cutaneous lupus erythematosus that tends to affect the face, scalp, and ears. The rash may appear as pink to red papules and plaques. Chronic lesions become hyperpigmented or hypopigmented and atrophic, and lead to a scarring alopecia if they involve areas of hair growth. Discoid lupus erythematosus may be clinically indistinguishable from sarcoidosis; however,
on histologic examination, discoid lupus erythematosus demonstrates atrophy with an interface dermatitis involving the basal layer of the epidermis.5 Tattoo granulomas are a granulomatous hypersensitivity reaction to the pigment used in tattooing. These lesions are often clinically indistinguishable from sarcoidosis, but they occur only in areas of tattooing. Histologic evaluation reveals granulomas with pigment-laden macrophages.1
References 1.
2.
3. 4. 5.
James WD, Berger TG, Elston DM, Odom RB. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2006:708-714. Rubin AI, Stiller MJ. A listing of skin conditions exhibiting the koebner and pseudo-koebner phenomena with eliciting stimuli. J Cutan Med Surg. 2002;6(1):29-34. Sagi L, Trau H. The Koebner phenomenon. Clin Dermatology. 2011;29(2):231-236. Anderson KE, Benezra C, Burrows D, et al. Contact dermatitis: a review. Contact Dermatitis. 1987;16(2):55-78. Patel P, Werth V. Cutaneous lupus erythematosus: a review. Dermatol Clin. 2002;20(3):373-385,v. Source: Adapted From Am Fam Physician. 2011;84(8):949-950.
Lab Update Vitamin B1, Plasma
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Thiamine or thiamin, sometimes called aneurin, is a water-soluble vitamin of the B complex (vitamin B1), whose phosphate derivatives are involved in many cellular processes. Thiamine deficiency can lead to myriad problems including neurodegeneration, wasting and death. A lack of thiamine can be caused by malnutrition, a diet high in thiaminase-rich foods (raw freshwater fish, raw shellfish, ferns) and/or foods high in antithiamine factors (tea, coffee, betel nuts) and by grossly impaired nutritional status associated with chronic diseases, such as alcoholism, gastrointestinal diseases, HIV-AIDS and persistent vomiting. It is thought that many people with diabetes have a deficiency of thiamine and that this may be linked to some of the complications that can occur. Well-known syndromes caused by thiamine deficiency include beriberi and Wernicke–Korsakoff syndrome, diseases also common with chronic alcoholism.
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