Medinews_May_2011 by IJCP

Vol. 11, No. 5, May 2011

ISSN 0971-880X

Single Copy Rs. 100/-

Pages 12

Dr KK Aggarwal Gr. Editor-in-Chief, IJCP Group

Member The Indian Newspaper Society

Official Voice of Doctors of India

d i t o r i a l

10 Simple Steps to Help De-stress 1. Frequently late? Apply time management principles. Consider your priorities (be sure to include time for yourself) and delegate or discard unnecessary tasks. Map out your day, segment by segment, setting aside time for different tasks, such as writing or phone calls. If you are overly optimistic about travel time, consistently give yourself an extra 15 minutes or more to get to your destinations. If lateness stems from dragging your heels, consider the underlying issue. Are you anxious about what will happen after you get to work or to a social event, for example? Or maybe you’re trying to jam too many tasks into too little time. Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee 2. Often angry or irritated? Consider the weight of cognitive distortions. Are you magnifying a Sr Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India problem, leaping to conclusions or applying emotional reasoning? Take the time to stop, breathe, Group Editor-in-Chief, IJCP Group reflect and choose. Editor-in-Chief, eMedinewS Chairman Ethical Committee, Delhi Medical Council 3. Unsure of your ability to do something? Don’t try to go it alone. If the problem is work, talk to a Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) co-worker or supportive boss. Ask a knowledgeable friend or call the local library or an organization Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) that can supply the information you need. Write down other ways that you might get the answers or emedinews@gmail.com http//twitter.com/DrKKAggarwal skills you need. Turn to CDs, books or classes, for example, if you need a little tutoring. This works Krishan Kumar Aggarwal (Facebook) equally-well when you’re learning relaxation response techniques, too. 4. Overextended? Clear the deck of at least one time-consuming household task by hiring help. If you can, hire a housecleaning service, shop for groceries through the Internet, convene a family meeting to consider who can take on certain jobs or barter with, or pay teens for work around the house and yard. Consider, what is truly essential and important to you and what might take a backseat right now. 5. Not enough time for stress relief? Try mini-relaxations. Or make a commitment to yourself to pare down your schedule for just one week so you can practice evoking the relaxation response every day. Slowing down to pay attention to just one task or pleasure at hand is an excellent method of stress relief. (Cont’d on page 6...)

Three in every four adults, aged between 18 and 65, suffered from some form of headache disorder, including migraine and tension-type headaches, last year. The World Health Organization (WHO) says headaches are the most common health disorders across the world, but they are often neglected and under-treated. According to the world’s first ‘Atlas of Headache Disorders 2011’ brought out by the WHO, 50% suffering from headaches opt for self-medication, oblivious to bouts of pain. Neurologists examine only 10% headache patients, and the rate is even lower in Africa and South-East Asia. The report says, over 10% of those suffering frequent headaches have migraine, and 1.7-4% of the adult population is affected by headache for 15 or more days every month. Information on the societal impact of headache exists in only 18% of countries that responded for the report. Three types of headache disorders have been underlined as most frequent migraine, tension-type and those caused by medication-overuse. (Source: TOI, May 5, 2011)

Make Sure

During Medical Practice

OH MY GOD! I FORGOT THAT AZT REDUCES THE PLATELET COUNTS AS WELL

Make sure: AZT can cause thrombocytopenia, an effect which requires its administration with utmost care in patients with bleeding diathesis. KK Aggarwal

Fitness Update

An HIV-positive patient who is also a hemophiliac presents with severe joint bleeds after being started on AZT.

Char Dhaam Yatra

©IJCP Academy

Neglect, Under Treatment Ails Headache Disorders

Special

Expert Opinion

Photo Quiz

News & Views

Dr KMK Masthan

IJCP Publications Pvt. Ltd.

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Fitness Update Nutrition Fit Facts and Tips Weight Management

Adequate Nutrients within Calorie needs

• To maintain body weight in a healthy range, balance

• Consume a variety of nutrient-dense foods and beverages

calories from foods and beverages with calories expended. • To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity.

Food Groups to Encourage • Consume a sufficient amount of fruits and vegetables

while staying within energy needs. Two cups of fruit and two and half-cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level. • Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables and other vegetables) several times a week. • Consume three or more ounce-equivalents of wholegrain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains. • Consume three cups per day of fat-free or low-fat milk or equivalent milk products.

within and among the basic food groups while choosing foods that limit the intake of saturated and trans-fats, cholesterol, added sugars, salt and alcohol. • Meet recommended intakes within energy needs by

adopting a balanced eating pattern, such as the US Department of Agriculture (USDA) Food Guide or the Dietary Approaches to Stop Hypertension (DASH) Eating Plan.

Women During Pregnancy and the Postpartum Period • Healthy women who are not already highly active or

doing vigorous-intensity activity should get at least 150 minutes of moderate-intensity aerobic activity a week during pregnancy and the postpartum period. Preferably, this activity should be spread throughout the week. • Pregnant women who habitually engage in vigorous-

intensity aerobic activity or who are highly active can continue physical activity during pregnancy and the postpartum period, provided that they remain healthy and discuss with their healthcare provider how and when activity should be adjusted over time.

How to Burn Calories Instead of Storing Them: Turn Bad Fat into Good Fat?

World’s Largest Exercise Class Gets Kids Active Around the Globe

By changing the expression of a gene that affects body weight regulation and turns ‘bad’ white fat into brown ‘good’ fat, US scientists believe they may have found a way to help the body burn calories instead of storing them, opening the door to better treatments for obesity.

In conjunction with May as Exercise is Medicine® Month, ‘The world’s Largest Exercise Class’ is coming to children and schools around the world. Project ACES (All Children Exercise Simultaneously) engages millions of children, parents and teachers each year to participate in physical activity at their schools and homes.

Lead researcher Dr Sheng Bi, an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues were researching appetite regulation in rats when they made their discovery.

Through Project ACES, children learn the value and importance of good nutrition, adequate physical fitness and healthy decision-making - lessons they can carry well into adulthood.

To Feel Better, Exercise Harder: Study Vigorous exercise offers more of a mood boost than less strenuous exercise, a new study finds. UK researchers compared 11 sedentary people who did moderate and highintensity exercise. Their mood was assessed before, during, immediately following and 20 minutes after they did the workouts. The participants’ moods were more negative

during and immediately after high-intensity exercise, compared to when they did the less strenuous exercise or no exercise. However, their mood 20 minutes after doing the vigorous workout was much better compared to before the workout. This type of improvement did not occur after moderate or no exercise, the investigators found. —Rajat Bhatnagar, International Sports and Fitness Distribution, LLC

Char Dhaam Yatra Special Preventing Acute Mountain Sickness • Slow ascent is the best prevention.

• Preventive drugs are given if one has had high altitude

• If one lives below 5,000 feet (1,500 meters), one should

avoid ascending rapidly. On the first night, avoid sleeping above 9,000 feet (2,800 meters).

• Between 5000-10,000 feet have a night halt. • If one is planning to travel above 9,800 feet (3,000

meters) one should not ascend more than 1,600 feet (500 meters) per day.

illness previously or wants to ascend quickly. • The drug is acetazolamide to be started a day before

the ascent and to be continued for 48 hours or until one reaches the highest point of the trip. 



• One should take a full day rest for every 3,200 feet

(1,000 meters) ascent.

• On rest Day, one should not ascend higher- or



• For better adjustment one should climb high and sleep



overexert.

Acetazolamide can temporarily cause carbonated drinks to taste unpleasant. Other side effects can include the need to urinate more frequently, numbness or tingling in the hands or feet, nausea, drowsiness or blurry vision. Acetazolamide is not recommended for pregnant women.

low. One should hike to a higher altitude during the day and return to a lower elevation to sleep at night.

Acetazolamide is a sulfa medicine, but many people with a sulfa allergy can take acetazolamide without a problem.

• One should not overexert during the first few days at

• Dexamethasone is a steroid that may be recommended

• One should not consume alcohol and sleeping pills,

as a preventive treatment if one is allergic to acetazolamide.

altitude.

especially in the first two days.

• If one stays at elevations above 4,900 feet (1,500 meters)

in the weeks before one ascends may allow one to ascend faster.

• If one drinks caffeine (coffee, tea, soda) regularly, he

or she should not stop drinking it before or during the trip. Caffeine is safe at high altitudes, and stopping it suddenly can cause symptoms similar to acute mountain sickness.

• One should be more careful if he or she has had

acute mountain illness or another high altitude illness previously.

• Taking aspirin or ibuprofen can help to prevent

the headache that often occurs with acute mountain sickness. • If one intends to ascend quickly, one can start taking

aspirin or ibuprofen before the ascent or when headache occurs. • If one had high altitude pulmonary edema in last visit

or wants to ascend quickly to altitudes above 8,200 feet (2,500 meters), one may also take nifedipine (commonly used to treat high blood pressure), dexamethasone or acetazolamide to prevent lung swelling.

Traveling Precautions People with certain medical conditions need to take special precautions when traveling at high altitudes. • If one has angina or had a heart attack in the past: Have

a cardiac evaluation. One should consult if there is chest pain, shortness of breath or dizziness while traveling. • Asthma does not worsen at high altitudes. • At high altitude, the blood thickens and the blood

pressure rises. This may increase the risk of a stroke. • If one does require oxygen for the lung disease at home,

one might need oxygen at high altitude; a higher oxygen flow rate is needed at high altitude.

• In sickle cell disease, oxygen will be needed for travel

above 7,000 feet (2,100 meters). If one has sickle cell trait, altitude-related complications are rare, except at very high altitude (over 14,000 feet or 4,200 meters). • Diabetics be aware: Blood glucose meters can give

inaccurate results at high altitudes. Consult the manufacturer of the meter for recommendations about high altitude readings. Above 5,000 meters, some of the diabetic climbers experience hypoglycemia after dinner with nocturnal hyperglycemia probably because of delayed absorption of carbohydrates at high altitude and rapid absorption of the Lispro insulin used. One should delay insulin administration until the end of dinner.

Expert Opinion Medicolegal Update Should a Doctor Perform CPR in an Already Injured Chest Patient? When a person is in need of Cardio Pulmonary Resuscitation (CPR), it means that the person is in cardiac arrest. This is to say that they are unconscious, not moving, not breathing normally. If this is the case, they are presumably in cardiac arrest or in a state that justifies CPR. • If the person is awake, is breathing normally and

therefore does not appear to need CPR, it would be correct that chest compressions and CPR may complicate the already damaged chest and further complicate the victim’s injuries. • As soon as the victim becomes unconscious, is not

breathing normally and now appears to need CPR, Emergency Services would be contacted and CPR would be initiated regardless of the injuries of the patient. • If the person needs CPR, this means that they are

Gyne Update Atrophic Vaginitis A 55-year-old woman, an executive, comes with complaints of itching of vagina and on being interrogated tells that there is increasing vaginal dryness and that sex is painful. She is about three years postmenopausal and although she has begun systemic hormone replacement therapy (HRT) and continues to use it, she still has complaints of vaginal dryness and pain with intercourse. Her other medical history is essentially negative and she was (previously) determined to be a good candidate for systemic therapy. When you evaluate her today she is still a good candidate for systemic therapy. Concern: Atrophic vaginitis is in epidemic proportions. About 80% of postmenopausal women are symptomatic and about 20% present with atrophic vaginitis symptoms; of those, about 1-5% will seek specific treatment for atrophic vaginitis symptoms. Many will seek treatment at a relatively advanced age, about 5-10 years after menopause. The reason is an age-related increase in the severity of symptoms: <5% among premenopausal women, going upto about 25% of women by one year after menopause and to 50% by years 3-5. Patients would rarely come out about sexuality problem themselves; you have to bring out this problem by talking tactfully. You have to talk like “We are interested in taking care of you as a complete person, understanding all of the issues that are going on, not only with your physical health, but also your emotional health and your intimate health is also important as well.” — Dr Maninder Ahuja, Secretary General IMS

clinically dead. If the victim does not receive CPR, they will simply graduate to permanent death. • This is why, regardless of the chest injury, if the person

is ‘dead’ or in need of CPR, compressions are to be given as per the American Heart Association (AHA) guidelines even if the complications could include those of punctured lungs, lacerated organs or bruised/ punctured heart muscle. These injuries must be recorded in clinical sheet. • This would be based on the theory that a person in

need of CPR is already dead and will not be harmed more even if there are negative side effects from providing chest compressions. If a person remains dead, surgery is not an option but if the person is resuscitated with CPR, we have an opportunity to fix the injuries that may have been aggravated by doing CPR. —Dr Sudhir Gupta, Additional Professor Forensic Medicine and Toxicology, AIIMS

Obesity Update Obesity in Pregnancy – National Health Service Guidelines All pregnant women with a booking body mass index (BMI) >30 should be provided with accurate and accessible information about the risks associated with obesity in pregnancy and how they may be minimized. Women should be given the opportunity to discuss this information. A Swedish population-based observational study of 151,025 women examined the association of change in BMI between successive pregnancies with adverse outcomes during the second pregnancy. The risk of pre-eclampsia, gestational diabetes mellitus (GDM), large-for-gestationalage babies, cesarean section and stillbirth was linearly related to interpregnancy weight gain. Interpregnancy weight reduction among women with obesity has been shown to significantly reduce the risk of developing GDM. A population-based cohort study of 4,102 nondiabetic women with maternal obesity prior to their first singleton pregnancy found that a weight loss of at least 4.5 kg before the second pregnancy reduced the risk of developing GDM by upto 40%. —Dr Parveen Bhatia and Dr Pulkit Nandwani

Infertility Update What are the prerequisites of donor insemination? The decision regarding donor insemination is complex, and patients may need psychological counseling to aid in this decision. The partners should be given psychological counseling by a qualified mental health professional. —Dr Kaberi Banerjee, Director Precious Baby Foundation

Rabies Update Is it essential to perform an antibody test on the patient following antirabies vaccination? Antibody tests, i.e., rapid fluorescent inhibition test (RFFIT), mouse neutralization test (MNT) are done only at selected few reference centers in India. Antibody tests are not required on a routine basis following antirabies vaccination if vaccination is correct and reliable. A person started with PVRV wants to change over to HDCV or PCEC or PDEV or vice versa. What should be done? Of the currently available TCVs such as HDCV, PCECV, PVRV and PDEV, all are equally good and approved by WHO. All are interchangeable following nonavailability of one brand or due to allergy to one of the CCVs or PDEV. All are considered protective throughout the world against different strains of rabies viruses in different parts of the world. —Dr AK Gupta, “Author of RABIES - The Worst death”

Lab Update Serum Calcium Hypocalcemia (or low serum calcium level) must be interpreted in relation to serum albumin concentration (Some laboratories report a ‘corrected calcium’ or ‘adjusted calcium’ which relate the calcium assay to a normal albumin. The normal albumin, and hence the calculation, varies from lab-to-lab). True decrease in the physiologically active ionized form of Ca++ occurs in many situations: Hypoparathyroidism, vitamin D deficiency, chronic renal failure, magnesium deficiency, prolonged anticonvulsant therapy, acute pancreatitis, massive transfusion and alcoholism Drugs producing hypocalcemia include most diuretics, estrogens, fluorides, glucose, insulin, excessive laxatives, magnesium salts, methicillin and phosphates. —Dr Arpan Gandhi and Dr Navin Dang

Where there is Determination there is Success Think of all that you wanted to achieve in the past few days. Now check if you have achieved it or are still trying for it. Check if you have left anything midway. Pick out one of the things that you wanted to achieve or create an aim for yourself and think, “I am the one who is victorious and I will achieve whatever I set out to. I will not leave any task unfinished.” —BK Sapna (...Cont’d from cover page)

6. Feeling unbearably tense? Try massage, a hot bath, mini-relaxations, a body scan or a mindful walk. Practically any exercise - a brisk walk, a quick run, a sprint up and down the stairs - will help, too. Done regularly, exercise wards off tension, as do relaxation response techniques. 7. Frequently feel pessimistic? Remind yourself of the value of learned optimism: A more joyful life and quite possibly, better health. Practice deflating cognitive distortions. Rent funny movies and read amusing books. Create a mental list of reasons you have to feel grateful. If the list seems too short, consider beefing up your social network and adding creative, productive and leisure pursuits to your life. 8. Upset by conflicts with others? State your needs or distress directly, avoiding ‘you always’ or ‘you never’ zingers. Say, ‘I feel _____ when you _____.’ ‘I would really appreciate it if you could _____.’ ‘I need some help setting priorities. What needs to be done first and what should I tackle later?’ If conflicts are a significant source of distress for you, consider taking a class on assertiveness training. 9. Worn out or burned out? Focus on self-nurturing. Carve out time to practice relaxation response techniques or at least indulge in mini-relaxations. Care for your body by eating good, healthy food and for your heart by seeking out others. Give thought to creative, productive and leisure activities. Consider your priorities in life: Is it worth feeling this way or is another path open to you? If you want help, consider what kind would be best. Do you want a particular task at work to be taken off your hands? Do you want to do it at a later date? Do you need someone with particular expertise to assist you? 10. Feeling lonely? Connect with others. Even little connections - a brief conversation in line at the grocery store, an exchange about local goings-on with a neighbor, a question for a colleague - can help melt the ice within you. It may embolden you, too, to seek more opportunities to connect. Be a volunteer. Attend religious or community functions. Suggest coffee with an acquaintance. Call a friend or relative you miss. Take an interesting class. If a social phobia, low self-esteem or depression is dampening your desire to reach out, seek help. The world is a kinder, more wondrous place when you share its pleasures and burdens. Source: From Health Beat (Harvard Newsletter)

Photo Quiz

Treatment-Resistant Plaque on the Thigh

50-year-old woman presented with a plaque on her thigh that had been slowly growing for several months. It was mildly pruritic and scaly, and sometimes appeared irritated. The patient was treated with clotrimazole 1% compounded with betamethasone dipropionate 0.05%, applied twice daily for more than three months. This preparation relieved the pruritus, but did not resolve the plaque. She had no personal or family history of psoriasis or atopic dermatitis. She was taking no other medications and was otherwise healthy. Examination revealed a 5 × 7-cm erythematous plaque with a raised, scaly border (Figure 1). The central portion of the plaque had scattered, follicularly based, erythematous papules and postinflammatory hyperpigmentation. A potassium hydroxide (KOH) preparation of scale from the plaque revealed innumerable branching hyphae. The patient began a four-week course of topical econazole cream twice daily. The scaling resolved by the end of the treatment, but multiple erythematous papules remained within the affected area (Figure 2).

Figure 1.

Question Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis? A. Allergic contact dermatitis. B. Bacterial folliculitis. C. Majocchi granuloma. D. Pityrosporum folliculitis. E. Steroid-induced acne.

Pediatric Update How do we manage a case of chronic constipation in children? The basic aim for treating such cases is cleaning of fecal retention, prevention of further retention and promotion of regular bowel habits. The general approach includes: Disimpaction; initiation of maintenance treatment with laxative and Dietary modification; toilet training and close follow-up. — Dr Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity

Figure 2. (For Answer and Discussion, see page 10...)

Strict Exercise Regimen Beats Back Blood Sugar A meta-analysis found that any regular regimen of physical activity - be it aerobic exercise, resistance training, or a combination of the two - was associated with about a 0.67% decrease in glycated hemoglobin levels compared with controls, according to Beatriz Schaan, MD, ScD, of Hospital de Clinicas de Porto Alegre in Brazil, and colleagues. They reported their findings in the May 4 issue of the Journal of the American Medical Association.

Mild Hyponatremia may Increase Fracture Risk in Elderly Mild hyponatremia - low sodium in the blood - may be a risk factor for vertebral and non-vertebral fractures in elderly men and women, researchers reported at the 13th European Congress of Endocrinology in Rotterdam, The Netherlands.

News & Views Using Reprocessed Dialyzer Membranes Using reprocessed dialyzer membranes did not appear to put dialysis patients at any greater mortality risk, researchers said at the National Kidney Foundation Spring Clinical Meetings. For this retrospective modeling study, patients were followed for one year at centers where reprocessed dialyzers, sterilized with per acetic acid, were used almost exclusively and then compared with patients at centers that only employed single-use dialyzers.

Cath Lab has Role in Treatment of Heart Defects Cardiac catheterization, used predominantly as a diagnostic method, should be added to the toolbox for treating heart defects in children, according to the American Heart Association (AHA). The AHA offered a laundry list of 22 catheter-based treatment scenarios that should be considered for pediatric heart defects in a statement appearing online in Circulation: Journal of the American Heart Association.

Rising Asthma Prevalence Baffles Experts The proportion of Americans with asthma rose by almost a full percentage point, to 8.2%, from 2001 to 2009, according to the Centers for Disease Control and Prevention (CDC), despite improved outdoor air quality and reduced indoor exposures to tobacco smoke. Moreover, rates among African-American children were more than double the national average and increased faster than for other groups, CDC researchers reported online in Mortality and Morbidity Weekly Report. (Medpage Today)

Salt Study Discounts Link to Hypertension In a study that seems likely to re-energize the debate over dietary salt, European researchers found that the changes in the amount of sodium excreted in the urine were related to changes in systolic blood pressure. But they were not linked to diastolic pressure or the risk of developing hypertension, according to Jan Staessen, MD, PhD, of the University of Leuven in Leuven, Belgium, and colleagues. And levels of urinary sodium excretion were inversely related to the risk of dying of cardiovascular causes, Staessen and colleagues reported in the May 4 issue of the Journal of the American Medical Association. Taken together, Staessen and colleagues argued, the findings do not support “the current recommendations of a generalized and indiscriminate reduction of salt intake at the population level.” (Medpage Today)

ACE Inhibition with Ramipril may Reduce Rate of Renal Events among Patients with Proteinuria Angiotensin-converting enzyme (ACE) inhibition with ramipril reduced the rate of renal events among patients with proteinuria in all body mass index strata, but the effect was greater among obese patients, according to the results of a post-hoc analysis published online April 28 in the Journal of the American Society of Nephrology.

Antileukotrienes as Good as Standard Asthma Therapy In the ‘real world’ of asthma treatment, leukotrienereceptor agonists may be just as effective as the gold standard of inhaled glucocorticoids as both a first-line and add-on therapy. Two real-life trials found the drugs were equivalent as monotherapy in symptom reduction at two months and approached equivalence at two years, according to David Price, MD, of the University of Aberdeen in Scotland, and colleagues. (May 5 issue of the New England Journal of Medicine).

First Autologous Organ The race is on to build the first complex organ. Describing what it will take to achieve this momentous milestone was Doris Taylor, PhD, Director of the Center for Cardiovascular Repair, Medtronic Bakken Professor of Integrative Biology and Physiology, and Professor of Medicine at the University of Minnesota, during Monday’s State-of-the-Art Address, “Rebuilding Autologous Organs: Cells, Scaffold, Organ.” Rebuilding an organ involves collecting appropriate types and numbers of cells, selecting the right scaffold, decellularizing the scaffold and seeding the scaffold with the cells. When this concept works, the end result is an organ that performs its appropriate function (American Transplant Congress Philadelphia 2011).

Secondhand Tobacco Smoke Associated with Higher Blood Pressure Exposure to secondhand tobacco smoke appears to be associated with higher blood pressure in boys, researchers found. Among boys ages 8-17, those who lived with a smoker had an average systolic blood pressure that was 1.6 mmHg higher than in those who did not live with a smoker (p < 0.001), according to Jill Baumgartner, PhD, a research fellow at the University of Minnesota’s Institute on the Environment in St. Paul.

Consensus Document Advises Treating Hypertension in those Age 80 or Older Major medical organizations last week released an expert consensus document to manage older patients with or at risk for hypertension. While 64% of men and 78% of women older than age 80 years have high blood pressure, only one in three men and one in four women have adequate control of their blood pressure. (http://content.onlinejacc.org/cgi/content/full/ j.jacc.2011.01.008) Results from the Hypertension in the Very Elderly Trial (HYVET) in 2008 showed clear benefits for using antihypertensive therapy in people age 80 years and older, including a 30% reduction in stroke, 23% reduction in cardiac death, 64% reduction in heart failure and 21% reduction in all-cause mortality. • Targeting blood pressure <140/90 mmHg in persons age 65-79 years and a maximum systolic blood pressure between

140 and 145 mmHg in persons 80 years and older (if tolerated).

• Angiotensin-converting enzyme (ACE) inhibitors, β-blockers, angiotensin receptor (AR) blockers, diuretics and

•

• • •

calcium-channel blockers are all effective in lowering blood pressure and reducing cardiovascular events among the elderly. The choice between drugs should be based on efficacy, tolerability, comorbidities and cost. Antihypertensive drugs should generally be started at the lowest dose, then increased in gradual increments as tolerated. If the first drug reaches its maximum dose, then a second should be added - a diuretic if it wasn’t the first drug. If the antihypertensive response is inadequate after reaching full doses of two classes of drugs, a third drug from another class should be added. When blood pressure is >20/10 mmHg above goal, therapy should be initiated with two antihypertensive drugs. One should check blood pressure measures in the standing position also. Lifestyle changes may be all that are needed for milder hypertension. (Physical activity, restriction of salt, weight control, smoking cessation and avoidance of excessive alcohol intake-more than two drinks for men and one drink for women daily).

The Long-term Metabolic Impact of Early Nutrition

Human Lung Stem Cells: A Breathtaking Discovery?

Nutrition during the first days or weeks of life may have long-term consequences on health, potentially via a phenomenon known as the metabolic programming effect, according to a study presented at the Pediatric Academic Societies (PAS) annual meeting in Denver. Metabolic programming is the concept that differences in nutritional experiences at critical periods early in life can program a person’s metabolism and health for the future.

Blood and intestine, are known to regenerate in adults from multipotent stem cell populations. Other organs, like the lungs, traditionally have not been thought to possess such cells. In a paper published this week in NEJM, Kajstura et al challenge this paradigm. They claim to have found human lung stem cells: Self-renewing cells with the potential to form a range of lung cell types and structures, from bronchioles to alveoli to blood vessels.

FDA Panel Narrowly Endorses Bone Graft device An FDA advisory panel narrowly recommended approval for an investigational bone graft device that uses a growth factor protein to regrow bones in the foot and ankle. The device is called Augment and is made by BioMimetic, which is seeking approval for the device to be an alternative to harvesting a patient’s own bone for the fusion procedure. The FDA’s Orthopaedic and Rehabilitation Devices Panel voted 10-8 on Thursday that the benefits of Augment outweigh

the risks. Such a close vote generally is considered a split vote. Those who voted in favor of the device saw it as a safe and effective alternative to autograft, but those who voted against it were highly critical of how BioMimetic carried out its study and said the numbers don’t show that the device is effective. Source: Medpage Today

Stress may Predict Development of Impaired Glucose Metabolism in Normoglycemic Individuals Perceived stress and stressful life events predict the development of impaired glucose metabolism (IGM) over five years in previously normoglycemic individuals, according to results from the Australian Diabetes, Obesity and Lifestyle study (AusDiab).

(...Cont’d from page 7)

Discussion

Summary Table

The answer is C: Majocchi granuloma.

Condition

Characteristics

A Majocchi granuloma is caused by the invasion of follicles by a dermatophyte. It leads to a wellcircumscribed, annular plaque that is sometimes boggy or crusty, with overlying pustules. Majocchi granuloma can appear anywhere, but usually occurs on the shins or wrists. It is associated with occluded areas, shaving, or topical steroid use.

Allergic contact dermatitis

Localized (sometimes generalized), eczematous or morbilliform eruption; vesicles may be present; other morphologies—rarely urticarial— sometimes occur

Bacterial folliculitis

Follicular, painful papules and pustules; usually occurs on the scalp or extremities; often caused by staphylococcal species, but can be caused by gram-positive and gram-negative organisms

During the course of treatment, the patient developed the granuloma because of inappropriately potent topical steroids used to treat dermatophyte infection.1,2 This has also been called tinea incognito because of the lack of classical findings, such as peripheral scaling. The potent steroid blunts the host response, allowing the fungus to grow and invade the follicles despite the presence of the antifungal. Potent topical steroid use may lead to other potential complications, including steroid-induced atrophy and perioral dermatitis.3,4

Majocchi granuloma

Well-circumscribed annular plaque; sometimes boggy and crusted, with overlying pustules; usually occurs on the shins or wrists; associated with occluded areas, shaving, or topical steroid use

Pityrosporum folliculitis

Mild to moderately pruritic, dome-shaped follicular papules and pustules; usually occurs on the upper back and chest, and less commonly on the face and scalp

Steroidinduced acne

Small, firm, follicular papules; usually occurs on the forehead, cheeks, and chest; commonly associated with systemic steroids, and occasionally inhaled or topical steroids; resolves with discontinuation of causative steroid

To fully treat follicular dermatophyte infections, systemic antifungals, such as terbinafine, griseofulvin, or itraconazole, are necessary. Topical antifungals are unable to adequately penetrate the follicle. Superficial dermatophyte infections that do not affect the follicles usually respond to appropriate treatment using a topical antifungal alone.5 If pruritus is the main symptom, an over-the-counter, menthol-containing lotion or cream can be added. An allergic response to a medication is an important consideration when the dermatitis seems resistant; however, it is uncommon for allergic contact dermatitis to have a follicular pattern—it is more commonly eczematous in appearance.4 Allergic contact dermatitis is usually a localized, but sometimes generalized, eczematous or morbilliform eruption. Vesicles may be present. Other morphologies—rarely urticarial—sometimes occur. Bacterial folliculitis can occasionally cause pruritus, but it is more often painful.4 A localized, annular pattern would be an unusual presentation for bacterial folliculitis. Bacterial folliculitis causes follicular papules and pustules that can occur anywhere on the body, but usually on the scalp or extremities. The condition is often caused by staphylococcal species, but can be caused by gram-positive and gramnegative organisms. Pityrosporum folliculitis, or Malassezia folliculitis, is not annular. It usually occurs on the upper back and chest,

and less commonly on the face and scalp. The condition leads to mild to moderately pruritic, dome-shaped follicular papules and pustules. It is caused by commensal yeast that has overgrown and invaded the follicles. Like Majocchi granuloma, it is often unresponsive to topical antifungals alone and may require systemic treatment.4 Steroid-induced acne is typically caused by systemic steroid use, but can occasionally be caused by inhaled or topical formulations. Classically, it presents as a monomorphous acneiform eruption with small, firm, follicular papules, usually on the forehead, cheeks, and chest.4

References 1. 2. 3. 4. 5.

Kastelan M, Massari LP, Brajac I. Tinea incognito due to Trichophyton rubrum—a case report. Coll Antropol. 2009;33(2):665-667. Romano C, Maritati E, Gianni C. Tinea incognito in Italy: a 15-year survey. Mycoses. 2006;49(5):383-387. Elgart ML. Tinea incognito: an update on Majocchi granuloma. Dermatol Clin. 1996;14(1):51-55. James WD, Berger TG, Elston DM, eds. Andrew’s Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2006. Thomas B. Clear choices in managing epidermal tinea infections. J Fam Pract. 2003;52(11):850-862. Source: Adapted from Am Fam Physician. 2011;83(6):753-754.

FDA okays Everolimus for Rare Pancreatic Tumors

Staying up Late at Night may Lead to Weight Gain

The FDA has approved everolimus (Afinitor), the first new treatment in 30 years for advanced pancreatic neuroendocrine tumors (pNET) that cannot be removed by surgery or that have spread to other parts of the body.

According to a study published online May 4 in the journal Obesity, staying up late at night can lead to an additional two pounds a month weight gain.

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