This document summarizes the non-gastrointestinal causes and approach to evaluating a patient with chronic diarrhea.
1) If the patient has lost weight rapidly, has a fast pulse, or abdominal pain timed to meals, tests should be done to rule out conditions like thyrotoxicosis or mesenteric ischemia.
2) Neuroendocrine tumors should be ruled out with nuclear imaging tests if the patient has symptoms like wheezing, duodenal ulcers, or severe watery diarrhea.
3) Somatostatinoma should be considered and tested for in diabetic patients. Evaluating for non-GI causes is important for patients with chronic diarrhea that has not improved after gastroenterologist evaluation.
This document summarizes the non-gastrointestinal causes and approach to evaluating a patient with chronic diarrhea.
1) If the patient has lost weight rapidly, has a fast pulse, or abdominal pain timed to meals, tests should be done to rule out conditions like thyrotoxicosis or mesenteric ischemia.
2) Neuroendocrine tumors should be ruled out with nuclear imaging tests if the patient has symptoms like wheezing, duodenal ulcers, or severe watery diarrhea.
3) Somatostatinoma should be considered and tested for in diabetic patients. Evaluating for non-GI causes is important for patients with chronic diarrhea that has not improved after gastroenterologist evaluation.
This document summarizes the non-gastrointestinal causes and approach to evaluating a patient with chronic diarrhea.
1) If the patient has lost weight rapidly, has a fast pulse, or abdominal pain timed to meals, tests should be done to rule out conditions like thyrotoxicosis or mesenteric ischemia.
2) Neuroendocrine tumors should be ruled out with nuclear imaging tests if the patient has symptoms like wheezing, duodenal ulcers, or severe watery diarrhea.
3) Somatostatinoma should be considered and tested for in diabetic patients. Evaluating for non-GI causes is important for patients with chronic diarrhea that has not improved after gastroenterologist evaluation.
This document summarizes the non-gastrointestinal causes and approach to evaluating a patient with chronic diarrhea.
1) If the patient has lost weight rapidly, has a fast pulse, or abdominal pain timed to meals, tests should be done to rule out conditions like thyrotoxicosis or mesenteric ischemia.
2) Neuroendocrine tumors should be ruled out with nuclear imaging tests if the patient has symptoms like wheezing, duodenal ulcers, or severe watery diarrhea.
3) Somatostatinoma should be considered and tested for in diabetic patients. Evaluating for non-GI causes is important for patients with chronic diarrhea that has not improved after gastroenterologist evaluation.
diarrhoea who has been under the also complains of chronic abdominal pain but the pain has got a fixed timing care of a gastroenterologist and has not to intake of food then I would ask for improved and is looking for another Doppler studies of the abdominal opinion. Following is my approach to such mesenteric vessels to rule out a patient where the gastroenterologist mesenteric ischaemia. must have excluded the G.I. causes. 2. Rule out neuro endocrine tumours a. If this patient has rapidly lost weight which in the modern days can be within 3-4 months diagnosed very easily by nuclear b. If this patient has only frequency of imaging called as 'Drotat Scan' or stools and not watery diarrhoea Octreotide Scan -----in following c. If this patient has fast pulse even after patients ; waiting in the clinic for more than half a. If the patient has been having an hour, ------ then, I would look for wheezing like an asthma patient to thyrotoxicosis. rule out carcinoid tumour I would then ask for ;- b. If the patient has symptoms of a. Thyroid blood tests duodenal ulcer also b. Nuclear thyroid scan c. If severe watery diarrhoea with c. Antibodies against TSH receptors hypo-kalaemia (V.I.Poma of the 1. If the patient in addition to diarrhoea small intestine) Ex. Hon. Physician, Jaslok Hospital and Bombay 3. Finally, in a diabetic patient, somato Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant statinoma to be ruled out by nuclear Medical College and JJ Hospital, Mumbai - 400 008. imaging.
The struggle of carotid artery stenting
In the Lancet, Leo Bonati and colleagues describe the results of the international Carotid Stenting Study (ICSS), a randomised controlled trial comparing carotid artery stenting and carotid endarterectomy. In this primary analysis in 1713 patients, the main finding was that, at a median follow-up of 4.2 years, the incidence of the primary endpoint - any fatal or disabling stroke - was virtually identical in the two groups; the difference between the groups was only three events (52 vs 49). Nevertheless, an excess of any stroke was observed in the stenting group, with a 5-year cumulative risk of 15.2% compared with 9.4% in the endarterectomy group (HR 1.71, 95% CI 1.28-2.30), although functional disability and quality of life did not differ between groups. Meta-analysis of randomised trials suggest that, in the periprocedural phase, patients allocated to stenting have a significant excess of minor strokes, whereas patients undergoing endarterectomy have signigicantly more myocardial infarctions and cranial nerve injuries. In patients younger than 70 years, 30-day rates of stroke and death are similar after stenting and endarterectomy, and in the long term the rates of death or disabling stroke are similar for the two procedures at all ages. The Lancet, 2015, Vol 385, 490
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SPO2 of 64% in Your Clinic may not Indicate an Emergency in A Chronic Pulmonary Disease
OP Kapoor
R ecently, I saw a patient of extensive
bilateral thickened pleura. He was operated upon for chylothorax 1 year back oxygen machine. Though, he was breathless like a COPD patient, he was not in respiratory and also had filarial oedema of the legs and distress. I have written the history of this bilateral hydrocoele. This patient is living patient just to stress that although in only on continuous oxygen (concentrator), acute bronchial asthma patient, a fall of nebuliser and bi-pap at home but off and SPO2 to even 95% signifies danger and on goes to the office in a vehicle. He came to even hospitalisation, in a chronic patient my clinic for opinion without any portable even a low level of 64% does not signify impending death. This shows the Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant importance of possessing a Pulse Oximeter Medical College and JJ Hospital, Mumbai - 400 008. (Rs. 2000/-) by a G.P. than a stethoscope!
Natriuretic peptide tests in suspected acute heart failure
A reliable tool for assessing acutely breathless patients Heart failure should always be considered in patients with shortness of breath and reduced exercise tolerance, especially older people, and irrespective of comorbidities such as chronic obstructive pulmonary disease. Symptoms and signs are rarely enough for diagnosis, and additional investigations usually follow. Measuring the serum concentration of natriuretic peptides improves diagnostic accuracy in patients with suspected heart failure in the non-acute setting, and evidence for these tests also being helpful in patients with suspected acute heart failure is growing. Their conclusion that natriuretic peptide concentrations below these thresholds rule out heart failure, with and without reduced ejection fraction, is a major step towards routine use of these tests in emergency departments and the safe but rapid assessment of patients presenting with subacute or acute breathlessness. What about the role of natriuretic peptides in the non-acute setting? Adults with slow onset heart failure typically present to primary care, and studies suggest that measuring natriuretic peptides concentrations can also be useful in this setting: using lower thresholds than those used in acute settings (35 ng/L for BNP and 125 ng/L for NTproBNP). Supporting evidence is incomplete however, and recommended thresholds for excluding heart failure have not yet been fully evaluated. Routine use of tests for natriuretic peptides will improve the management of patients with acute breathlessness. These tests help doctors rule out heart failure quickly and identify those who would benefit from additional confirmation tests, typically echocardiography. Frans H Rutten, Arno W Hoes, BMJ, 2015, Vol 350, 10
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Cost Effectiveness / Yield / Medical Economics Role of Vaccines in Adults in Modern Days OP Kapoor
T here is nothing better than what you
can do to a patient of C.O.P.D. than prescribing vaccines to prevent only. Also Hep. A vaccine should be given to all. Hep. B vaccine should be given only if 'Pneumonias' which kill them. Thus you Anti HBs is negative, unless the patient is give one dose of Inj. Prevener followed by immune suppressed. Inj. Pneumovax vaccine after eight weeks. If young girls who start menstruating Also Inj. Influenza vaccine (Vaxigrip, are brought by the parents then H.P.O. Influvac) should be given every year. In vaccine should be offered to prevent fact, every one above the age of sixty must cervical cancer. Others should be be given these vaccines. educated and then offered. There are many young patients who Finally, incidence of Herpes Zoster travel and lead a fast life and cannot afford increases with age. All elderly patients to lose a day. They should be offered should he vaccinated for this illness. The typhoid vaccine (Typhoid TCV) one dose vaccine is still not available in India and Ex. Hon. Physician, Jaslok Hospital and Bombay the chicken pox vaccine will not serve the Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant purpose. Medical College and JJ Hospital, Mumbai - 400 008.
STEMI care in China: a world opportunity
Since 2005, reductions in door-to-balloon times in the USA have not been associated with improved survival, by contrast with the benefits achieved by acceleration of reperfusion in the preceding decade when these times were much longer than they are today. Across the European Union, meaningful differences in the use of reperfusion therapies (fibrinolysis vs primary percutaneous coronary intervention), and 30 day mortality, have been documented between countries, mostly independent from the organisation of health care and economic wellbeing within specific countries. Notably, only about eligible patients with ST-segment elevation myocardial infarction (STEMI) in COMMIT received reperfusion therapy (principally urokinase). More than 85% of the overall acute myocardial infarction cohort had STEMI. Nonetheless, no change was noted from 2001 to 2011 in the frequency of reperfusion therapy (which stood at 55% overall in 2011, much the same as in COMMIT), and just over a quarter of patients admitted with STEMI in 2011 underwent primary percutaneous coronary intervention (an increase from 10.6% in 2001). Notably, the median symptom onset to hospital admission time remained more than 12 h throughout the study period. In many countries primary percutaneous coronary intervention is now used in more than 80% of patients receiving reperfusion therapy. Major emphasis must be placed on early patient presentation (requiring public education of acute myocardial infarction symptoms and prompt response), followed by rapid diagnosis and reperfusion therapy in all appropriate patients (ultimately with primary percutaneous coronary intervention or a pharmacoinvasive stragegy). Ajay J Kirtane, Gregg W Stone, The Lancet, 2015, Vol 385, 400-401
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Symptoms and Signs/Obsolete/Evergreen/New Oedema in a Patient of Joint Pains and Fever OP Kapoor
I n a patient of acute illness of fever with
severe joint pains, chikungunya comes high in differential diagnosis. There are What I would like to stress is that appearance of oedema of the leg or any part of the limb is in favour of diagnosis of patients who are not very clear in chikungunya. Unlike this fluid collection their recognition of joint pains with very in the limbs, in dengue fever there is also severe bodyache as seen in dengue small bilateral pleural effusion in the chest fever. and fluid in the abdominal cavity. The Ex. Hon. Physician, Jaslok Hospital and Bombay aetiology of all this fluid collection is not Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant very clear. Rarely, facial oedema may be Medical College and JJ Hospital, Mumbai - 400 008. noticed.
Management and prevention of exacerbations of COPD
In general, viral and bacterial infections are the most important triggers of exacerbation. Previous data have suggested that the median duration of recovery time after an acute exacerbation is 7-10 days for lung function as measured by peak expiratory flow, although there is wide variation, and a minority (<10%) of patients never recover to their pre-exacerbation lung function. About a quarter of inpatients treated for an acute COPD exacerbation do not respond to initial treatment and experience adverse outcome, defined as either death, intubation, or need for readmission or intensification of drug therapy. Clinical trials have shown that the addition of oral or intravenous corticosteroids to antibiotics significantly decreases treatment failure rates in inpatients with COPD exacerbations and prevents relapse in outpatients with an exacerbation. A recent RCT suggested that, in patients presenting to the emergency department with acute exacerbation of COPD (most of whom were admitted), a five day treatment course with 40 mg of prednisone daily was non-inferior to a 14 day treatment course. Gold guidelines recommended that patients with severe dyspnoea, increased work of breathing, and respiratory acidosis (pH ≤7.35 or arterial carbon dioxide pressure ≥45 mm Hg, or both) should be considered for this treatment, provided they are conscious and able to protect their airway and deal with respiratory secretions. Two classes of bronchodilators are in widespread use for COPD: long acting antimuscarinic agents (LAMAs) and long acting â agonists (LABAs). The tiotropium powder inhaler is the best studied LAMA. The recent systematic review on chronic tiotropium therapy in COPD suggests that, compared with placebo, tiotropium reduces COPD exacerbations by 22%. Clinical studies suggest that LABAs can also prevent exacerbations, although the effect size is slightly less than for LAMAs. Moxifloxacin is a respiratory fluoroquinolone with activity against bacteria that are associated with COPD exacerbations. However, this subject is controversial. The safety of disease self management and exacerbation action plans needs further assessment before this strategy can be recommended for all patients. Shawn D Aaron, BMJ, 2014, Vol 349, 27-30
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Viral Fevers with Rash OP Kapoor
T here are 5 viruses which can cause
skin rash in an adult patient having fever. Unfortunately, a skin rash may not 2. Chikungunya - macular papular rash can often occur 3. E. B. Virus - in infectious mono- appear on the first 1-2 days and nucleosis often rash is precipitated sometimes appears when the fever is when ampicillin is prescribed to the subsiding. patient The following are the viruses which can 4. H1N1 virus - in a patient with swine cause rash :- flu, rashes have been reported though 1. Dengue - rash of dengue usually not very common appears after 3-4 days 5. HIV Virus - any patient coming with Ex. Hon. Physician, Jaslok Hospital and Bombay fever and an undiagnosed rash, blood Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant HIV test must be done to exclude that Medical College and JJ Hospital, Mumbai - 400 008. virus.
Potential Relief for Refractory Angina
The mortality among patients with refractory angina is surprisingly low, but the effect of persistent, recurrent, and frequent symptoms on quality of life is substantial and emphasises the need for alternative therapeutic options. The newest drug in this therapeutic area, ivabradine, which is approved in Europe, has been shown to reduce angina and improve exercise time in patients with chronic coronary disease. However, its role has been called into question on the basis of the results of the Study Assessing the Morbidity- Mortality Benefits of the If Inhibitor Ivabradine in Patients with Coronary Artery Disease (SIGNIFY) trial. SIGNIFY showed that ivabradine may be harmful for patients with activity-limiting angina with regard to cardiovascular death and myocardial infarction. Although coronary-artery bypass grafting and percutaneous coronary intervention have been well established as therapies for patients with angina, there is also a long history of studies of other interventional procedures for such patients, including internal mammary-artery implants (Vineberg operation), intrapericardial talcum powder or asbestos, internal mammary artery ligation, omentopexy, transmyocardial laser revascularisation, gene therapy, and more recently, cell therapy. Another approach, manipulation of coronary venous return to improve perfusion of ischaemic myocardium, has been studied with a variety of methods including partial or complete occlusion of the coronary sinus, in a fixed or dynamic fashion, with or without retroperfusion, and in a variety of preclinical and clinical settings. The Coronary Sinus Reducer for Treatment of Refractory Angina (COSIRA) trial, the results of which are now published in the Journal, was a double-blind, sham-controlled trial of a coronary-sinus reducing device in patients with refractory angina. Should trials such as the COSIRA trial, to be more convincing, include an assessment of whether the blinding procedure was effective, since the interpretation depends on that assumption? What do we conclude from the COSIRA trial? The study, although small and thus inconclusive, was well performed and showed significant improvements in reducing angina and improving quality of life. If confirmed in subsequent trials, coronary-sinus reducing therapy may be a welcome and needed addition to the options to improve the quality of life of patients with refractor angina. Christopher B. Granger, Bernard J. Gersh, N Engl J Med, 2015, Vol 372, 566-567
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Disease Pattern In India Should the Word 'Bronchitis' Be Used - in Private Practice OP Kapoor
A lthough, in most of the infectious
fevers, bronchitic cough is often present as a part of general viraemia (or bronchitis can occur because of the underlying bronchiectasis or other allied conditions. septicaemia?), a patient presenting with It will be a good habit, if all other cough as the only symptom should not be coughs are treated as "Bronchial Asthma" diagnosed as a case of Bronchitis, unless (without Asthma). Other conditions in the he is a smoker. differential diagnosis of this illness would There are other conditions where include Tropical Eosinophilia, Intestinal Ex. Hon. Physician, Jaslok Hospital and Bombay parasites and many other allergic Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant disorders. Medical College and JJ Hospital, Mumbai - 400 008.
â blockers, atrial fibrillation, and heart failure
â blockers have revolutionised the treatment of patients with heart failure and reduced ejection fraction. These guidelines state that â blockers are indicated in all patients, except those with atrioventricular block, bradycardia, and asthma. Patients with atrial fibrillation differed in a number of important ways from those without atrial fibrillation - e.g. they were older, more often men, had worse symptoms, and were more commonly treated with digoxin and amiodarone. The results of the present meta-analysis suggest that â blockers are unlikely to be harmful to patients with heart failure and reduced ejection fraction and atrial fibrillation. Because these patients are particularly high risk, it is our view that as the possibility of benefit remains, practice should not change until these new findings are scrutinised further. Additional issues should be addressed before any conclusions are drawn, such as the possibility of a drug interaction between digoxin and â blocker treatment, unmeasured confounding such as a conduction system disease or pacemaker use, potential benefit in patients with previous myocardial infarction, and whether patients with milder symptoms might respond differently to those with more advanced disease. Perhaps the greatest concern of all is that we have no clear explanation for the current findings. The Lancet, 2014, Vol 384, 2181-2182
Inuit Got Cancer On Paleo Diet - Arctic Eskimo Primal Low-Carb Native Non-Vegan Paleolithic Diet of Fatty Fish & Meat Now Found Harmful and Resulted in Disease and Death