Biopsy a diagnostic tool to diagnose cancer and other disease

There has been always a mixed thought among the individuals and many of us thinks it as a dangerous mode of diagnosis which may actually aggravate the disease or may lead to rapid spread of the cancer, if it is present. the fact is biopsy is themost important, harmless and confirmatory method of diagnosis of many cancers and other diseases. here I have narrated the facts of biopsy and its use and preocedure in various diseases.

Biopsy for diagnosis of cancer

Biopsy is the term when asked to do, chills down the spine of an individual as one straightway imagine that he or she is suffering from cancer. But this is not always true. Biopsy is meant for investigation and is not always used to detect cancer but also the diseases like tuberculosis, infections and cancers too.

There is nothing more severe surgery during biopsy as in this procedure, a part of the ulcer or tumor is incised and sent for investigation. The detection of disease is done according to the cellular pattern of the tissue incised.

Biopsy is a painless procedure and can be done as an outpatient s procedure. There are myths that biopsy may lead to spread of cancer which is absolutely false. It creates no harm and neither it spreads cancer or any disease.

Some common biopsies

Here are the discription of some common biopsy encountered in the field of medicine to diagnose some important diseases.

Endometrial biopsy

Endometrial biopsy is done in a patient with irregular bleeding. The lining of the endometrium is taken and sent for examination. The process to take the sample may be by dilatation and currettage or hysteroscopy.

Dilatation and curettage is done under genral anaesthesia and the endometrial lining is take as a sample for investigation. Hysteroscopy is done by inserting a fibre-optic tube and taking the tissue in the presence of bright light.

Endometrial biopsy is done to diagnose dysfunctional uterine bleeding, endometrial cancer, endometritis and even any polyps.

Prostate biopsy

It is the most common investigation done for a man above 50 years of age and have history of hesitency, increased frequency and retention of urine. The biopsy is recommended if there is any doubt in the consistency or size of the prostate in digital rectal examination. The biopsy material is taken through rectal route by inserting a proctoscope. Though a prostate specific antigen is diagnostic for prostate cancer.

Liver biopsy

Liver biopsy is done to diagnose certain diseases like hepatitis, hepatoma or liver cancer and even it is a good diagnotic tool for cirrhosis of liver. The biopsy material is taken by inserting a needle between the lower two ribs that is 9th and 10th ribs under local anaesthesia and the liver tissue is taken out with the help of that needle for histological examination.

Skin biopsy

Biopsy of skin is most important diagnostic tool for skin diseases as this is the only confirmatory method to diagnose skin cancers. Most skin biopsies are done under local anaesthesia with an injection. A shave biopsy is good for diagnosisn basal cell carcinoma while a punch biopsy is good to diagnose squamous cell carcinoma and melanoma of skin.

Bone marrow biopsy

Bone marrow biopsy is done by insertin a needle in the iliac crest a bone near the hip joint. It is the region which is protuded at the hip. But in some case biopsy can also be taken from the sternum or breastbone. It is a painful process thus done under local anaesthesia. The bone marrow material is sucked by aspirating needle and examined. Bone marrow biopsy is helpful in diagnosing leukemias, lymphomas, kala azar and certain diseases related to blood.

Breast biopsy

Breast biopsy determines whether the lump of the breast is a benign or a malignant cancer. Breast cancer is the most common cancer in females world wide and breast biopsy is most important diagnostic tool. In some cases where there is a family history or there is any doubt of malignancy, whole breast is excised and then sent for biopsy.

Bone biopsy

Bone biopsy is done to diagnose certain diseases like tuberculosis and cancer of the bones. It detrermines the type of cancer whether it is ewings carcinoma, osteosarcoma or soteoid osteoma.

A biopsy is taken either at the operation theatre or as the outpatients procedure and examined at the histopathological centre. Thus it is important the the viability or the microcellular structure of the material should remain intact till a slide is prepared and examined, Thus the material is kept directly in formalin solution to carry and it should be immediately sent to the laboratory for examination.

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Targeted therapy in cancer

Chemotherapy is an essential part of treatment of various cancers. It can be used to improve the quality of life as palliative treatment or can be used prior to other modes of treatment (neoadjuvant therapy) or to destroy remaining cancer cells after other modes of treatment (adjuvant therapy). Details of chemotherapy, its mode of delivery, side effects etc is given at Chemotherapy in Cancer Patients.

In the recent approach to treat cancer target therapy and hormonal therapy has been a boon. Though the cost of treatment is prohibitive for common people but there are several patient benefit schemes.

What is targeted therapy for cancer

Targeted therapy for cancer is an approach where the molecular defect of a particular type of cancer is detected and targeted with sophisticated molecules in order to eradicate the disease from the grassroot level. The targeted therapeutic agents interfere with specific molecules involved in carcinogenesis and tumor growth.

How targeted therapy in a cancer works

The targeted therapy agents are generally administered orally or as an injection. They are organ specific and target on protiens of the cancer cells which are involved in the signaling process. Thus interference in the signaling process hampers further growth and multiplication of cancer cells. As the targeted therapy is organ specific, the side effects are much less than normal chemotherapy.

Types of targeted therapy of cancer

There has been lots of clinical trials to test new treatment options for patients suffering from cancer. A few trials came with some types of targeted therapy which are

Apoptosis-inducing drugs

These drugs enhances the apoptosis or cell death of the cancer cells. One of the example is Velcade (bortezomib) which causes destruction of cancer cells by blocking enzymes called proteasomes, which help to regulate cell function and growth of those cells. Velcade has been successfully used in treatment of multiple myeloma. Another example is Genasense (oblimersen), which blocks the production of a protein known as BCL–2, which promotes the survival of tumor cells. This drug has been successfully tried in various leukemia, lymphomas and other solid tumors.

Small-molecule drugs

These drugs act on specific enzymes used by cancer cells for their growth. Gleevec (Imatinib mesylate) is an example which acts by targeting abnormal proteins, or enzymes, formed within the cancer cells and stimulate uncontrolled growth. Gleevac has been successful in treatment of chronic myeloid leukemia and certain gastrointestinal cancers. Another drug Iressa (Gefitinib) has been successfully used in small cell cancer of the lungs which is very much sensitive to chemotherapy. Iressa acts by destroying or inhibiting epidermal growth factor receptors.

Many more researches are going on and newer options in the form of gene therapy, monoclonal antibodies, vaccines are being tried. The goal of this trials are obviously to treat cancer and eradicate from grassroot level.

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Treatment and Prevention of Swine flu

Swine flu which has been in the news for last few days due to its another outbreak starting at Mexico and now spreading globally has created a panic worldwide, all steps are taken to restrict its spread so that it may not comes out to be pandemic for which the disease is quiet capable of.

Swine flu is a viral disease caused by orthomyxovirus, an influenza virus and this time a new strain H1N1 has been seen. For details about Swine flu one may see Swine flu and mode of its spread.

The symptoms are that of other flu consisting of high fever with chill, fatigue, coughing, sneezing, sore throat and sometimes even diarrhea and vomitting. Death takes place due to severe respiratory infection leading to dyspnoea and respiratory failure. Diagnosis is done by history of contact and some investigations confirm the diagnosis. Details can be seen at Symptoms and diagnosis of Swine flu.

Though it is better to take a measure to prevent ourself from this disease, but still those who had got infected should start treatment as early as possible.

Treatment of Swine flu

Traditionally amantadine and rimantadine are the antiviral agents used for influenza virus, but the newer strain of this virus in this outbreak is resistant to these antiviral agents.

As per Center of disease control (CDC) recommendation there are two antiviral agents which has been effective in treatment of Swine flu, these are Tamiflu (oseltamivir) and Relenza (zanamivir. These antiviral agents helps to recover faster and also prevents from life threatening complications. The treatment should be started as soon as possible preferably within 2 days of symptoms even without confirmatory diagnosis.

Many suggests that these drugs are not required as it is a self limiting disease, but now the role is proven and should always be taken without any hitch.

Vaccine for Swine flu

In 1976 when there was an outbreak of Swine flu, vaccines were made available and many person who has been vaccinated at that time may be in euphoria that they are protected, but the fact is previous vaccine is not at all protective as this is a different strain of influenza virus and till date there is no vaccine for this virus. Though WHO is in process to develop vaccine against this but one should not wait and should take other precautionary measures.

There are vaccine for influenza virus and those who are not immunized should take the vaccine as it protects from many types of flus though not the Swine flu causes by genetically modified H1N1 strain.

Prevention of Swine flu

This is the most important and probably the most recommended step to fight against this outbreak of Swine influenza virus causing flu.

The most important step is to restrict its spread by hamperin he mode of spread. The disease occurs primarily in pigs but it is not necessary to avoid porks as the virus is killed above 70 degree centigrade. So the pork should be well cooked before taking it.

The disease spread through respiratory tract so a face mask shoud be used while going out to avoid being infected through aerosols.

The centre of disease controls recommends following preventive steps to be taken.

* Hands should be properly washed and preferably by an alcohol based cleanser. Alcohol is supposed to be a virucidal.

* People should avoid touching their nose, throat, mouth and even eyes as the these are the places where viruses are present and by touching them it may even spread by contacts apart from aerosols.

* There should be proper disposal of coughs and sneeze in an alcohol containing garbage. If the cough spreads on the body or hand it should be immediately washed.

* One should not come in contact of a sick person and there should be at least 6 feet distance from a sick person.

* A health personnel or anyone who have to come in contact with sick person should use personal protective equipment that should be fit-tested N95 respirator [if unavailable or wear a medical (surgical mask)].

* If you are travelling cooperate with the authority who checks for the fever and follow their rules and regulations.

A preventive measure is utmost necessary and this is the only step which can restrict this outbreak of Swine flu from being pandemic.

I will request all the readers to go through the entire article and ask all their doubt and like a responsible person help the world to fight against thsi deadly outbreak of Swine flu.

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Symptoms and diagnosis of Swine flu

The recent outbreak of Swine flu in Mexico and now spreading in USA, New Zealand and other American and European countries has created a panic among people as it has already taken about 150 lives in Mexico alone.

The causative organism is same a virus of orthomyxovirus group but this time with a different strain, thus even a vaccinated person is not safe enough. This time the strain in H1N1 a genetically modified strain. The virus primarily infect pigs and human beings are the secondary hosts. The disease is highly contagious and spread mainly through respiratory tract by coughing and sneezing. Details about Swine flu and its mode of spread can be seen at Swine flu and its mode of spread.

As the disease is deadly dangerous one must not be casual and should always emphasize and judge their illness and if any doubt arises should rush to the hospital and inform the Centers for Disease Control and Prevention.

The diagnosis of Swine flu mainly depends on the signs and symptoms it produces and based on this the investigation is done to detect the virus.

Signs and symptoms of Swine flu

The person suffering from Swine flu may be febrile and the temperature may be high above 100 to 102 degree F. There may be malaise and bodyache, nausea and vomitting can occur. Upper respiratory symptoms including sore throat, coughing and sneezing may be present. There may be early sign of fatigueness and dehydration due to diarrhea in later stage.

Nasal congestion and rhinorrhea may be seen and in some cases even eye may show the signs of conjuctivitis. In severe case there may be pneumonia and may lead to respiratory failure which the cause of death due to Swine flu. Respiratory distress with fever may be the warning sign and should be investigated immediately.

Who should be investigated for Swine flu

As the sign and symptoms of Swine flu is more or less same as other viral illness causing flu, it is difficult to select a candidate for diagnosis, though during outbreaks as it is at present all cases of fever with acute respiratory illness should be investigated for Swine flu.

In general the investigation for Swine flu should be done in all suspected case which is defined as as a person with acute febrile respiratory illness with onset within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection.

A close contact means a contact with an infected person within about 6 feet of an ill person who is a confirmed case of swine influenza A virus infection.

Investigations are done to confirm a case, the investigations required in a suspected case of Swine flu are

Investigations for Swine flu

To confirm a suspected case of Swine flu following investigations are done. Though a proper history always holds the key to detects the close contacts and suspecting a case.

Reverse transcriptase-polymerase chain reaction (RT-PCR)
In this detection and quantification of mRNA is done. This test detects the viral load in an individual.

Viral culture
The throat swab is generally taken to culture virus from the suspected cases. Though if it is not detected doesnt rule out the disease.

Detection of antibodies
This is a sensitive test and there is four-fold rise in swine influenza A (H1N1) virus-specific neutralizing antibodies.

Thus a timely detection and confirmation of the case can not only save the life of the sufferer but can also be helpful in restricting the spread of the disease, as the outbreak is in a danger to be global and can take a shape of pandemic.

The treatment and prevention is the field where the concern should be at utmost priority. To know about treatment and prevention please see Treatment and Prevention of Swine flu.

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Swine Flu - A new terror spread at Northern America

Swine flu has been creating a panic in Northern America and most of the cases has been detected in Mexico, about 11 cases has been reported in USA, almost all countries has been alert for this disease caused by influenza virus or orthomyxovirus. Though there are several serotypes of influenza virus causing swine flu like H1N1, H1N2, H3N1, H3N2, and H2N3. But now a days H1N1, H3N2, and H1N2 subtypes are creating terror. In earlier days it was H1N1 subtype as the main cause prior to 1998 and the role of pig was demonstrated after 1998 when H3N2 subtypes was isolated in them.

What is swine flu

Swine flu is a flu like syndrome usually affecting respiratory tract and is highly infectious caused by the group orthomyxovirus. It is completely different from the bird flu which was in limelight in 2004. This disease is usually transferred from infected pig to human, but there are also reports suggesting its spread directly from man to man via aerosol.

The swine flu is most contagious disease especially in the early days that is first 7 days which is generally the incubation period and the disease is not manifested, thus a preventive approach is utmost necessary even when one is in contact with normal appearing person during outbreaks.

Outbreaks of Swine flu

2009 outbreak is the third outbreak of swine flu and has started from Mexico, though cases has been detected from US and other parts of Northern America. Genetic resortment in the strain of H1N1 is the major culprit for the outbreak which are stealing sleeps now a days.

It has already taken 100 lives at Mexico, while cases has been detected in USA, New Zealand, Spain and even Hong Kong. As it is highly infectious and due to the continuous genetic changes in the virus, anti viral drug could not target the virus, a precautionalry measure is the best way to stop this disease to become pandemic globally.

Earlier outbreaks of Swine flu

It was in 1918 when the first outbreak of Swine flu was occured and was due to serotype H1N1, it became pandemic, in 1976 it was again detected and Fort Dix was the sufferer who died due to this, then vaccination against this was developed. In 2007 a genetically modified virus again spreaded thier disaster in Philippines. Thus the conclusion stays that in spite of being too much dependent on vaccination, it is better to have other precautionary measures.

How does swine flu spread?

Swine flu like any other flu is an infection of respiratory tract and this is the place where the virus reside. Primarily the disease occurs in pigs and the respiratory trsct of pigs are the reservoir for this virus. Once a human being gets infected then coughing and sneezing spreads the virus from one to another. The human being is infective upto 7 to 10 days after getting infected and can pread infection during that period even by being close as the air route is the mode.

The myth that it can spread by eating pork is absolutely false. The virus is thermosensitive and gets destroyed above 70 degree centigrade. Thus a well cooked pork is absolutely safe and can be take. Though uncooked and improper cooking may be at risk.

The climate ideal for the virus is at the beginning of cold but the recent outbreak has turned out to break this rule and even summer season is not spared.

If any one suffering from fever and cough, coryza should immediately attend the hospital and get themselves investigated and diagnosed as it has been declared as a medical emergency in many countries.

Don,t forget to visit Symptoms and diagnosis of Swine flu to know whether your fever is due to Swine flu or not.

There are some antiviral still which can be effective, though the newer strain of virus is resistant to most of them, so better is to prevent ourself from getting infection. So please visit Treatment and Prevention of Swine flu.

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Loosing weight after child birth - Never do these mistakes

A young mother always gives the utmost importance to loosing weight after childbirth. Some may go for extra effort and do some mistakes which should always be avoided. If these mistakes are avoided, then it be not only benefit mother but also to the newborn child also.

It can become frustating for a woman to find herself with extra pounds after childbirth, but losing weight after childbirth is a process that should not be taken lightly. Giving birth is probably the single, most demanding experience a woman can put her body through.

Although giving birth is a blessed event, there are precautions a new mother should be aware of, especially where losing weight is the goal. Losing weight too rapidly can be hazardous. Just as the birthing process took time, so should losing weight after pregnancy be done with patience.

As a doctor just I want to clear three important things to young mother, who are in too hurry to lose their weight after child birth.

Don't neglect nutrition

There is huge demand for proper nutrients by the body during and after pregnancy. After pregnancy all mothers need continued nutrition so that they can be healthy and active to take care of their baby. Never restrict your calorie intake as restricted calories can often equal less nutrition. Most lactation experts recommend that breast feeding mothers should eat whenever they are hungry. But many mothers may be so tired or busy that food gets forgotten. So, it is essential to plan simple and healthy diet.

Although high calorie intake is recommended after pregnancy, but those foods should better be avoided which contains high calories but less nutritive value like junk foods, fast foods, beverages like colas, tea, coffee etc. Carbonated drinks should be taken to a minimum. More fruits, milk and milk products and proteins intake should be encouraged.

Don't begin exercise too early

Most of the women are so much worried for thier weight gain during the entire pregnancy period, that they start vigorous exercise to shed their extra fats and weight as early as possible, but this should be avoided. The uterus expands to its maximum during the pregnancy and even after child birth, it doesnt regain its original size immediately. It takes about 6 weeks for involution of uterus to its original size, the period known as puerperium.

Most women with normal vaginal delivery can begin a formal exercise program after the puerperial period of 6 weeks is over, though this time frame may be slightly longer for some women especially those delivering be caeserean section. The skin may heal earlier but the internal wound may still be raw in caeserean section thus starting an execise program too soon will delay the recovery and could potentially injure the women's body permanently.

Don,t give up rest

Rest is very important for a new mother, but the fact is that no one misses sleep like a new mother. A baby's first few things are very busy, hectic time that will put big demands on the mother's routine. Ongoing sleep disturbances can lead to irritability and depression which can be another reason for weight gain. It also affects decesion making. It is hence, important to rest whenever possible. Many woman thinks day sleeping can be a reason for weight gain, but in a new mother it does not apply. The best way for a woman is to sleep when the baby sleeps.

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Chemotherapy in Cancer Patients

Chemotherapy is a treatment modality of cancers and can be used as a lone measure or with other modalities like surgery and radiotherapy. Chemotherapy actually acts as a growth barrier for the cancer cells, but the main drawback is that it also harm the healthy cells which have the capability to divide rapidly such as cells of oral cavity, hair follicles or intestine.

Role of chemotherapy in cancer

Chemotherapy is given with an intention to perform a role in curing the patient, to control cancer complications or to ease cancer symptoms to improve quality of life which is called palliative treatment.

Many a times chemotherapy is used in an improvised manner to facilitate other modes of treatments like making a tumor compact and smaller so that in can be removed surgically or can be destroyed by radiotherapy. This is also known as neoadjuvant therapy.
In many cancer a surgery or radiotherapy is done and the remaining cancer cells are destroyed by using chemotherapy, this type of therapy is called adjuvant therapy.
Thus as a whole chemotherapy in a cancer patient can be a mode of treatment either alone or can precede or succeed to other modalities of treatments.

Do all cancer patient need chemotherapy

No all cancer patients may not require chemotherapy, it depends on the type and sensitivity of a cancer cell towards the chemotherapeutic agent. A doctor decide based on this and on the basis of age, general health, nutritional status and any associated diseases like diabetes, renal failure, asthama or hypertension or any heart disease.

The dose may even vary from person to person even if the cancer type is same. The dose depends mainly on body surface area of the patient. Thus two person getting chemotherapy for same cancer may have different doses and the cost of treatment may vary.

What are modes of administration and treatment schedule of chemotherapy

There are various modes to administer chemotherapy, it may be injectable, oral or even topical. An injectable chemotherapy can be given either intravenous which is rapidly absorbed as directly infused in the blood or may be intramuscular which absorbs and then goes to the circulation.

Chemotherapy is given in cycles and it depends on the type of drugs used forchemotherapy to determine next cycle. If may be daily, weekly or even monthly. In this gap period the body is rested and allow time the body to rest and produce new, healthy cells. The number of cycles depends on the attending oncologist and physician.

Usually but not as a rule 6 cycles of chemotherapy is given, but sometimes chemotherapy agents are given till disease progression. Sometimes doctors may change the chemotherapy agents or alter the schedule of cycle depending on the tolerance and toxicity. Some patient may not respond to one set of chemotherapy agents may be shifted to another set.

Side effects of chemotherapy

Side effects of chemotherapy generally depends on the health status of the patient before going for chemotherapy, type of chemotherapy agent used, type of cancer and and stage at which it is diagnosed. Profile and dose of chemotherapy also play a part in side effects.

The most common side effects encountered during chemotherapy are nausea, vomitting, cramps and poor appetite. There may be hair loss which is not permanent, dry mouth,mouth sores (stomatitis), difficult or painful swallowing (esophagitis),
diarrhea, constipation, fatigue, bleeding, susceptibility to infection and infertility.

The serious side effects may include damage to liver, heart, kidney, lungs and brain. Apart from that individual chemotherapy agent may have specific side effects.

Are side effects of chemotherapy managable
Now a days there are some wonderful medicine available to combat the side effects and are given upfront to tackle these side effects successfully. For example ondansetrones are very much effective in tackling chemotherapy associated vomitting. Mesna is used for prevent the renal side effect hemorrhagic cystitis caused by use of cyclophosphamide.

Point to remember - During chemotherapy most of the patients starts consuming vitamins, health drinks and other various nutritional supplements. It is advisable not to consume them without doctor,s recommendation as these may reduce the efficacy of chemotherapy.

There are something more to know about cancer, for them look at

Types, causes and symptoms of cancer.

Some common facts about cancer.

Healthy food for cancer patients.

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Thyroid disorders causes depression

Hypothyroidism is a very common entity seen in our clinical practice, there are many symptoms encountered for which one may suspect of hypothyroidism like baradycardia or low pulse rate, goitre, cold intolerance weight gain, decreased libido etc. There may be changes in skin and hairs too.

Hypothyroidism and depression

One of the most common symptom of hypothyroidism is depressed mood. Hypothyroidism can often lead tofrank depression that usually respond to thyroxine treatment. However most patients with major depression are euthyroid. On further assessment, a number of subtle abnormalities in the hypothalmus-pitutary axis occurs in large proportion of depressed patients that include alteration in serum concentration of thyroid hormone and TSH.

According to the review made by studies done, the prevalence of depressive symptoms in hypothyroidism is approximately 50%, whereas in hyperthyroidism it reaches upto 28% of the cases. Clinical depression is reported to occur in less than 40% of cases of people suffering from hypothyroidism. There is a strong possibility that the presence of subtle thyroid dysfunction is a negative prognostic factor for depression and may demand specific therapeutic intervention.

Thyroid dysfunction and depression have overlapping features that can cause misdiagnosis. In addition to specific symptoms of hypothyriodism likeconstipation, appetite decrease, decreased concentration, decreased libido, delusions, depressed mood, diminished interest, increased sleep, weight gain and fatigue seem to appear more frequently in patients with comorbid depression and hypothyroidism. Hence the presence of these symptoms should be a warning sign to clinicians for the need of thyroid investigations.

Action of thyroid hormone on brain

Thyroid hormone has important actions in the adult brain, and is associated with neuropsychiatric complaints and symptoms. These symptoms constitutes a long spectrum of emotional and cognitive problems directly related to changes in the brain secondary to multiple factors, and the major factor include direct effects of thyroid abnormalities and hormone deprivation.

In severe hypothyroidism there may be melancholic depression and even dementia. On treatment there is an improvement and may even comes out to be in a normal stage when a patient becomes euthyroid.

Diagnostic criteria in hypothytoidism with depression

The thyroid cause of depression can be established by seeing the following diagnostic criteria.

A positive family history increases the risk of having a thyroid abnormalities in a patient with depression.

If the depression or anxiety is of acute onset or occurs suddenly, then a thyroid abnormality can be suspected.

It is a general feature that depression is commonly seen in hypothyroidism while a panic attack or anxiety neurosis is seen in case of hyperthyroidism.

When a depression doesnt respond to conventional antidepressant the cause of depression may be suspected due to hypothyroidism, the cerebrospinal fluid is thus examined which may show increased free T4 level. This decreases on treatment and thus a patient may show signs of improvement.

Thus depression may be treated by behavioural therapy, antidepressants, but when there is no improvement, dont forget to analyse thyroid status of the patient.

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Artificial or sugar free sweeteners for diabetes

Sugar has been considered as a contraindicated product in diabetes and person with diabetes lose its sweetness in terms of food. No sweets, no sweet dishes makes a depresive meal and to combat that there are some alternative sweeteners which can be used in place of sugars. These alternative sweeteners are either without any calories or have very less calories.

Types of alternative or sugar free sweeteners for diabetics

There are generally three types of alternative sweeteners available which can be safely used in diabetics, these have either no calorie or very less calorie. Some sweeteners are non glucose carbohydrates.

i. Artificial swwetener without having any calorie like saccharin, sucralose, acesulfame-K and cyclamates.

ii. Aspartame is another artificial swwetener, though considered as non caloric but contains some caloric value of 4 calories per gram.

iii. The third type of alternative sweeteners are non glucose carbohydrates like fructose, xylitol, sorbitol polydextrose, maltodextrose and isomalt.

How much safe are alternate sweeteners or sugar free sweeteners

There are several myths and misconceptions regarding safety of these sugar free sweeteners. These nonsenses are spreaded at many internet sites and many tabloid newspapers.

There has been controversies about causing bladder cancer by saccharin in rats, but human beings are not rats, but there has been intensive studies for saccharin and are determined to be safe. It is the most used sugar free sweetener in India specially in tea and coffee. But there is not any reports of increasing incidence of bladder cancer among them.

Similarly Aspartame suffers from the rumor of causing Alziemer's disease, Parkinson,s diseae and even multiple sclerosis. One of the most consistent harmful effects attributed to the use of Aspartame is brain cancer. But after an intensive study now American Cancer society, Food and drug Act (FDA) and National Cancer Institute all claimed that Aspartame is not related to any cancer and there is no increase in the incidence of brain cancer due to the use of aspartame.

There are similar several rumors about sucralose, acesulfame-K etc but studies have discarded all these rumors.

Who can use alternative sweetener or sugar free sweetener

All diabetics and obese persons should use this sugar free sweeteners, women who are more health conscious and wants to avoid calorie intake can use it.

Though sugar free sweeteners are safe enough still, personally I recommend to to be used by pregnant ladies and children in large quantities.

In pregnant ladies it should be avoided because of the tendency of sugar free sweeteners to cross placenta and can be exposed to fetus. The fetus is unable to excrete them properly and the bladder of fetus might be exposed to sugar free sweeteners for longer time.

Children needs calories for proper growth and development, thus in children there is no role of sugar free sweeteners merely to have calorie free sweeteners.

I will be describing the role, safety profile and use of each sugar free sweetener individually. Do visit the site again.

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Effects of diabetes on eyes

Diabetes is a chronic disease and not a single organ is spared from its effects. The incidence of diabetes is rising exponentially. As far as effect of diabetes on eyes are concerned, it should be remeberred that in India, diabetes ranks the second most common cause of blindness, just after cataract, while in many Western Countries, it is so far the most common cause of blindness.

It is a well known fact that retinopathy can occur in many Type 2 diabetes mellitus patients, thus a it is essential to have a basic baseline evaluation of vision in all patients with type 2 diabetes.

Visual evaluation in diabetes

A visual evaluation in a patient of diabetes should include a complete nd detailed history of visual symptoms. There may not be complete loss of vision initially, but blurring of vision, double images and difficulty in reading may be seen and should be assessed.

Measurement of visual acuity and intraocular pressure is mandatory. Refractory errors should always be corrected after a period of stable control. Cataract and glaucoma, specially open angle glaucoma are more common in diabetics and should be actively assessed with special focus and attention.

Ophthalmic examination through dilated pupil should be done and retina should be examined by fundoscopy and retinoscopy to see and neovascularization or any small microaneurysm which are the earliest changes in eyes of a diabetic.

Patients of diabetes at special risk for eye problems

It is necessary to give a special attention to patients who are at special risk. The patients at special risk include

* Diabetic women who are planning a pregnancy. In these women a detailed eye examination should be done. A person must know that mere checking of refractory error at Snellens chart is not enough for a detailed eye examination. Retina, choroid and fundus should be examined in detail by an ophthalmoscope.

* All pregnant should undergo a detailed eye examination for the presence of retinopathy at the time of diagnosis and then as frequently as required depending on the findings and conditions.

* Those patients who are hypertensive and are smokers are at special risk. If the urine shows the presence of microalbuminuria, then also that patient is at special risk and should be dealt accordingly.

* A patient having detoriation in visual acuity or having an unexplained visual symptoms, retinal abnormalities or increase in intraocular pressure with or without frank glaucoma are at special risk.

* Any patient having retinopathy which may be either preproliferative which constitutes findings like cotton wool spots on retina, multiple intraretinal hemorrhage, venous beading or intraretinal microvascular changes or abnormalities, or with proliferative retinopathy including features like preretinal or vitreous hemorrage, formation of new blood vessels in retina called neovascularization, traction retinal detachment or fibrosis of the vessels or with macular edema haqving features or hard exudates constituting lipids.

The examination of the eye in these patients at high risk should always be done at regular interval as once a frank diabetic retinopathy occurs, it is tough to treat.
One should follow the schedule of eye examination as mentioned below as prevention is always a better step than cure.

Schedule of examination of eye in diabetes

The schedule of examination of eye depends on the type of diabetes and condition of the patient if there is an special case like pregnancy. The schedule recommended is as follows-

Examination schedule of eye in Type 1 diabetes

Type 1 diabetes is not age related and can be present even in young ones and is insulin dependent. As diabetic retinapathy depends on the duration and not the extent of blood glucose, the first examination of the eye is recommended within 3 to 5 years after the diagnosis of the diabetes once the patient is above 10 years of age. The follow up examination should be done annually even if there is no signs and symptoms.

Examination schedule of eye in Type 2 diabetes

Type 2 diabetes is often seen in obese and is mostly affected by environmental factors. There is a possibility of presence of diabetes much earlier than it has been diagnosed, thus the examination of eye should be done as soon the diabetes is diagnosed and then an annual follow up should be maintained even if there is no features of eye involvement.

Examination schedule of eye in Pregnancy with preexisting diabetes

Pregnancy with preexisting diabetes is always at higher risk, during pregnancy the glucose level may further rise. The examination schedule of eyes should be followed prior to conception if there is preexisting diabetes and then during first trimester to assess the effect of pregnancy in diabetes and ultimately to eyes. The follow up depends on the result of examination of first trimester.

Thus a diabetic patient should have a special precaution for their eyes and an alert approach and regular check up can lead to decreased incidence of blindness and even other eye problems.

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Treatment and prevention of Buerger's disease (Thromboangiitis obliterans)

Buerger's disease is a disease in which there is occlusion of small and medium arteries leading to ischemia of the part supplied by that artery which in turn cuases ischemic ulceration and gangrene. It is almost exclusively seen in smokers and men. There are many other risk factors too but smoking holds the key. Details about the disease and its risk factors are can be seen at Buerger's disease : A vascular disease in young smokers .

The diagnosis of Buerger's disease depends on its sign and symptoms, predisposing factors and there are some investigations to differentiate from ome other vasculitis and autoimmune diseases which can mimick Buerger's disease. The main symptoms include intermittent claudication, migratory thrombophlebitis and Raynaud,s phenomenon. Arteriography can detect the occlusion of the vessels. Complete details about sign, symptoms and diagnosis can be seen at Diagnosis of Buerger's disease.

Treatment of Buerger's disease is too difficult, but there are some medical as well as surgical treatment available to save the patient.

Medical treatment of Buerger's disease

Frankly speaking there is no treatment for Buerger's disease, thus an approach to reduce symptoms and minimize morbidity is the aim.

Abstinence from smoking

A complete abstinence from any form of tobacco either smoking or chewing should be maintained. Some person in order to quit smoking start using nicotine patch, even that is not allowed in a person with Buerger's disease. Quitting smoking may not reverse th disease but will certainly arrest its progression.

Thrombolytic therapy

Though thrombolytic therapy is not basically a treatment for Buerger's disease but due to occlusion of arteries, there may be turbulence in the blood flow leading to formation of thrombus which may obstruct important vessels like coronary artery and can be life threatening. In order to prevent that thrombolytic therapy is given in form of heparin in acute cases and aspirin as a preventive measure.

Prostaglandins

Recent development in the treatment of Buerger's disease is the use of prostaglandins. Intravenous iloprost has been used with some success in aressting the disease. Intravenous iloprost use is probably of greatest value in slowing progressive tissue loss and reducing the need for amputation in patients with critical limb ischemia during the period when they first discontinue cigarette smoking. Iloprost is an expensive drug and has been used selectively in USA.

Other medication required are antibiotic to prevent infection of the ulcer and analgesics to relief of pain. A very recently Isner and colleagues reported improved healing of ischemic ulcers and relief of rest pain in a small series of patients with Buerger disease using intramuscular gene transfer of vascular endothelial growth factor.

Surgical treatment of Buerger's disease

A mere reduction in smoking may not be sufficient to prevent the relentless progression of the disease. An established arterial occlusion often needs surgical interventions. A direct arterial surgery is not at all applicable, hence the surgical procedure required is -

Sympathectomy

Sympathetectomy of dissecting the sympathetic nerve supplying the occluded vesels may often result in healing of the ulcers and improvement in skin nutrition and relief of the pain.

Other surgical procedures may be required are omenatal transfer and Spinal cord stimulator implantation.

Amputation

In order to save the patient and to arrest progression sometimes a conservative amputation of the affected limb may be required.

Prevention of Buerger's disease

Whenever a discussion about Buerger's disease comes, abstinence for smoking is the first and prompt advice. Other preventive modes are to avoid exposure of cold which may prevent constriction of arteries and the ischemia may be less.

Cardiovascular exercises in form of running and aerobics should be encouraged.

Buerger's exercise is encouraged which include elevation and declination of limbs through waist which increases circulation.

Thus quit smoking and save your limbs is the basic fundamental of Buerger's disease. Preventive measures should be taken as early as possible to avoid disability nd morbidity.

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Diagnosis of Buerger's disease (Thromboangiitis obliterans)

Buerger's disease is also called Throboangiitis obliterans, a disease in which the small and medium sized arteries gets occluded leading to ischemic ulcers which is difficult to heal. Smoking remains the key factor and it is often said that You can't have a leg if you smoke.

There are other risk factors too, details of which can be seen at Buerger's disease : A vascular disease in young smokers

Diagnosis of Buerger's disease depends on the proper history, clinical signs and symptoms and there are few investigations.

Distinguishing features of Buerger's diseae

The most important distinguishing feature of Buerger's disease is that there is no atherosclerotic changes in the arteries, there is no deposition of any plaques and the occlusion is without any pathology in the elastic lamina or arteries. There may not be any tenderness but the limbs may look red and edematous.

Symptoms of Buerger's disease

Symptoms of Buerger's disease include pain which may be intense due to ischemia or improper blood supply due to occlusion of blood vessels. There may be gangrenous ulceration of the foot, toes and fingers.

Intermittent claudication may be seen.

There may be superficial thrombophlebitis that is inflammation of the veins. This thrombophlebitis is migratory and the inflammation often migrate from one vein to other.

The limbs are generally cool, thogh pulse is felt but there may be tingling, numbness in both upper and lower limbs.

There may be Raynaud,s phenomenon that is blanching of hand and feet may be seen on exposure to cold and later dilatation of capillaries which may lead to edema.

Investigations for Buerger's disease

Though the above mentioned sign and symptoms in a young male who are smokers is sufficient to diagnose Buerger's disease but there are some investigations done to differentiate from other related diseases. These investigations are-

Blood test in Buerger's disease

Blood test is done to see erythrocyte sedimentation rate which is usually elevated in certain autoimmune diseases. Autoantibodies may be tested to differentiate it with certain diseases like scleroderma, Systemic lupus erythematosus (SLE), Rheumatoid vasculitis, mixed connective tissue disorders.

X Ray - Presence of cervical rib or carpal tunnel symdrome should be excluded by X ray.

Allens test for Buerger's disease

Allens test is done to detect the extent of occlusion of arteries. In this the patient is asked to make a tight fist and the artery is occluded by thumb of the doctor and then released, the back flow of blood in seen and thus estimated the occlusion.

Arteriography

Arteriography or angiography is done to visualise the occlusion of the arteries. Generally 3-4 arteries are involved in Buerger's disease. Arteriography may show a characteristic corrugation of the femaral arteries as well as the distal arterial occlusion and helps to distinguish the condition from presenile atherosclerosis. Arteriography also helps to exclude other forms or arteritis like poly arteritis nodosa, Juvenile temporal arteritis and other vasculitis.

As early the diagnosis is made better could be the outcome of treatment and lower will be the morbidity and mortality. The occlusion of artery is difficult to manage and sometimes amputation of the limb may be required to save the patient. Thus a proper treatment and preventive measure is required which is detailed in Treatment and prevention of Buerger's disease.

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Buerger's disease : A vascular disease in young smokers

Buerger's disease also known as thromboangiitis obliterans is a disease exclusively found in young men who are chronic smokers. It is an inflammatory condition of the arteries and involves mainly medium and small arteries. The incidence of Buerger's disease is seen more frequently in men under age 40. The disease is more prevalent among Asians and individuals of eastern European descent.

What is Buerger's disease

Buerger's disease or thromboangiitis obliterans is a disease in which there is occlusion of small and medium arteries mainly plantaris, tibial ans radial arteries. There is also inflammation of the veins which may in suferficial as well as deep veins. Raynaud's phenomenon may be seen which can be described as an abnormal sensitivity in the direct response of the cold.

Raynaud's phenomenon

On exposure to cold the small blood vessels constricts and as a result the part supplied by these vessels becomes blanched and incapable of finer movements and gradually the capillaries dilate and get filled with blood giving a dusky and swollen appearance.

Raynaud's phenomenon is typically seen in females but when it appears in male and that too in young one below 40, it is certainly due to Buerger's disease.

Risk factors for Buerger,s disease

Buerger's disease is of unknown etiology but there are certain risk factors or predisposing factors for its cause. These are

Smoking

Smoking is the most common risk factors and now a days the incidence is increasing even when nictine is being taken in other forms like chewing tobacco or nicotine patch, but still it is only smoking which hold the major risk.

Age, Sex and Race

Buerger's disease is a disease of young men, thus a person above 40 years having features of claudication or raynaud's phenomenon in certainly not due to Buerger's disease. Men is the most commonly affected. Earlier it was an exclusive disease of men but as the incidence of smoking has increased in women, the incidence in women is now a days increasing.

Natives of India, Korea, and Japan, and Israeli Jews of Ashkenazi descent (Eastern Europe), have the highest incidence of the disease and less incidence is seen in USA and Northern Europe.

Genetic factor

Buerger's disease is also genetically linked and a person having HLA-A9, HLA-A54, and HLA-B5 are more prone in developing the disease.

Causes of Buerger's disease

The cause of Buerger's disease is unknown but smoking holds the key. The vessels particularly the arteries get swollen due to rush of blood preceded by a contriction due to cold exposure. The arteries specially the smaller arteries is occluded and there the muscles gets necrosed due to ischemia causing ischemic ulcers which is very difficult to heal and sometimes may even lead to amputation of the limb.

Diagnosis of the Buerger's disease depend upon the classical features and history of the predisposing factors with some investigations like arteriography. Details of sign and symptoms and diagnosis can be seen at Diagnosis of Buerger's disease.

It is a disease difficult to treat and absotute abstinence from alcohol is necessary. Patient may get much help by normal arterial surgery and sometimes sympathectomy may require. In severe cases amputation of the limb may be required to save the patient. Thus one should be extremely conscious. Though now a days prostaglandins has been effective in arresting the disease. Though prevention is the bestmeasure to save the limb and to protect from disbility, morbidity and mortality. For detail treatment see at Treatment and Prevention of Buerger's disease.

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Types of Non Hodgkin,s lymphoma

Non Hodgkin's lymphoma are the cancer of lymphocytes and more commonly seen in children, most of the cases are of B cell origin but few may be of T cell origin. Viral etiology has been seen in some of its type. Immunosuppression is the most common risk factor involved. Details regarding causes and risk factors may be seen at Non Hodgkin's lymphoma : A cancer of immune system

There are many variants or types of Non Hodgkin's lymphoma, out of which Burkitt's lymphoma is the most common one and constitutes about 40% of all childhood lymphoma. The common type of Non Hodgkin's lymphoma are -

Lymphoblastic lymphoma

It is the second most commonest lype of childhood lymphoma and constitute 30% of all childhood lymphoma. In this type the bone marrow is involved at very earlier stage. It presents as a mediastinal mass in most of the cases.

The most common presenting features are rapidly enlaging neck and mediastinal lymph adenopathy. This lymphoma is though of B cell origin but has a tendency to progress into T cell acute lymphatic leukemia. Tdt is a tumor marker and may be present in all cases when investigated.

The prognosis of this type of Non Hodgkin,s lymphoma is very poor.

Burkitt's lymphoma

Burkitt's lymphoma is the fastest growing human cancer and constitute 40% of all Non Hodgkin's lymphoma. It is caused by Epstein Barr virus and the most common presentation of its endemic form also called African type is in the form of jaw tumor which involves maxilla and mandible.

In non endemic form or sporadic type it presents as abdominal tumor most commonly and then tumor of head and neck.

Lymph node invlovement in this type of lymphoma is rare. There may be a chromosomal translocation of 8 ; 14 and can be detected in chromosomal analysis.

Large cell lymphoma

It is also one of the common type of childhood lymphoma, the most common sub type being anaplastic one. The most common primary sites involved in this lymph node cancer are nasopharynx, Waldeyer ring of oropharynx ring made by lymph nodes, cervical nodes and skin.

The the involvement of bone marrow is relatively uncommon in this lymphoma but there is greater frequency of extranodal and visceral involvement and the most common organ involved is stomach.

Small lymphocytic lymphoma

This type of lymphoma cherish for its long survival and better prognosis though bone marrow involvement is almost in all cases. It occurs primarily in older age group and it is a low grade lymphoma that does hve any follicular architecture.

This type of lymphoma is often misdiagnosed by chronic lymphocytic leukemia and Waldenstorms macroglobulinemia and should be differetiated from that.

This type of lymphoma has an indolent course and a better survival rate.

Follicular lymphoma

This is the most common type of Non Hodgkin's lymphoma seen in adults and it presents as a generalised painless lymphadenopathy. At the time of diagnosis bone marrow involvement is seen in most of the cases. Involvement of extranodal site is uncommon.

It has a characteristic t 14 ; 18 translocation of chromosome and may be detected by chrosomal analysis. This lymphoma though have an indolent course but is stubborn in nature and difficult to cure.

Adult T cell lymphoma

Adult T cell lymphoma is caused by retrovirus HLTV 1. It may presents with features like skin lesion which may resemble lesions like in mycosis fungoides, there may be enlarged spleen and liver. Generalised lymphadenopathy may be seen. There may be lytic bone lesions and increased calcium level in blood.

This type of lymphoma may be diagnosed by seeing increased serum LDH level, increased serum level of CD25 which is the tumor marker of this cancer.

The patient suffering from adult T cell lymphoma are more susceptible to oppotunistic infections with Pneumocystis carnii and other fungi as the virus belongs to same group as of HIV AIDS virus.

Cutaneous T cell lymphoma

Cutaneous T cell lymphoma consists of two variants called mycosis fungoides and sezary syndrome and is characterised by cutaneous or skin lesions and lymphadenopathy. It is considered as a tumor of peripheral CD4 and T cells.

Sezary syndrome is infilteration of bone marrow and peripheral blood with circulating leukemia cells called sezary cells in presence of generalised exfoliative erythroderma.

Secondary infection is most frequent in this type of lymphoma and may be the most common reason of death. Treatment is required locally for skin lesions as well as systemic.

AIDS related lymphoma

These are high graded lymphoma and is present in AIDS as diffuse histiocytic or immunoblastic type. Non Hodgkin's lymphoma occurs in 10 to 30% cases of AIDS. Here again extranodal involvement is very common and central nervous system is most commonly involved followed by gastrointestinal tract.

Opportunistic infections are common as there is already immunosuppression and this is the major reason of death in patients suffering from AIDS related lymphoma.

Though there are many classification according to grade of histology, but the major types and a brief about them has been described here.

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Non Hodgkin's lymphoma : A cancer of immune system

Non Hodgkin's lymphoma is basically a cancer of the immune system as it occurs in lymphatic system which is mainly for immune purpose. Though the lymphatic system consists of lymph nodes, lymph fluid and lymphatic vessels but the most common origin of Non Hodgkin's lymphoma is lymph nodes. Hodgkin's and Non hodgkin's lymphoma ae two types of malignant cancer of the lymph nodes while Hodgkin's is more common in adults and Non Hodgkin's lymphoma is more common in children.

What is Non Hodgkin's lymphoma

Non Hodgkin's lymphoma is a malignant cancer or lymphocytes. The origin is mainly from B cell lymphocytes in 90% of cases and only in 10% it is of T cell origin. The incidence of Non Hodgkin,s lymphoma is almost 5 times more than Hogkin's lymphoma and is more often seen in children and the survival rate is good if detected early and treated early.

There are many types of Non Hodgkin's lymphoma but the most common present in children is Burkitt's lymphoma also called Devita's cancer which have a viral etiology and lymphoblastic lymphoma also called Robbin's cancer.

In adults most common type of Non Hodgkin's Lymphoma seen is Follicular type of lymphoma.

Causes of Non Hodgkin's lymphoma

The causes of Non Hodgkin's lymphoma is unknown but a viral etiology is seen in some of its types. The most common type of Non Hodgkin,s lymphoma is children called Burkitt's lymphoma or Devita's cancer is caused by a virus called Epstein Barr virus which is also known to cause infectious mononucleosis or glandular fever. High grade B cell lymphoma is also caused by Epstein Barr virus while Adult T cell lymphoma which is common Non Hodgkin's lymphoma in adults is caused by Human T lymphocyte virus 1 (HLTV 1). HLTV 1 is a retrovirus while HLTV 3 is also a retrovirus which is more commonly known as HIV virus and causes AIDS.

In Non Hodgkin's lymphoma there is production of abnormal lymphocytes and in many cases bone marrow involvement takes place which may be a poor prognostic feature.

Risk factors for Non Hodgkin's lymphoma

There are certain risk factors especially in children, most of the risk factors are related to immunosuppression or decreased immunity. There are certain genetic diseases related to immune system like
Wiskott - Aldrich syndrome,
Ataxia telangectasia,
X linked agammaglobinemia,
Chediak Higashi syndrome
X linked lymphoproliferative syndrome

Children suffering from above mentioned diseases are more prone to develop this lymph node cancer. Viral infection is another risk factor as mentioned in the causes that it can develop Burkitt's lymphoma.

Any child or even adult on immunosuppressive therapy are more prone to develop Non Hodgkin's lymphoma.

Another important risk factors include chronic persistant exposure to antigen stimulation such as malaria or intestinal parasitic infestation. So deworming is most important in children at frequent intervals.

There are various types of Non Hodgkin's lymphoma and the presentation, prognosis and diagnosis may differ in each. To know the various types please refer to Types of Non Hodgkin's lymphoma.

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Treatment and complications of mitral valve prolapse

Mitral valve prolapse is the most common heart disease present in young women. There may or may not be any cause, but its familial tendency is proven. Details about mitral valve prolapse may be seen at Mitral valve prolapse : A heart disease of young women

Though most of the cases of mitral valve may be asymptomatic and may occur sometimes as a normal variant in case of anxiety, but in severe cases there may be palpitation, arythmia, fatigue, chest pain and even fever.

Diagnosis is done by ECG, but confirmatiory diagnosis is by echocardiography. Details of symptoms and diagnosis can be seen at Symptoms and diagnosis of mitral valve prolapse.

Treatment of mitral valve may be simple reassurance to prescription of some medicines or medical treatment. In much severe case surgical treatment may be required.

Medical treatment of mitral valve prolapse

The treatment of mitral valve prolapse may consist of reassurance in asymptomatic cases to medical and surgical implications as per the severity and complications.
The medical treatment may consist of the following-

Beta blockers

In case when the mitral valve prolapse is associated with symptoms like fatigue, irregular heart beats, palpitaions or chest pain, beta blockers are used. The main beta blocker used is atenolol or metoprolol. How ever many doctors even prescribe calcium channel blockers like verapamil for this symptoms.

Antibiotics

Many doctors do not find the use of antibiotics in this disease, but a prophylactic antibiotic is necessary to prevent from a deadly complication called infective endocarditis.

Aspirin and anticoagulants

The associated regurgitation or even the prolapse may lead to formation of embolus and can cause ischaemic heart disease, to prevent this low dose aspirin is given. The dose of aspirin is a debatable issue and doctors prefer from 75mg per day to even 300 mg per day. Regular use of aspirin certainly can cause gastritis, so now a days clopidogrel and ticlopidine is also used for tha same purpose, but still aspirin is most preferred. Other anticoagulants may be used with aspirin.

Surgical treatment of mitral valve prolapse

Surgical treatment of mitral valve prolapse is necessary when it is associated with severe mitral regurgitation. The main surgical procedures done are

Valvuloplasty

In valvuloplasty the repair of valve is done, it may be balloon valvulaplasty where a balloon is placed which acts as a valve. The valve leaflets are reconnected and excess tissue of the valve is plicated.

Valve replacement

Valve replacement is done where there is no scope of valve repair. In this case a metallic valve is replaced in place of original valve. Now a days biological valves are even used such as valve of pigs and this may have a better compatibility and oral anticoagulants may not be required which is essential in mechanical or metallic valves. However a boilogical valve may need frequent replacement, thus havent been much encouraged.

Complication of mitral valve prolapse

In severe cases mitral valve prolapse may have some serious and severe complications, these complications may need serious attention and immediate hospitalization. These complications are-

Congestive heart failure

Congestive heart failure may be due to severe mitral regurgitation, which itself is a complication of mitral valve prolapse. The heart is congested due to leakage of blood and there may be increase in afterload and may lead to failure.

Infective endocarditis

Infective endocarditis is a serious complication as the congestion of blood may make the endocardium more prone to get infected. A prophylactic antibiotic may prevent this deadly complication.

Arrythmia

Irregularity in heart beat is due to abnormal flow of blood in left chamber of heart, this arrythmia may be harmless, but may also cause sudden cardiac death, an antiarrythmic drugs is sometimes necessary to combat this situation.

Thus mitral valve prolapse is the commonest heart disease of young females and every time a youngious or have palpitation, a complete check up is absoliutely necessary.

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Symptoms and diagnosis of mitral valve prolapse

Mitral valve prolapse also called Barlow's syndrome of floppy valve syndrome or click murmur syndrome is more commonly a disease of young females and may be present even after hyperactive state like anxiety neurosis. There are other causes too. The detail of the cause of mitral valve prolapse may be seen at Mitral valve prolapse A heart disease of young women..

The diagnosis of mitral valve prolapse is based on the clinical symptoms and investigations like ECG and echocardiography. Though many patients remain undiagnosed as they don,t visit the doctor, because most cases may be a normal variant and may not show any symptoms.

Symptoms of mitral valve prolapse

Most of the cases of mitral valve prolapse are asymptomatic and the prolapse is mild. These patients are never diagnosed or accidently diagnosed when investigated for other cause, however no treatment is required in asymptomatic cases.

Fatigue
Among the symptoms of mitral valve prolapse, the most prominent is fatigueness. Due to leakage in the blood flow, patient easily gets fatigued.

Palpitation and anxiety
In mitral valve prolapse there may be increased heart rate and patient may feel the palpitation, this is due to imbalances in the autonomic nervous system controlling heart rate.

Chest pain mimicking angina
Some patient may suffer from chest pain which may be like pain in angina pectoris, but the chest pain in mitral valve prolapse does not changes by exertion and may not be relieved by nitroglycerine.

Fever
In some case there may be associated fever and this may typically indicate mitral valve prolapse in a patient with above symptioms with fever.

Mitral valve prolapse may be rarely associated with strokes occurring in young patients. These patients appear to have increased blood clotting tendencies due to platelets.

Signs of mitral valve prolapse

The signs of mitral valve prolapse is found after auscultating the heart or left precordium. A mid systolic click sound may be heard due to prolapse of the valve and tensing of the chordae tendinae that occurs during systole of contraction of ventricles.

Often the patient with symptomatic mitral valve prolapse may have mitral regurgitation that is leakage of blood from left ventricle to left atrium during systole. Thus a late systolic murmur may be heard due to this leakage, it large regurgitation the murmur may be pansystolic means it may be heard throughout the systole.

Diagnosis of mitral valve prolapse

A mitral valve prolapse can be diagnosed on the basis of certain investigations. An electrocardiography is done and if the abnormaility is seen and there is suspect, echocardiography confirms the diagnosis.

Electrocardiogram

Electrocardiogram in short ECG reveals inverted or biphasic T waves in leads II, III and aVF, there may be ventricular premature contractions as well. Though a normal ECG does not rule out mitral valve prolapse hence echocardigraphy is done which is confirmatory.

Echocardiography

A two dimensional echocardiography is confirmatory diagnosis and it identifies the abnormal position and prolapse of the mitral leaflet. It also identifies the thickening of the leaflet and this condition is more prone for infective endocarditis.

Color doppler studies

Color doppler studies may be helpful in identifying and evaluating the the mitral regurgitation if present.

Angiocardiography

Angiocardiography is done to reveal prolapse of the posterior and sometimes both mitral leaflets.

Treatment of mitral valve prolapse may include from reassurance in asymptomatic cases to even surgical treatment like valvular replacement if a severe mitral regurgitation is associated. Details is give at Treatment and complications of mitral valve prolapse.

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Binge drinking is dangerous for health

Individuals consider alcohol as an upper or a downer depending on the reason they are drinking. And some times, one drink leads to another and another; and before you know it, you are on a drinking binge.

Binge drinking in the United States is defined as the consumption of 5 or more drinks in a row by men; or 4 or more drinks in a row by women; at least once in the previous 2 weeks. Heavy binge drinking includes 3 or more such episodes in 2 weeks.

Social drinking has becoming an accepted norm. The young start imitating their elders; experimenting starts early. 82.8% of adults who drink today admit to having their first drink of alcohol before age 21.

Effect of alcohol on mind

Alcohol is a depressant, which slows the function of the central nervous system and blocks messages that are trying to get to the brain; altering the individual’s perceptions, emotions, movement, vision, and hearing. In very small amounts, alcohol can help an individual to feel relaxed and reduce anxiety.

When the quantity of alcohol consumed increases, the result is intoxication. Then individuals may stagger, lose coordination, and slur speech. There is a tendency towards confusion and disorientation. Individuals react differently to alcohol, while some become very friendly and talkative, others become very aggressive and angry. They may act totally out of character. Reaction time also tends to slow down.

Binge drinking is as good as poisoning

Consuming large amounts of alcohol in a short period of time can cause alcohol poisoning. The first symptom of alcohol poisoning is usually violent vomiting. Extreme sleepiness, extreme confusion, low body temperature, bluish or pale skin, unconsciousness, difficulty breathing, dangerously low blood sugar, and seizures. It can also result in death.

Binge drinking has social, physical and mental implications.

Teen drinkers are more likely to get fat or have health problems, too. A study by the University of Washington found those who started having 5 or more drinks in a row regularly at age 13 were more likely to be overweight or have high blood pressure by age 24 than their non-drinking peers. Those who continue drinking heavily into adulthood risk damage to their organs, such as the liver, heart, and brain.

Teens who drink are usually more sexually active and tend to have unsafe and unprotected sex. It can result in pregnancies and sexually transmitted diseases, that can change or even end lives.

The risk of injury even fatally, is higher when under the influence of alcohol. Alcohol use among male teenagers was related to one half of all drowning deaths.

Use of alcohol greatly increases the chance that a teen will be involved in a car crash, homicide, or suicide.

Binge drinking impairs judgment, so drinkers are more likely to take risks they might not have when sober. They may drive drunk and injure themselves or others. Not just driving, even walking is more difficult while intoxicated. In 2000, roughly one third of pedestrians 16 and older who were killed in traffic accidents were intoxicated.

Binge drinkers have a harder time in school and are more likely to drop out. Drinking disrupts sleep patterns. This can make it harder to stay awake and concentrate during the day. They struggle with studies and poor academic performance. Sports performance also gets affected to some extent because of the disturbed co-ordination.

Drinking can affect personality; making individuals angry or moody, resulting in friends drifting away.

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Zone diet - A optimum diet for Indian subcontinent and sportsperson

Zone diet is based on the scientific principle that an ideal diet should contain a fixed proportion of macronutrients at each meal. This must include carbohydrates (30%), fats (30%) and proteins (30%). However, these proportions differ from the current recommendations relating to optimum diet for healthy adults. Moreover, there is no data available that the weight loss from Zone Diet is optimised by the proposed quantities.

Zone Diet

This diet was first put forward in Italy in the year 1997 by a physician, Aronne Romano. It was experimented on patients and athletes and popularised by Barry Sears, a biochemist. Zone Diet has also inspired a large number of diet conscious Indians. Famous world celebrities including Hollywood actors are believed to have followed it.

Zone Diet is based on the theory that an optimum diet should comprise a fixed proportion of macronutrients at each meal. Dieters must follow recipes which are low in carbohydrates. Diet Zone foods contain carbohydrate counts which are not dominated by fat and protein. This enables the dieters to extract more energy from the carbohydrates in the food item instead of the fats and proteins. Contrary to general diets, Zone Diet makes dieters remain firm regarding the amount of calories they consume. This unique nutritional style ensures that dieters consume within 500 calories during main course meals and they consume within 100 calories while eating snacks.

Healthy Diet Tip – Avoid sugary beverages and oily foods

Avoid tempting and mouth-watering food items like deep fried bhatura, aloo-tikki, kachodi, samosa, balushahi, barfi, dalmoth etc. Moreover, junk food items such as burgers and pizzas with extra cheese and high calorie food items including fatty meats, margarine, butter, sugary beverages like sherbats, and sweetened aerated drinks are also best avoided.

Enjoy steamed corn, idlis, dhoklas, momos, sprouts, bhelpuri, popcorn, fresh salads, coconut water, chach and plain clear soups. Avoid fast foods at work by carrying home food that consists of whole grains, fruits and vegetables. They are both waistline and pocket friendly. Throw out all unhealthy snacks from your kitchen shelves and store readily available fresh fruits and vegetables.

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Mitral valve prolapse : A heart disease of young women

Mitral valve prolapse is known by many names like mitral valve prolapse, floppy mitral valve or Barlow's syndrome. It is most commonly seen in young females and have a familial incidence.

Though mitral valve prolapse remains asymptomatic and may not need surgical replacement of the valve as the prolapse is in posterior cusp of mitral valve and it may be differentiated from Read's syndrome where both antrerior and posterior cusps prolapses and invariably needs a valve replacement.

What is mitral valve prolapse

Human heart contains four valves namely mitral, tricuspid, aortic and pulmonary valves. Mitral valve is the valve present between left atrium and left ventricle of the heart and opens during diastole when pure blood flows from atrium to left ventricles from where it is supplied to whole body.

The mitral valve leaflets may be large in mitral valve prolapse. Alternatively there may be enlarged mitral annulus, abnormally long chordae which is the strings attached to the underside of the leaflets and connected to the ventricular wall, or disordered pappilary muscle contraction. These all may lead to prolapse of the mitral valve leaflet into the left atrium during ventricular systole and may cause abnormal contraction and mitral regurgitation which means a very small amount of blood may leak through, moving backward from the ventricle to the atrium.

Causes of mitral valve prolapse

In majority of cases the exact cause of mitral valve prolapse is unknown. Though mild mitral valve prolapse is very common and is often considered as a normal variant and can be seen in patients with anxiety neurosis and in hyperactive stage. There may be some pathological conditions too where mitral valve prolapse can occur, these are

Rheumatic heart disease

It is the heart disease associated with the abnormality of the heart muscles, the defect in chordae can occur in rheumatic heart disease and can lead to mitral valve prolapse.

Ischaemic heart disease

Though this is a rare cause of mitral valve prolapse, but a very common disease now a days and occurs due to less oxygen supply to the heart leading to ischaemia. Often the leaflets becomes weak and prolapse due to change in normal pressure of the atrium and ventricles.

Marfans syndrome

Marfans syndrome is a connective tissue disorder and apart from heart it can affect eyes, skeleton, blood vessels, nervous system, skin, and lungs. There may be other valvular disease like mitral valve regurgitation along with mitral valve prolapse.

Thyrotoxicosis

Thyrotoxicosis is an inflammation of thyroid gland along with hyperthyroidism. It often leads to anxiety neurosis and many may develop mitral valve prolapse.

Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is a symmetrical thickening of heart muscle. This asymmetrical thickening may lead to prolapse of the cusp causing mitral valve prolapse.

Atrial septal defect

Atrial septal defect is a congenital non cyanotic defect of the heart where there is defect in the atrial septum and blood may flow from ventricle to atrium. Though this is not a cause of mitral valve prolapse but it is often present along with atrial septal defect.

Features of mitral valve prolapse

Mitrla valve prolapse as mentioned may be a normal variant and may be asymptomatic in many cases, but fever, chest pain are some common complaints. Diagnosis is often done by electrocardiogram and confirmed br echocardiography. Details of symptoms and diagnosis is geven at Symptoms and diagnosis of mitral valve prolapse.

Treatment consists of beta blockers, some may even require surgical interventions, details of treatment may be seen at Treatment and complications of mitral valve prolapse.

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Pulled elbow - An elbow injury to children while lifting

Who dont like children? On the verge of playing often children are lifted holding the hand and while doing this the the laxed elbow gets pulled and leave the child with cruciating pain. Children are too small to reveal their complaints, so it is very much necessary to assess the condition by their parents and doctors.

What is pulled elbow

Pulled elbow is also known as nursemaid elbow as it occurs in children between 2 to 5 years of age. In this case the head of the radius is pulled partly out of the annular ligament when a child is lifted by the wrist. There is intense pain and the child is unable to move the affected limb. The forearm lies in an attitude of pronation. There may be mild swelling at the elbow, but not always.

What can be the future effect of pulled elbow

The pulled elbow occurs when the head of the radius is still cartilagenous and not completely ossified, this may lead to improper ossification and in future there may be tendency of recurrent dislocation. Though dislocation of elbow is not so common as dislocation of shoulder joint.

Diagnosis of pulled elbow

Diagnosis completely depends on clinical examination which reveals the symptoms of pain and inability to move the limb or mild swelling. In X ray should be done, though it may not reveal any thing as the sublaxated head is still cartilagenous and that will not come in an X ray. Still x ray is done to rule out any other bony injury.

Treatment of pulled elbow

Immediately ice fomentation should be done, treatment of pulled elbow can be done at home by an expert, though it is not recommended.

The head is reduced by fully supinating the forearm and applying direct pressure over the head of the radius. A sudden click is heard or felt as the head goes back to its place.

The effect is seen immediately and the child becomes comfortable and can start moving his elbow almost at the same time after the head goes to its place.

At many places in the net it is mentioned that a cast may be given or a sling may be applied, but it is not necessary at all in case of pulled elbow. If the procedure above is not effective then there might be any other injury as well along with pulled elbow. In that case a sling may be applied before going to the doctor and get it diagnosed. In that case child may need analgesics too.

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Diabetic foot - Save your foot from diabetes

Foot problem in diabetes is very common and should never be under estimated. After accidents complication of foot associated with diabetes is the most common reason for foot amputation.

Many of the foot problems occur in those with insensitive feet, may be due to inadequate circulation and is precipitated by infection or any injury. These precipitating factors are definite and thus is preventable in majority of cases and a patient can be saved from disability.

The most important aspect in the care of foot in a diabetic patient is to self screening of foot and taking proper care. Before that it is necessary to know why diabetic foot occurs and what are the precipitating factors.

Causes of diabetic foot

The ulceration of foot in a diabetes can be due to any cause which may lead to either poor circulation of blood oe parasthesia or less sensation or any other conditions which may lead to injury and infection of foot. The main causes of diabetic foot are

Decrease in blood circulation

An atherosclerosis or sclerosed arteries may lead in the turbulence of blood flow and even ischemia to muscles of foot, this may lead to ulceration and gangren formation even after a slight wear and tear or injury. As the diabetics are more prone to infection a slight ulceration may lead to secondary infection and becomes difficult to heal as the infective organism gets enough feed in the form of glucose to have a good growth and multiplication.

Decreased sensation of feet due to peripheral neuropathy

In uncontrolled diabetes, there is decreased in sensation of the foot due to peripheral neuropathy and this lead to risk of damage to the foot and even there may be mild cut or abrasion which may lead to secondary infection due to poor healing. There may be wear and tear of the foot while walking and specially when the footwear is hard or the person is barefooted and as there is less sensation there is not much feeling to avoid the minor injury or wear and tear.

Risk factors for developing diabetic foot

There are several risk factors for diabetic foot and during prevention the main aim is to have a check on this risk factors. These risk factors are -

Smoking

Smoking is the most significant risk factor as it predisposes to both the causes decrease in circulation as it promotes atherosclerosis and also causes neuropathy of foot. Thus a serious attempt should be taken to quit smoking in case of uncontrolled diabetes.

Faulty foot wear

As there may be sensory loss due to peripheral neuropathy, a hard foot wear may lead to more wear and tear and this minor tear can aggravate into a diabetic foot ulcer. Many footwear may cause minor injries and callus formation or any blistwer formation which should absolutely be avoided in diabetics.

A person with flat foot have more exposed area and this may lead to more prone towards injury.

Infections

In existing infections like athelete foot or any fungal infection or a nail infection may lead to serious ulceration due to secondary bacterial infection.

Thus the care of foot is most important as in many case this may result into amputation of the limb. A proper care can certainly prevent this.

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Treatment and prevention of plantar fascitis or heel spur

Plantar fascitis of heel spur is a painful condition and is mostly age related, the cause is mainly inflammation of the plantar fascia and there are many risk factor associated namely increased age, obesity and faulty foot wear. The details of its cause, risk factors and diagnosis is give at Plantar fascia.

Treatment of plantar fascia is often symptomatic and is very tedious to satisfy the patient suffering from it.

Though there are are different modes of treatment which are described below :-

Conservative treatment of plantar fascitis or heel spur

The conservative treatment include local, oral and injectable analgesics, local corticosteroids and in rare case surgery.

Analgesics

In severe pain and in acute stage local ice application may relieve the symptoms, non steroidal analgesics like ibuprofen, diclofenac and now a days aceclofenac may be helpful to get rid of the pain, but these analgesics may cause gastric irritation. Cyclooxygenase II inhibitors like eterocoxib can be used for maintainence or for longer duration more safely.

Local Corticosteroid

Local corticosteroids may reduce the inflammation, thus can be used in acute condition. These may act by process called iontophoresis where local corticosteroids are absorbed by electric current. In severe case corticosteroid may be administered as injection in the fascia to reduce inflammation, but in most case pain in the foot may also be due to diabetes, thus either it should not be preferred or used cautiously, further it may also cause damabe or shrinkage of plantar fascia.

Surgery

In very rare case when the pain is unbearable and all the method fails then surgery is the choice in which the plantar fascia is detached from the tuberosity of calcaneum, but this may lead to instability of the longitudinal arch of the foot.

Newer approach for treatment of plantar fascia

There are now a days various form of arch support, special form of shoes having a cushion at the heel end. Other treatment include-

Extracorporeal shock wave therapy

The treatment is based on therapy by sound wave as used for diagnostic purpose in ultrasonography. Though this is used when other conservative method fails and the condition is not acute, however it is not tolerated well by many patients. Short wave diathermy is another method but rarely used now a days for this purpose.

Arch support

Orthotics or arch support are used in the form of specially designed shoes having a cushion at the heel which helps to distribute the pressure evenly to the sole and thus minimizing wear and tear. Now a days and there are many splints used to support the arch, these are even used at night during sleep and this prevents early morning pain.

Prevention of plantar fascitis or heel spur

In spite of attempting several measures to get rid of this painful condition, many patients doesnt get proper satisfaction, so the best approach is to take measures which can prevent development of plantar fascitis. The preventive measures include

Weight loss, so that the pressure on the heel shuld be minimized.
Proper selection of foot wear which should not be hard at heel end and should be comfortable.

Though many doctors dont prescribe exercise but mild walking specially early in the morning on wet grass has been effective in some patients.

Thus preventive measure is the best.
Please feel free to ask your query. I will be glad to try my best to provide proper informations.

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Causes and symptoms of plantar fascitis or heel spur

Plantar fascitis also known as heel spur is a very common cause of pain in the heels especially in women, in athletes especially runners, in older adults in 50,s and in obese.

Plantar fascitis or heel spur is as a result of inflammation of the plantar aponeurosis at its attachment on the tuberosity of calcaneum, the heel bone. In non medical term it is inflammation of a band like structure which connects from heel to toes. Pain is the most prominent reason for seeking a doctor.

Causes of plantar fascitis or heel spur

The heel is a weight bearing portion of our body and contains a cushoin of fat, under normal wearing and tearing like in runners or due to excess weight as in obese person or due to ageing, it causes inflammation and thus causes pain.

Apart from the above conditions certain degenerative diseases like osteoarthritis or inflammation of fat pad of the heel or any disease of the subtalar joints may also cause pain in the heels.

A faulty foot wear which causes a tendency of the foot to pronate while walking may also lead to wear and tear of the plantar fascia or aponeurosis and cuases inflammation.

Risk factors for plantar fascitis or heel spurs

The most common risk factor for plantar fascitis is one which is unavoidable and that is ageing. With increasing the shock absorber of the heel which is in form of a fat pad is absorbed and muscles and fascia are more exposed to injury and wear and tear causing fascitis.

In obesity though fat is accumulated in the subdermal regoin but the fat pad of heels gets absorbed due to excess weight of the body and thus here fat becomes the enemy of the fat.

Faulty foor wear like hard sandles, or high heels which may lead to rolling of the heels most often can be some risk factors.

Some person may have flat foot or their foot arch is not proper and this lead to increased exposure to the sole of foot to the ground and may cause inflammation ofthe heels or plantar fascia.

Symptoms of plantar fascitis or heel spur

Pain along the heels is the most common and most often the only symptom of plantar fascitis. Pain may be cruciating,sharp and may aggravate in the morning and often improves with activity like walking or bouncing.

Though the pain is most often limited to heels but may spread to the sole along with the fascia. Though heel spur is not synonymous to plantar fascitis as it refers to a bone spur projecting forward from the tuberosity of the calcaneum and may be present even in the absence of plantar fascitis and without pain.

Diagnosis of plantar fascitis or heel spur

Diagnois depends on clinical examination and X rar. Clinical examination is the mainstay of diagnosis and it reveals marked tenderness over the medial aspect of the calcaneal tuberosity at the site of attachment of plantar fascia.

X ray may show a sharp bone spur projecting from tuberosity of calcaneum but may be insignificant for diagnosis as it may also be present in other conditions as well which may not be associated with any pain.

There are other conditions causing ain in the heels like diseases of calcaneum, fat pad inflammmation, retro calcaneal bursitis, Achillis tendonitis and diseases of subtalar joints.

The main aim of treatment for plantar fascitis is to reduce inflammation and to reduce pain. Analgesic, local steriod injections and SWD are some mode of treatment. Details are present at Treatment and prevention of plantar fascitis or heel spur.

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Glycemic index and its importance

Whenever we talk about carbohydrates we just discard them absolutely for a diabetic patient. But all carbohydrates are not alike and have a different effect on blood sugar level after eating.

The effect of carbohydrate or any food having potential to raise blood sugar level is measured in terms of what is called glycemic index of the food.

How glycemic index is measured

Glycemic index of any food is measured taking glucose as a reference. Glucose after taking orally gets absorbed quickly and its glycemic index is considered as 100. For measuring glycemic index at least 10 person is fed with the food to be measured and blood sugar is measured at every 15 minutes interval for first hour and every 30 minutes. A graph is plotted and compared with blood glucose level after standard 50 gm of glucose taken orally.

Glycemic index of any food can be low, moderate and high. A low glycemic food is considered when glycemic index is upto 55 and moderate when it is between 56 to 69 and high glycemic index is when it is above 70.

The food having low glycemic index is slowly absorbed and the there is slow and steady rise in blood sugar after its intake and lowers down steadily after a time interval. While food with high glycemic index is absorbed quickly and there is sharp rise in blood sugar level and keeps fluctuating. The insulin level of the body too tends to fluctuate and in a diabetic patient it is difficult to adjust a dose of anti diabetic drugs and insulin if the patient have high glycemic index food.

Benefits of low glycemic index diet

It is understood that a diabetic person should concentrate on food having low glycemic index while a hypoglycemic patient should take high glycemic index food. Though a person with sedentary life style should always prefer diet having low glycemic index.

Alow glycemic index diet not only helps to control diabetes but also increases sensitivity of insulin. Even a non diabetic person having obesity should prefer low glycemic diet as it curbs many heart diseases and even helps to curb down obesity. Females with PCOS is recommended to have low GI foods.

Which type of foods have low glycemic index

Not going details on the chart, it should be noted that salads, nuts, brawn and fruit juices baring a few like mango juice are of low glycemic index. Among milk soya milk is considered as best. Most of the person use to have cornflakes in the breakfast but it has a high glycemic index of about 83. Spagetti is ideal food for one who prefer pasta.

Glycemic index of bakery products

The3 bakery products are generally of high glycemic index and should be avoided as far as possible. Brown bread can be taken as it contains more fibres. All kind of wafers, biscuits even it is not sweet lies in medium or high glycemic index.

Glycemic index of Cereals
Among cereals bran is considered as best, pearl barley, instant or parboiled rice or kernel wheat should be preferred. Millets have the highest glycemic index among all cereals.

Glycemic index of dairy products
Most of the diabetics do not touch dairy product having a misconception that it may be of high glycemic index, but a fat free skimmed milk is ideal for them, yoghurts if taken without sugar is of very low glycemic index.

Glycemic index of Vegetables and fruits
All green vegetables with exception of broad beans are of low GI. Among fruits which should be avoided in diabetic or are of high GI are watermelon, mangoes, apricots, pineapple and raisins.

Though only carbohydrate content doesnt affect glycemic index, in fact there are a number of factors on which glycemic index of a food depends like its fibre content and viscosity of fibres, protein contents etc.

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Treatment and prevention of premature ejaculation

Premature ejaculation is a clinical entity which is often seen in young adults while erectile dysfunction is more seen with increasing age. Majority of cases of premature ejaculation may have some psychological factors associated. Treatment consists of some exercise, some behavioural therapy and some medications. Premature ejaculation may be mild to severe depending upon the time of sustainment and treatment largely depend on that.

Treatment of mild premature ejaculation

If a man has mild premature ejaculation and he ejaucualte within five minutes, then a simple distraction method may be sufficient, which means to distract the mind or divert the mind during the peak. Some behavioural therapy may be useful.

Behavioural therapy for treating premature ejaculation

Apart from distraction theory, some behavioural therapy may be required if the person is hyperactive, gets easily excited or suffer from anxiety or depression. A simple counselling may give the better result.

Local anaesthetic gel

In some cases local anaesthetic gel is applied to the male sex organ to get less sensation and stimulation so that ejaculation may be delayed. Most of the products advertising in market are made up of this only.

The main drawback of this treatment is that it dampen the pleasure to self as well to the partner. As it is locally applied some may find it irritating skin reactions and mucosal irritation to female sex partner.

Now a days love condom is available in the market which is advertise to increase the duration, it is nothing but a condom where a local anaesthtic benzocaine in it. The benefit of love condom is that the local anaesthetic does not come in contact to mucosa of vagina of females so there is no vaginal irritation.

Treatment of severe premature ejaculation

Severe cases needs some medications as well a very effective technique called squeeze technique is helpful in this case.

Masters-Johnson method or squeeze technique

This is the most acceptable treatment method for premature ejaculation and was discovered by Master and Johnson. In this technique the cooperation of partner is necessary and just at the time of climax the base of the glans is squeezed by keeping index finger at top and thumb at the ridge.

It has been seen that a man ejaculating within 30 seconds could hold even upto 30 minutes by this technique if it is done by proper way.

Antidepressants for premature ejaculation

The most common used antidepressants for premature ejaculation is fluoxetine(Prodep), other which are prescribed are sertraline, amitryptiline and clomipramine. Anti depressants should be taken only after prescribed by a comptant psychiatrist which usually prescribe them only when behavioural therapy fails. Dry mouth, nausea and irritation and dizziness may be the common side effects of these drugs.

Now a days clomipramine is also available as a nasal spray, this route is used for quicker action and to avoid the gastric side effects.

The latest drug which is used for premature ejaculation is another seroronin uptake inhibitor called dapoxetine marketed in the name of prozac. This tablet when taken orally is intended to lengthen the time between a man’s arousal and his climax.

Newer technique for treatment of premature ejaculation
In some Countries a newer technique has been implemented for treatment of premature ejaculation. In this technique a constricted ring is given and is advised to put it at the base of the head of sex organ for 30 minutes daily. However this techniques should be opted only under supervision of expert sex therapists.

Prevention of premature ejaculation

As in most of the cases psycholgical factor is the main culprit for premature ejaculation, thus a proper comunication, trust and understanding is necessary before performing sexual act.

There are some yoga which cn increase the celibecy and also helps in preventing premature ejaculation. Among yoga matsyasana, sharvangasana are the main. Apart from that kapalbhati pranayama should be performed regularly.

Thus the conclusion is that its in our hand to get rid of this disorder and if you follow the above instructions we can have an enjoyable life.

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Premature ejaculation - Types and causes

Premature ejaculation is the most common sexual problem and is a major reason of a conflict between partners. There is a tendency to hide these things but now a days people are coming out with there problems and seeking some medical advice. Before proceeding into details let us first know what does pre mature ejaculation means.

What is premature ejaculation

Most of the person relate premature ejaculation to erectile dysfunction or male impotence but it is absolutely a different entity.
The International society of sexula medicine defined premature ejaculation as a male dysfunction characterized by ejaculation which always or nearly always occurs prior to or within a minute of vaginal penetration;

and, inability to delay ejaculation on all or nearly all vaginal penetrations;

and, negative personal consequences, such as distress, bother, frustration and or the avoidance of sexual intimacy."

Thus premature ejaculation is completely different from erectile dysfunction where one can perform normal sexual act but unable to sustain to the desired period.

Types of premature ejaculation

Premature ejaculation can be primary or secondary. A cause or proper medical history can detect the type which may be responsible for premature ejaculation.

Primary premature ejaculation

Primary premature ejaculation is when the person never had a sustained sexual act and the tendency to ejaculate prior to desired time has been observed since his first act and continued to develop the same problem. There may not be any underlying pathology for its cause and some psychological factors is expected to play a role for its cause.

Secondary premature ejaculation

A secondary premature ejaculations means a person had normal coitus with sustained act prior and having a satisfactory sexual life then developing premature ejaculation. In majority of secondary form of premature ejaculation there may be medical problem like thyroid abnormality, hormonal disbalance or any change in neurotransmitters of brain.

Causes of premature ejaculation

About 90% of the cause of premature ejaculation is due to anxiety, fear or any other psychological cause. In few cases this may be due to substance abuse or some medical reasons like thyroid abnormalities or change in neurotransmitters.

Psychological causes of premature ejaculation

Anxiety and depression are the most common reason for premature ejaculation. There may be a fear or guilt feeling which may be depressive. Any bad sexual experience in the past can be another reason. Excessive over excitement or anger or any other hyper reactive state may lead to premature ejaculation.

Organic causes of premature ejaculation
Though organic cuases are very rare as a cause of premature ejaculation, but in some thyroid abnormalities, hormonal disbalance or disturbance in neurotransmitters of brain may lead to premature ejaculation. Some infections may also cause premature ejaculations especially infection of prostate glands.

There is nothing to get depressed or to feel embarassed as there are some simple techniques and medication to get rid of it. There may be many false advertisements but I should not be fool to follow them. The detail of treatment and prevention of premature ejaculations are given at Treatment and prevention of premature ejaculations.

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Whiskey not risky and gin no sin in diabetics

Often when any one ask that is alcohol risky for diabetics, we get a straight forward answer Yes and always there has been recommendation to stop them absolutely. But those were the earlier days when whiskey was considered risky and gin was a sin. Now a days it has been socially acceptable and hs been a part of social routine. As this juncture say no to alcohol is easier than to do it actually. It is better to make diabetics understand the additional problem of alcohol and ask them to drink sparingly and sensibly.

Effect of alcohol in our body

Studies suggested that a low and daily dose dose of alcohol reduces the risk of coronary heart diseases. The effect of alcohol has been demonstrated as a J shaped curve which means the risk decreses with low dose and increases exponentially as the dose is increased. In teetotalers or occassional drinkers, the mortality rate are higher than in those who consumes one to two drinks per day.

Though there is no contraindication of consumption of alcohol, but some points should be remembered by a patient.

What does moderation in drinking means

The present consensus is that one must not recommend alcohol to those who abstain but drinking in moderate quantity reduces the risk of coronary heart disease especially in men over 45 and women over 55. Moderation may be defined as one drink per day for women and two drink per day for men. One drink is equivalent to 12 ounce can of beer, 5 ounce glass of wine or 1.5 ounce of 80 proof spirit.

It should be remembered that beer in abroad has alcohol content not more than 3 to 3.5% while in India even mild beer contains not less than 6.75% of alcohol, trhus for India one drink may be 6 ounce of beer.

One should also note that alcohol contains calories with no nutritive value, the total consumption in diabetes should not exceed more than recommended thus one should calculate the calorie consumed by alcohol in order to maintain total calorie. Calorie can be calculated as
0.8 x proof x number of ounces = calories

Alcohol in diabetes

So if the total calorie consumption is maintained, one or two drink in patient with diabetes is not contraindicated at all, but the major concern is that a person taking drinks eat too much of high calorie snacks, if snacks is withdrawn then alcohol gets absorbed quickly giving quick high and even causes gastric irritation and with snacks leads to excess calories. The solution is to add salads and raw vegetables as the snacks along with drinks.

Patient with diabetes should avoid beer because beer have additional calories as it contains cabohydrates. Wine too contain sugar but in some imported wines alcohol is 12% in comparison to Indian brands which contain 18% thus have less calories.

It is advisable to take whiskey, rum, vodka or gin with water or soda or even on the rocks but the cocktails should be avoided as the cocktails are very rick is calories.

Risk of alcohol intake in diabetes

When I am enumerating the risk factors of alcohol intake, that clearly means risk with moderate intake of alcohol as binge dinking and teetotalers are always at risk. Moderate drinking is not harmful but in some condition a precaution is required.

Hypoglycemia is a complication of diabetes and alcohol may mask the hypoglycemia and even may precipitate it, so it is necessary to have good diet but the total calories should be maintained.

Metformin is prescribed in a diabetics who are generally overweight or obese and are on low calorie diet, thus it should be maintained that a total calorie from alcohol should not exceed 5% of total carolies intake. Metformin may cause a serious lactic acidosis in patients havind hepatic and renal impairments. Thus alcohol should be taken cautiously.

Glitazones also affects hepatic function and diabetics on glitazone should carefully take alcohol and should be monitored fo liver enzymes.

Thus we should remember that if we are careful and have the control on our drinks and its quantity then whiskey is no more risky and gin not a sin for diabetics.

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What is better than viagra - Cialis

Erectile dysfunction or male impotence is the most embarassing situation of men's life, being a doctor I often see the awkwardness and a sort of guilt feel on the face of the patient towards his partner while mentioning his problem.Till date

Till date viagra has been a solution for the men and had helped men with erectile dysfunction worldwide, but there is a certain drawback that the effects only last four to six hours and users often complain it takes the spontaneity out of sex.

To overcome such difficulty there is another pill which is considered better than viagra and that is Cialis. Viagra is sildenafil while Cialis is tadafil.

How Cialis or tadafil is effective

Cialis eases the problem of shorter acting viagra Cialis as it has the power to last for up to 36 hours and this helps in a relaxed sex without having it as pre-planned. Cialis has the ability to maintain erections for successful sexual intercourse and gives satisfaction with the hardness of erections and build up the confidence.

It is effective in mild, moderate and even severe erectile dysfunction and even erectile dysfunction caused by diabetes or hypertension.

There is a common false belief that that as Cialis or tadafil acts for 36 hours there may be erection so that long period but it is not so, erection occurs only after sexual stimulation, so if one is not sexually stimulaled it doesnt work.
Cialis increases the blood supply of penis twhen it is stimulated and the longer duration of action helps to maintain that erection.

When and how to take Cialis

In contrast to viagra which is to be taken one hour before the sexual act, Cialis is taken as a daily dose just like contraceptive pills in women. In can be taken in the morning, or with other medicines if any one taking or even at bed time. Dose should be 2.5 mg to 5 mg per day.

The effect of tadafil or cialis may not be felt for the first 2-3 days as it can take up to 4 to 5 days before the medicine may begin to work. Cialis may be available as 36 hours Cialis and daily dose Cialis. For a male suffering from impotence due to stress or depression may use 36 hours Cialis and in the mean time may try to get treated for the cause, while male having impotence due to diabetes or hypertnsion or any neurogenic cause may prefer daily dose of Cialis.

Side effect of Cialis

Like Viagra, Cialis too have some side effects and the most common are headache, upset stomach, back pain, flushing, pain in muscles and stuffy or runny nose. These side effects are transient and usually subsides after few hours.

Some of the serious side effects include priapism that is erection exceeding for more than an hour and if it occurs a doctor should be consulted. Like viagra, Cialis may also cause eye problems and even blindness.

Precautions while taking Cialis

If a person suffers from any heart disease or taking nitrates, a drug prescribed in angina should not take tadafil, stroke, long uncontrolled hypertension or peptic ulcers are the conditions when tadafil should not be taken. As Sildenafil and tadafil belongs to same gorup all the precautions of viagra should be taken with Cialis too.

The conclusion is that tadafil (Cialis) acts by same mode by what sildenafil (Viagra) acts but is a better choice as one may not have a timetable sex and can enjoy to its fullest.

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Weight loss surgery or bariatric surgery for morbid obesity

Obesity is a worldwide epidemic problem now, the initiation starts from childhood and in order to give a quality food and to fulfill all the desires of our child we often gets attracted to the fast food, oily foods and junks.

The control of obesity should be started at this point only and any ignorance lead to the most debilitating condition obesity which can form pillar for various diseases like diabetes, heart diseases and even cancers.

It is very easy to put on weight but often too difficult to lose weight on their own, even you try hard and get some success a Fad diet results in return to original weight or a weight gain after some time.

If we go through the article Methods of Obesity Management we derive a conclusion that it is the diet, exercise, yoga, behavioural therapy which are preferred as first line treatment of obesity, then it comes to diet pills or anti obesity drugs. Some prefer homeopathy phytolacca berry as anti obesity treatment.

What is bariatric surgery

Bariatric is the science which deals with causes, prevention, and treatment of obesity. Bariatric surgery also known as weight loss surgery is the surgical procedure for in order to reduce weight in case of morbid obesity.

Weight loss surgery or bariatric surgery generally results in greater weight loss than traditional treatment, and leads to improvements in quality of life and obesity-related diseases such as heart diseases, hypertension and diabetes. Though a combination of treatment is always preferred and surgery is the indicated or preferred in few cases.

When weight loss surgery or bariatric surgery is indicated

Weight loss surgery is indicated when there is morbid obesity or associated with morbid conditions which can cause serious impairment of quality of life or at times can be life threatening even.

The obesity is determined on the basis of body mass index (BMI) and bariatric surgery is indicated only when BMI is very high and where other non surgical methods fails to control it and quality of life continue to detoriate.

Body mass index calculation

There is a simple formula of calculating BMI, it depends on the the weight and height of the body. The formula is
( kg/m² ) (weight in pounds * 703 )
BMI = -----————————————-------------------
height in inches²

A BMI below 18.5 is considered as underweight, while upto 18.6 to 24.9 as normal. An overweight is one having BMI from 25 to 29.9 and BMI above 30 is considered as obese.

Effects of bariatric surgery or weight loss surgery

The basic principle of weight loss surgery is to change the anatomy of digestive system which can increase the satiety even after less diet and can even reduce appetite. Thus it is very much useful for a binge eater having morbid obesity. Weight loss surgery even lead to some hormonal change that helps in reduction of weight. The surgery lowers the risk of medical problems associated with obesity.

Weight loss surgery provides a drastic improvement in type 2 diabetes, blood pressure is controlled and even the dangerous triglycerides decreases significantly reducing the risk of cardiovascular complications and other serious heart disease. It is a form of gasric bypass surgery and it controls the serious complcations of obesity which may be dangerous and life threatening in obese persons who havent undergone the weight loss surgery.

Weight loss surgery increases the quality of life and the incidence of mortality due to obesity is significanly reduced. There is a myth that the surgery itself if complicated and life threatening. For that I must say that any surgery have some complications but if benefits exceeds the risk, it is wise to go for weight loss surgery if conventional method fails to increase the life expectancy.

Complication of bariatric surgery

Bariatric surgery or weight loss surgery is not an outdoor procedure and not similar to liposuction, it have the complications related to anesthesia and complications related to abdominal surgery. Proper consultation and control of diabetes before surgery lessen the complication to a great extent. The patient should undergo thoroughly checked and should discuss all their physical, mental and medical problems to the concern doctor before undergoing weight loss surgery.

Wish you a obesity free and fit and healthy life.

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Management of heat stroke

Heat stroke is very common in Asian and African subcontinent. The body teperature rises above 106 degree centigrade and there is no sweating thus the thermoregulatory mechanism fails. The effect can be mild to severe and affects nearly all organs of the body. It may even lead to sudden circulatory collapse or sudden cardiac arrest leading to death or person may survive with permanent neurological disorders. For detail see symptoms of heat stroke.

Thus the management of heat stroke should be initiated as early as possible. Management include aim to cool body temperature and some supportive measures.

Primary management of heat stroke

The primary management of heat stroke is to reduce the body temperature as quickly as possible by external means of heat dissipation. This is called evaporative cooling. For this direct ice application with fanning is done to promote evaporation and heat loss. This is the most acceptable mode of rapid cooling. Some times patient is immersed in ice cold water but it is not acceptable as it is a cumbersome process and also may lead to shivering and hypotension.

Cooling should be stopped once the body temerature comes to 38 to 39 degree Centigrade, other wise there is a chance of hypothermia which can lead to another problem.

In severe cases of heat stroke intravenous cold fluid is administered and even iced gastric or peritoneal lavage or enema is tried.

Supportive management of heat stroke

The supportive care includes to restore vital function of the body which may detoriate due to severe heat stroke. This includes

Secure airway

The most important is that the patient airway should be secured by endotracheal tube, if required. There should be adequate oxygenation by 100% oxygen. In comatose patient with severe respiratory depression assistd ventilation may be required.

Fluid replacements

Fluid replacement is done in small quantity as there is not much loss because there is no sweating in heat stroke. In older patients 1200 to 1500 crystalloides may be given monitoring central venous pressure. Acidosis can be combatted by 50 ml sodium bicarbonate intravenous. Glucose may be given if there is hypoglycemia.

Role of corticosteroid in heat stroke

Though role of corticosteroid is doubtful in heat stroke but if there is shock or edema or any adrenal insufficiency then corticosteroid is used to mange them.

Maintainence of urine output in heat stroke

Urine output improves after external cooling and fluid replacement. If there is fall in urine output then mannitol is given intravenous. If there is prolonged failure then it may even require dialysis.

Management of coagulopathy in heat stroke

If coagulopathy develops it is managed by blood transfusion. Clotting factors may require replacement.

Thus an early intervention an management may be life saving.

Prevention of heat stroke

Making a cool environment may not be possible at all work places to all, what we should take those preventive measures which are in our hand.

Drink plenty or water and keep yourself hydrated always, this may help to cool your body.

Wear light cloths of light color as it reflects sunlight while dark cloths absorbs them and may lead to heat stroke. But never be bare body as direct exposure of sunlight may even cause more serious heat stroke.

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Symptoms and manifestation of heat stroke

Heat stroke results from breakdown of thermoregulatory mechanism and there may be exertional and non exertional type of heat stroke. Obesity, diabetes, debility etc are the predisposing factors. The details are at Heat Stroke

Effect of heat stroke

Nearly all the tissues are susceptible to heat injury. High temerature raises basal metabolic rate and results in denaturation of enzymes, liquefaction of lipids and protein coagulation.

Tissue injury depends on depends on absolute tissue temperature and duration of exposure. Nearly all systems of body are involved in heat stroke.

Symptoms of heat stroke

As mentioned above nearly all system of body are affectd in heat stroke main being cardiovascular, nervous, renal and hepatic system. The symptoms are according to the effect on these organs.

Neurological symptoms of heat stroke

Neurological symptoms of heat stroke includes altered mental status, confusion, disorientation and seizures. In severe cases there may be stupor and patient may land up in coma. Some patients developing severe neurological features may survive but may be left with permanent neurological complications like dementia, amnesia and even hemiparesis. There may be ataxia, dysarthria and even neuropathies.

Cardiovascular symptoms of heat stroke

The pulse which is initially of good volume becomes weak and feeble as the shock may supervene, there may be hypotension and cardiovascular collapse due to myocardial injury and hypoxia. There may be irregularity in pulse that is arrythmias. In severe cases even death may occur due to circulatory collapse and sudden cardiac arrest.

Renal symptoms of heat stroke

There may be acute renal failure due to acute tubular necrosis which is induced by ischemia and myoglobin in urine caused by muscle injury by heat (rhabdomyolysis)

Gastrointestinal symptoms of heat stroke

The mucosa of gastrointestinal tract in injured which induces symptoms like nausea and vomitting.

Hepatic symptoms of heat stroke

There may be liver injury and even damage due to direct heat injury which may result in jaundice. In investigation we may see elevated bilirubin and SGPT. This liver injury my lead to coagulopathy lately.

Symptoms of heat stroke due to coagulopathy

Injury of clotting factors may take place resulting in petechiae and echymossis. Platelet count may be reduced. Disseminated intravascular coagulation can occur in severe cases.

Cutaneous symptoms of heat stroke

Heat stroke may lead to metabolic acidosis and lactic acid is accumulated leading to acidotic breathing. There may be loss of glucose and minerals and hypoglycemia, hypocalcemia and hypokalemia may occur.

Thus heat stroke can be medical emergency and early management is necessary which can be not only life saving but also can save from some permanent disability. See details of treatment at management of heat stroke.

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Heat stroke - A common problem in hot and humid climate

Before knowing about heat stroke we should first know about heat hyperpyrexia which is by definition a body teperature of more than 40 degree C or 106 degree F due to exposure of high environmental temperature.

Though human body has effective mechanism to acclimatize such climatic conditions but in some case when acclimatization mechanism fails, it leads to heat syndrome or heat hyperpyrexia.

Heat hyperpyrexia can occur in two ways i. heat stroke and ii. heat exhaustion.

Heat stroke

Heat stroke is a catastrophic condition in which there is complete breakdown of thermoregulatory mechanism of our body and the body temperature raises above 41 degree centigrade or 106 deg Farenhiet. This high fever may be associated with loss of sweating and there may be profound disturbance in consciousness,

Loss of sweating is the characteristic of heat stroke.

Risk factors for heat stroke

There are certain predisposing factors for heat stroke. High environmental temperature is the commonest one andmost of the cases are seen in the month of May to June especially in Indian and African subcontinents. A humid climate adds as a precipitating factor and the sea coasts are more humid.

Old age and debility are another predisposing factors as the body mechanism is weaker and more prone to heat stroke.

Diabetes, obesity and alcoholism add as a risk factor as the fat content are more prone as in obesity the exposure area is more. In diabetes and alcoholism the basic metabolism of body is hampered and makes more prone to heat stroke.Any associated infection or cardiovascular accidents lead to alter normal basic thermoregulatory mechanism of body and can lead to heat stroke.

Less water intake, dehydration which may be due to heavy exercise or excessive physical work may lead to depletion of salt and water and may be a risk factor for heat stroke.

Forms of heat stroke

As mentioned in the risk factor heat stroke can be caused by salt depletion which can be due to excess work of exertion, thus heat stroke can occur in two forms-

Exertional heat stroke

Exertional heat stroke occurs in unacclimatized young person who perform strenuous work like a sportsman playing in hot humid climate, an athelete, soldiers and labourers. They perform heavy and strenuous work in hot and humid climate and lead to heat stroke.

Classical or non exertional heat stroke

This form of heat stroke occurs generally in elderly and debilitated persons or suffering from diseases like diabetes, taking anticholinergic drugs or any diuretics. Patient on drug for Parkinson's disease are also prone to unexertional heat stroke. This for is often epidemic during heat waves of hot summer climate.

Heat stroke can affect almost all organs and system of our body. Details of its effect is given here at symptoms of heat stroke.

Management should be initiated as early as possible and main aim should be cooling of body temperature by ice bags and fanning. Details of management is given at management of heat stroke. This aticle also provide some preventive measures for heat stroke.

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Acute mountain sickness : A common problem at high altitude

Hills are the charm and most of the people prefer to go to hills for a good vacation, but there are some who just fall into trouble rather than to enjoy due to sickness caused by high altitude. Some may face a tolerable sickness but some may even have emergencies.

High altitude is above 2700 meters from sea level and there may be low temperature, low oxygen and increased radiation which are the culprit of causing the problem.

The type of problems may be acute mountain sickness to more severe high altitude pulmonary edema and high altitude cerebral edema.

Acute mountain sickness

Acute mountain sickness is a benign and reversible condition occuring in travellers ascending to altitude of 3000 meters. There may be hypoxia which stimulate renin to angitensin to finally aldosterone which releases ADH which results in to fluid retention. Hypoxia may also lead to dilatation of cerebral blood vessels with increased blood flow.

Symptoms of acute mountain sickness

The symptoms develop within 6 to 24 hours of an ascent and vary in severity from trivial to incapacitating. Headache is the prominent presenting symptom and can be over forehead(frontal), it is throbbing and aggravates by any exertion and is more severe in morning. Headache is due to dilatation of cerebral blood vessels.

In a severe cases there may be some other associated symptoms along with headache like anorexia, giddiness, insomnia, nausea and vomiting. Sometimes ataxia and peripheral edema may be present.

In rare instances some may find high altitude intolerable and may suffer with some serious sequelae like high altitude pulmonry edema and high altitude cerebral edema.

Management and prevention of acute mountain sickness

The best way to manage acute mountain sickness is to acclimatize by ascending gradually but as most of the person are tourist and time factor may be important so this may not be feasible to all.

In mild cases, rest and an analgesic and antiemetic are adequate and symptoms resolve after 12 to 48 hours at a stable altitude though may recur with further acsent.

If there is persistent symptom and severe form of illness acetazolamide is given which is a carbonic anhydrase inhibitor. It is given in a dose of 250 mg 8 hourly for 2-3 days. The symptoms of high altitude is probably due to alkalosis and that is why it respond to acetazolamide.

Dexamethasone 8 mg should be given immediately followed by 4mg 8 hourly if symptom persists. Though it is a steroid and should its use should be limited to severe symptoms.

The person should always be alert and if high altitude pulmonary edema or high altitude cerebral edema occurs should report to the doctor immediately.

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Subdermal implants for long term contraception

Though injectable contraceptives are a boon for those who have a busy daily schedule and often forget and missed their oral pills. These injectable contraceptives though is better in compliance but have certain advantages and disadvantages.

But monthly injecttions was too intolerable for some women and that lead to exploration of other route of progesterone delivery havin slow and sustained release, longer in action and fewer in side effects. Then came subdermal implants as a long acting contraceptive measure.

Subdermal implants for long term contraception

Though there are misconceptions about subdermal implants but it has no adverse value in fact it is more effective than oral contraceptive pills having lesser side effects as it avoids hepatic first pass metabolism.

The different types of subdermal implants frequently used are-

Norplant

Norplant consists of two rods each containing 70 mg levonorgesterol which releases 50 microgram daily and once implanted acts for 3 to 5 years.

It acts by suppressing endometrium and 50% by suppressing ovulation. It is implanted on medial side of upper arm under local anaesthesia.

The best timing of implantation is on the first day of menstrual cycle, or within 5 days following an abortion or 3 weeks after delivery. A barrier contraception should be used for the first week as it may take a week to act to its maximum.

The main disadvantage of Norplant is that it needs removal at the end of the use and if there is intolerable side effects.

Implanton is an implant where single rod is used and is effective for 3 years, though it also needs to be removed.

Capronor is an implant which doesnt require removal as it consist of a single biodegradable capsule containing levonorgestrel and its effect last for one year.

The return of fertility occurs in about 40 percent within 3 months of removal and to 90 % in about 2 years. In about 10% it may require request removal because of side effects or wishing for a child.

Advantages of dermal implants

The main advantage is that it is long acting and have sustained effect, it is coital independent and there is no requirement of frequent injections or daily dose of pills.

Pregnancy rate is too low as it is quiet effective method of contraception. As it avoids hepatic first pass thus systemic side effects are too low.

It can be safely used in lactating women and at all ages even at age over 40 years.

Disadvantages of dermal implant

The most disturbing disadvantage which can lead to request removal is breakthrough bleeding. There may be amennorhea and irregular cycles as happens with progesterones.

In some cases about 1 in 100 there is report of ectopic pregnancy, infertility may occur in few cases and the other side effect of progesterone may exist.

There may be local infection at the implant site though this can be avoided by maintaining hygiene.

One disadvantage is that it requires both insertion and removal, though now a days biodegradable capsules are available like Capronor which does not require removal.

Norplants are too costly for a normal person to bear, thus it is not so popular in developing countries like India.

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Advantages and disadvantages of injectable contraceptives

Injectable contraceptives are progesterone mainly depot medroxy prodesteone acetate (DMPA) and Norethisterone ethantate (NETO). In some countries for less failure rate these are combined with small amount or estrogen and given deep intramuscular once a month. To know in detail about them refer to Injectable contraceptive : No tension for missing pills.

Though the development of injectable contraceptive pills have eased the women and the compliance has been improved but it has some advantages as well as disadvantages too which are enumerated below-

Advantage of injectable contraceptives

The advantages of injectable pills starts from a good compliance and the worry to miss pills is no more, thus there is good compliance and the added advantage is that the women is under regular medical supervision.

In can be given to a patient with sickle cell anemia where oral contraceptive is usually not recommended. It is also suitable for lactating women.

The side effects of lipids and carbohydrate metabolism is avoided as it contains no or very little estrogen and that too in special preparations like mesigyna, cyclofem etc. The other estrogenic side effects are also avoided.

While using injectable contraceptives the incidence of pelvic inflammatory diseases, ectopic pregnancies and functional ovarian cyst is low. If also protects from endometrial cancer.

Though the return of the fertility is a bit delayed and that too more with DMPA but more than 80% of woman concieve within 1 year after leaving the contraceptive measures.

Disadvantages of injectable contraceptives

There are few disadvantages of injectable contraceptive too and as it is injectable one, it cant be withdrawn, so these side effects of progesterone have to be tolerated till the progestogenic effect is over.

There may be a little weight gain, depression, a feeling of bloating and belching in the stomach, and pain can occur in the breast, but these effects are temporary and is reversed when the effect of injection is over.

There may be menstrual irregularity and even amenorrhoea in about 20 to 40% women at the end of one year with DMPA and NETO. There may be profuse bleeding in 1 to 2 % of cases.

As mentioned above there may be delay in return of fertility but most women concieve in 1 year after. In general fertility returns within 6 month in DMPA and within 3 month in NETO after the last injection.

When there is prolonged amenorrhea it may lead to osteopenia due to strong antiestrogenic effect of DMPA and it may lead to reduce bone mass density and may induce osteopenia.

Though injectable contraceptives may increase blood LDL level but neither it is contraindicated not have any adverse effect on blood pressure.

Note : Injectable contraceptives both DMPA and NETO are contraindicated in breast cancer.

Now a days there are contraceptive measures which is implanted below dermis of skin and is long acting upto3 to 5 years. To know more see Dermal implants : Long term contraceptive measures.

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Injectable contraceptive : No tension for missing pills

Often there is a complain from young women especially who are working that they slept being too much tired and forgot to take the pills and the whole cycle they remain in additional stress, apart from the stress of their normal routine work. To overcome this inconvenience of daily compliance of oral pills a depot injection consisting of progestogens have been developed.

Types of injectable contraceptives

Generally there are two types of injectable contracetives used. Other types like once a month injections are derived from this two types. These are

DMPA or depot medroxy progesterone acetate

Depot medroxy progesterone acetate is given in microcrystalline aqueous suspension and is injected deep intramuscular. A monthly injection of 25 to 50mg DMPA combined with 5mg estradiol is sufficient to confer contraception. Some may even use higher dose like 150 mg DMPA or 300 mg which can provide a contraception for a period of 3 months and 6 months respectively. Pregnancy rate may be seen 1 per 100 with DMPA.

Norethisterone ethantate or NETO

Norethisterone ethantate or NETO is used in castor oil solution and is given deep intramuscular. A 200 mg of NETO is recommended every 2 months as a contraceptive measure. The advantage of NETO over DMPA is that the the contraceptive effect abolish more quickly than DMPA after the effect of the drug. Pregnancy rate is seen 0.6 per 100 women years with NETO.

Once a month injections for contraception

This is an injectable contraception having a combination of estrogen and progesterone and is available in some countries in the name of-

Mesigyna

This contains NET 50 mg and oestradiol valerate 5 mg in half ml of injection and is given deep intramuscular. The failure rate is much lower to 0.4 per 100 women year.

Cyclofem

Half ml of cyclofem consist of 25 mg DMPA and 5 mg oestradiol cypionate. The failure rate is even lower than mesigyna and other added advantage is that there is less menstrual irregularities than DMPA or NETO when used alone.

Other once a month injectables are Marvelon and Femovon both containing both progesterone with small quantity of estrogen.

When to administer injectable contraceptives

Injectable contraceptives are mainly preffered for lactating mother or in multipara even non lactating.
The ideal time of injection is within one month of delivery of the child if the mother is not lactating or one month after abortion.

In lactating women the injection may be delayed upto 10 weeks and may be given in the third month because there is lactating amenorrhoea and ovulation in such women is delayed for 10 weeks.

Where there is a good thing there are some bad things too as a complementary and the injectable contraceptives are not any exception, so there are several advantages and some disadvantages too. To know about them please refer to advantages and disadvantages of injectable contraceptives.
Now a days there are even some implants which is implanted beneath the skin in subdermal region which provides a long term contraception, may be upto 5 years. To know about them please see Dermal implants for Long term contraception.

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Management of renal colic

Renal colic is considered as a medical emergency as the pain is cruciating and agonizing, though some tests should be done to diagnose the cause but management is to be started without delay. The symptoms is to be relieved immediately. To know the symptoms and diagnosis please see Renal colic : An acute pain in lower abdomen.

Management of renal colic

The management of renal colic includ immediate treatment to relief pain and then to cure the cause. As it a medical emergency, following treatment should be started immediately, even the patient is at home.

Immediate management can be started as soon the person suffers from renal colic, he should be kept on bed and a doctor should be called, following steps should be taken to treat a patient with renal colic.

Bed rest

Patient with renal colic should be on bed rest and a warmth over the affected area should be given to relive pain. A hot water bag or even a bottle with warm water can solve the purpose.

Analgesics and antispasmodics

Analgesics may be given in the form of injection diclofenac, but in severe colic patient may require morphine 15 mg or pethidine 100 mg intramuscular injection. Dextropropoxyphene or pentazocine may also be useful if given orally in case above drugs can't be given.

Atropine 0.6 to .12 mg may be given intramuscular which acts to relieve spasm of abdomen. Drotaverine (drotin) now a days or hyoscine (buscopan) can be used orally.

Urinary antiseptic

If there is infection urinary antiseptics are to be given in the form of antibiotics, but this should be started only after the sample for culture and sensitivity of urine is taken, otherwise antibiotics may hamper the result or urine culture. Till the proper sensitive drug is tested by urinary sample one could start norfloxacin 400 mg or ciprofloxacin 500 mg twice daily.

Fluids

A high fluid intake is advised to achieve a good urinary output. An increased concentration of urine in case of dehydration is also a cause of renal colic and if there is no retention, patient should take adequate fluid. If the urine output is falling then one should go immediately go for investigations like plain x ray urinary tract, pyelography, cystoscopy to detect the cause.

Management of the cause of Renal colic

The cause may be a urinary tract infection, or prostate enlargement of any obstruction due to stone, tumor etc.

After getting the basic idea of sensitive antiboitic by culture and sensitivity test which comes after 72 hours, one should administer the antiboitic accordingly.

If th urinary obstruction is present due to a treatable cause like stone, it should be removed surgically. Only medical treatment is unlikely to cure this problem.

Obstruction due to enlarged prostate if it is benign should be treated accordingly, details of treatment is given here. Treatment of enlarged prostate.

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Renal colic : An acute pain in lower abdomen

Often a person suffer suddenly by an intense pain in the lower abdomen associated with pain in groin and low back. This is nothing but a renal colic, colic literally means pain and it is due to the renal or kidney problems.

Causes of renal colic

Causes of renal colic may include acute retension of urine, the most common cause in male is benign enlargement of prostate. Other causes may be any urinary obstruction which may be due to stone.

A urinary tract infection may also lead to sudden pain in the loin or renal colic quiet often. Dehydration may be one factor causing renal colic.

Symptoms of renal colic

Renal colic presents as sudden acute onset of intense pain in the loin that may radiate into the lumbar region or low back, down to the groin and even to the testicles of the same side.

The pain may last from few minutes to several hours and till the pain is there that leaves the patient in rolling in the bed and writhing in agony. Retention of urine may or may not be present depending upon the cause.

Diagnosis of renal colic

Renal colic is a medical emergency as the pain is agonizing and gives no time to diagnose, however the diagnosis of the cause is must while management is on.

Urine should be sent for culture and sensitivity to detect any urinary tract infection and type of drugs sensitive if at all there is an infection.

The cause of urinary retention should be diagnosed and if the patient is above 50 years of age diagnosis of enlarged prostate should be done.

Pyelography, X ray, ultrasonography and cystoscopy may be required to find the any urinary obstruction of any other pathology of the urinary tract.

The pyelography may reveal the region of onstruction, cystoscopy is done by inserting a fine tube with camera and visualize the bladder and urethra. Ultrasonography may detect the condition of kidney whether is hydronephrosis due to accumulation of fluid caused by obstruction of urinary tract, or a stone in the path of rinary tract. Sometimes a stone in the ureter causes intense pain and may require surgery to get relief from it.

The management should start immidiately and the symptomatic management should not wait for diagnostic result. For detail of management see management of renal colic.

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Reversible and irreversible form of hair loss or alopecia

Baldness or hair loss in medical term is called alopecia. Contrary to the belief there are some form of alopecia which are reversible. specially those which are non scarring. In general apopecia is of two types-

Non cicatrical or reversible alopecia

Non cicatrical alopecia where there is no scarring and hair follicles are retained and hair loss is potentially reversible. There are three types of non cicatrical alopecis namely

Alopecia aerata
Male pattern alopecia, and
Diffuse alopecia

Though the exact cause is not known but is expected to be due to excess androgens, genetic cause or related to age of the patient. Psychological factors too may play a major role in non cicatrical alopecia.

Cicatrical alopecia or irreversible alopecia

Cicatrical alopecia is a scarring type of alopecia and hair follicles are lost, so it is irreversible.
In cicatrical alopecia the skin is usually atrophic or scarred.

Causes of cicatrical alopecia

The important causes of cicatrical or irreversible alopecia are

Physical trauma like long term traction of hair, burn leading to loss of hair or any x ray irradiation.

Fungal infection like kerion and favus causes irreversible hair loss, though early use of antifungal may save the remaining hairs but the lost hair may not come again.

There are some bacterial infection like lupus vulgaris or tuberculosis of skin, carbuncle, folliculitis decalvans which causes irreversible hair loss.

Viral infection like herpes zoster may cause cicatrical or irreversible alopecia.

There are some cutaneous diseases like pseudoplade, follicular lichen planus, lupus erythematosus and scleroderma may also cause irreversible hair loss.

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Unwanted hair growth on face and body in females : Hirsutism and hypertrichosis

Excessive hair on the face or body is quiet irritating especially in females and every one want to get rid of as quickly as possible. Excessive growth of hair may be either hirsutism which is excessive hair growth of terminal hair and is androgen dependent and other is hypertrichosis which is excessive hair growth and non androgen dependent. Androgen is the hormone which is responsible for male characters and is also present in females but in very less quanity.

Causes of hirsutism of excess hair growth

Hirsutism is caused by production of excess androgen in females and this production may be of different reasons. The cause can be divided as endocrinal and non endocrinal depending upon the cause of increase of androgens.

Endocrinal causes of hirsutism

Endocrinal causes consist of different diseases leading to excess production of testosterone or other androgen. These diseases are

* Polycystic ovary or polycystic ovarian syndrome - In this condition there are many small cyst in ovaries and there may be excessive androgen and less estrogen production.

* Congenital adrenal hyperplasia - This is a condition where there is hyperplasia of adrenal gland there may be excess production of dihydroepiandrosterone and steroids which have masculinism character and lead to excessive hair growth.

* Adrenal adenoma - It is the benign tumor of adrenal gland and causes excess production of androgens by adrenal glands.

* Hilus cell tumor - This is a virilizing tumor of the ovary where there is prominent male character and excessive hair growth.

Non endocrinal causes of hirsutism

Non endocirnal causes consist of racial, there may be familial history and this may be a reason. In some case the cause is idiopathic or unknown. There are certain drugs which may lead to hirsutism like phenytoin (eptoin) used in seizures or epilepsy, minoxidil an antihypertensive used for hair production, androgens and corticosteroids.

Hypertrichosis is in excessive hair growth which is non androgen dependent and non endocrinal most often.

Features associated with hirsutism

Hirsutism may be associated with other features like deepening of the voice, hypertrophy or enlargement of clitoris, acne, breast involution, increase in muscular mass and recession of fronto temporal hair line.

All these are the musculine characters present and is usually seen in endocrinal causes where virilism is the reason of incresed hair growth or hirsutism. Hirsutism due to adverse effects of certain drugs may not have these associated feature but the other adverse effects of that drugs.

Treatment of hirsutism

The treatment consists of the treatment of the cause like anti androgen therapy in congenital adrenal hyperplasia and Polycystic ovary. Ovarian cystectomy or drilling may be done in PCOS. Excision of adrenal adenoma should be done if present. Withdrawl of drugs if the adverse effect is more difficult to tackle than its benfit.

In general the treatment of hirsutism consists of a three pronged attack using cosmetic methods namely waxing, bleaching, use of depilatory cream and electrolysis.
Suppressive therapy including dexamethasone and oral contraceptives may be used. Peripheral androgen blockers are used in some case mainly spironolactone and cyproterone acetate.

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Miliaria : A rash and itching due to excessive heat

The heat is on and the most irritating part of the heat is the itching and small vesicles especially on neck and back. This is nothing but an abnormal skin condition called miliaria.

Causes of Miliaria

Miliaria is due to blockage of sweat gland which is caused due to excessive heat and humidity. The blockage of sweat gland is at different level like at mouth called the sweat pore or the intra epidermal part or at dermo epidermal junction and the rashes formed is different due to blocakge at different part.

Types of Miliaria

Miliaria is of three types and is dintinguished by the site of blockage of sweat gland. All three types gives a typical form of rash and is described below.

Miliaria crystallina

Miliaria crystallina is due to blockage of the sweat pore or the mouth of the sweat gland. The characteristic appearance is generally tiny vesicles which shine. This is generally asymptomatic.

The most common sites affected are back and abdomen, trunk and extremeties may also be affected.

Miliaria rubra

Miliaria rubra also called prickly heat is due to blockage of sweat duct at its intra epidermal part. This is characterized by an appearnace of small grouped papules or papulovesicles and is sorrounded by erythema. There is intense pruritis or itching. Children usually scratch to bleed most oftenly. The redness is clearly seen in white persons. In blacks the erythema may not be visible.

The most common sites affected are trunk and neck. A feeling of cold gives relief. This is the most common type of miliaria seen by a dermatologists.

Miliaria profunda

Miliaria profunda is due to blockage of sweat gland or sweat duct at the dermo-epidermal junction. The skin lesion is in the form of colored papule and is seen most commonly on the trunk and extremeties. There is intense itching and the surface appears to be rough.

Treatment of Miliaria

The main aim of treatment of miliaria is to prevent excessive sweating, many person use talcum powder which have some cooling effect, this should be avoided in children which usually develop cough and cold. Some powder containing some anti histaminics should be used.

The glycerinated soaps, hot water and irritants should be avoided. In case of severe itching, local application of calamine lotion is recommended and it should be supplemented with anti histaminics orally. In mild cases topical use is sufficient.

Some dermatologists recommend ascorbic acid or Vitamin C 1 gm daily. This has a prophylactic role and may prevent skin from miliaria when exposed to excessive heat and humidity.

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Diagnosis and Treatment of Guillian Berre Syndrome

Guillian Berre Syndrome a disease involving mtor neuron affects very rapidly and at times paralyze the whole body. Though caused by an unknown etiology, there are several pre disposing factors like respiratory infection, diarrhea, lymphoma etc. There is demyelination of motor nerve and the organ and muscles supplied by that nerve get paralysed.
The most important thing is that palate is spared and never get paralyzed. Details about cause, factors responsible for it and clinical features can be seen at Guillian Berre Syndrome A sudden onset of complete paralysis.

Diagnosis of Guillian Berre Syndrome (GBS)

As this diseases is acute in onset a quick diagnosis can save a life. For this a complete medical history is taken to know the process of evolvement of the paralysis. Past history of any infections and the presences of sensory function. Patient may feel the touch but cannot move.
There are different investigations done to confirm the diagnosis and it should be done after hospitalizing the patient. These investigations are-

Lumbar puncture and CSF examination in Guillian Berre Syndrome(GBS)

A fine lumbar puncture needle is inserted between L1 and L2 vertebra and cerebrospinal fluid (CSF) is take for biochemical analysis. As the pain sensation is intact it may be preferrably done under local anaesthesia. The biochemical analysis of CSF fluid reveals cytoalbuminic dissociation which is characteristic of Guillian Berre Syndrome(GBS). There may be xanthochromia that is yellow coloration of CSF which is normally colorless if there is no pathology.

Nerve function test
Nerve function test is done by electromyography in which the function and strength of the muscle is detected to know the extent to nerve damaged supplying that muscle.

Another test is the nerve conduction test where a particular nerve is stimulated and the conduction is measured.

These two tests detect the extent of damage of nerve and the possibility of further damage thus provide a platform for management.

Treatment of Guillian Berre Syndrome(GBS)

Guillian Berre Syndrome is a self remitting disease and it is 100% reversible, the main aim is to keep the respiration intact for at least 3-4 weeks by which the remission starts. The normal trend of the progress of the disease is progression in first 2 weeks, plateu or remains as it is in next 2-4 weeks and then remission starts.

The most important thing is that the patient should be hospitalized only at those hospital where there is facility for artificial respirator.
There are some medicines prescribed which doesnt have a curative role but in important in treatment of Guillian Berre Syndrome. These are-

Intravenous immunoglobulin for GB syndrome
Intravenous immunoglobulin is not curative but is a very important drug for GBS as it checks the progression of the disease. Thus the recovery or remission phase starts earlier and there may be quick remission as the extent of damage is checked. It sgould be started as early as possible. Intravenous immunoglobulin after 2 weeks is of no use as the disease is already progressed to its maximum level.

Methyl prednisolone injection
Its role in GBS is doubtful but some physician prescribes it and believes that it may help in quick remission of the disease.

Plasmapheresis

Plasmapheresis means exchange of plasma and is done to remove the antibody formed which may be the cause of demyelination of nerve. Its role is also doubtful but most physician prefer plasmapheresis as a mode of treatment of GBS.

Anti oxidants and adjuvant drugs

Vitamin B complex, anti oxidants etc are used to strengthen peripheral nerves but these are nothing more than a placebo.

Physiotherapy

Physiotherapy has a key role as when the remission starts most of the muscles get stiffened due to dis use. Physiotherapy should be started gradually as it will be very painful in the initial stage but gradually the flexibility is regained.

One should not do vigorous exercises to recover quickly as it may not help at all, in fact it may lead to damage of muscle and ligaments.

Complication of Guillian Berre Syndrome(GBS)

The most deadly complication of GBS is the respiratory failure which the only reason of mortality in this case. GBS is 100% reversible if an intensive care is taken. The involvement of diaphragm leads to respiratory failure and for this artificial respirator is required for maintian the respiration of the patient till the recovery period starts and innervation of diaphragm is myelinated and become functional.

In few cases in spite of intensive care there is mortality dur to respiratory failure.

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Guillain-Barre syndrome - A sudden onset of complete paralysis

Guillain-Barre syndrome also called acute infective polyneuritis is a medical emergency and 100% of the case requires hospitalization, though it is a self remitting disease and affects motor neurons, thus paralysing the muscles. The most dangerous aspect is if it involves phrenic nerve and diaphram is paralyzed, respiration may stop and patient may not be able to survive.

Causes of Guillain-Barre syndrome

Though the exact cause of Guillain-Barre syndrome is not known but it is beleived to be a viral origin. There may be a prior history of respiratory tract infection, flu or any form of viral infection causing diarrhea etc. There may be an onset of fever backache and pain in the limbs. In Guillian Berre syndrome there is an attack of the motor nerve and they get demyelinated which means the the protective covering of the nerve called myelin sheath gets damages and unable to get the signal to function therefore the organ supplied by that respective nerve gets paralyzed or defunct.

Factors associated for the cause of Guillain-Barre syndrome

The prior history of respiratory tract infection and diarrhea is the most common pre disposing factors. A bacteria called Campylobacter jejuni which is usually infected by consumption of uncooked foods and causes diarrhea may be an important risk factor.

Though very rare, but some incidences of Guillain-Barre syndrome has been seen after the vaccination for Influenza. Though the incidence is too low to discard this vaccination.

Some viral infections causing HIV AIDS, and Infectious mononucleosis are the associated risk factors. Guillain-Barre syndrome has also been in increased incidence in a patient of Hodgkin's lymphoma.

Clinical features of Guillain-Barre syndrome

The onset of Guillain-Barre syndrome is acute of sub acute and starts with slight weakness in the lower limb or upper limb, usually lower limb is affected first. There may be tingling but that is not due to any sensory involvement as sensory involvement is not at all.

Rapidly the demyelination starts from periphery to center and there may be involvement of the four limbs. The disease may spread and may involve facial muscles, bladder and bowel. One may feel to micturate but can micturate, similar may be with bowel. The patient may not even flicker his fingers . There may be unilateral or bilateral facial palsy, dysphagia or diffculty in swallowing due to pharyngeal palsy and ophthalmoplegia.

There may be severe pain in the whole body especially back as the sensation is intact but the muscles are not functioning. The most dangerous part is the involvement of motor nerves supplying the diaphragm and if it is involved there may be respiratory difficulty to cessation of respiration if the whole nerve supplying diaphragm is involved.

The treatment should be started immediately, though it is a self remitting disease and in most of the cases there is not any residual paralysis and patient is cures 100%, the main aim is to protect the respiration by stopping the spread of demyelination and to assist respiration artificially, if diaphragm is involved.
The detail diagnosis and treatment is given at diagnosis and treatment of Guillain-Barre syndrome.

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Treatment and prevention of boils and carbuncles

Boils also called furuncle is a common skin infection and the hair follicles are commonly infected leading to a raised pustule with a pointed pus end. Carbuncles are most commonly present in diabetics and is also a skin infections with multiple pus points and more severe constitutitonal symptoms.

Treatment of boils and carbuncles

In milder cases of boils and carbuncles a local compress with potassium permanganate solution with topical antibiotic like sodium fusidate is sufficient, but when the carbuncle or the furuncle is sorrounded by cellulitis, a systemic antibiotic is required. Before administerating systemic antibiotic culture and sensitivity of pus should be done to determine the antibiotic of choice.

In case of large, fluctuant lesion with pus incision and drainage should be done. It is very important to determine the time and stage of lesion before undergoing incision and drainange as too early incision in a furuncle is harmful and if there is pus formed and antibiotic is started then pus may be absorbed and there may be a solid lump in place of cellulitis if antibiotic is administered which is called antibioma.

The constitutional symptoms may be relieved by antipyretics and analgesics. Predisposing factors like diabetes should be properly controlled for rapid healing and to avoid recurrence.

Non Conventional treatment of boils and carbuncles

The bark of an Australian tea tree botanical name being Melaleuca alternifolia, has been used as an antiseptic and antifungal agent. It has a great healing effect of skin diseases. The oil is extracted from this Australian tea tree and had be used topically. It is also used in several skin allergies.

Prevention of boil and carbuncle

Personal hygiene is the most important part to prevent boils and carbuncles. Washing hands before using any antiseptics or touching an abrasion or cut is important. Squeezing of small papule or pimples should be avoided.

In case there is wound it should be cvered always and while doing hot compression the cloth and water should be clean enough.

Blood sugar should be controlled and an over cautiosness is require to maintain hygiene in diabetic patients.

One should not share some personnal items like razor etc. The small woung if discharges should be cleaned by alcohol based solutions to avoid formation of carbuncles.

Thus these are the mode of treatment of a boil or carbuncle. Preventive approach lead to lower the incidence of infection.

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Carbuncle : A common skin infection in diabetics

A carbuncle is a confluent mass of furuncles and is characterized by painful, red, indurated swelling which becomes pustular and necrotic and the pus discharges from multiple opening. It is almost similar to boil of furuncle but the only difference is there is mutiple pus point here.

Causes and features of carbuncles

Carbuncles is also caused by a bacterial infection Staphylococcus aureus as in boils. In fact is may be considered as a more severe or chronic form of a boil. The constitutional symptoms like feverand pain may be moderate to severe. There is local tenderness at the site and fever may sometimes be swinging associated with chill.

Carbuncles sometimes if left untreated may get worse and the infection may spread via bloodstream and may cause septicemia or the infection of the blood. Now a days the resistant variety of Staphylococcus called meticillin resistant Staph aureus (MRSA) is more responsible for causing carbuncle.

Common sites involved in carbuncle

As in boils the hairy part is the most common site for carbuncle too, but more than axillae it is present on the back, nape of skin and buttocks. Face is rare part where carbuncle can occur as the acne is less present in a person with diabetes causing carbuncle in comparison to a boil. The lesion of carbuncle heals slowly by granulation and scar formation.

Factors responsible for formation of carbuncle

One factor which is almost always a culprit is diabetics. Carbuncle is the common skin infection in diabetics as the diabetics are more prone to infections. A diabetic having mild abrasion or cut can end up forming a painful carbuncle if not treated early. Immunosuppressive drugs or corticosteroids are also responsible as they suppress the immune system of the body and make the skin more prone to infection. Other skin lesions like dermatitis or fungal infection can lead to a secondary bacterial infection causing carbuncles in an immunocompromised or diabetic patients. Other factors responsible are poor hygiene, malnutrition and obesity.

Diagnosis of Carbuncle

A pustular skin lesion with multiple pus points and necrotic lesion. There may be a history of immunosuppressive drug intake or corticosteroid intake. Diabetes is present in most of the cases and the level of blood sugar should be checked as the controlled sugar level may help in quick healing. Pus culture and sensitivity test is done which reveals the bacteria causing infection and the drug on which it is sensitive.

Treatment is antibiotics with some vitamins supplements, control of sugar level and symptomatic drugs for constitutional symptoms. Details is given at Treatment and Prevention of boil and carbuncles.

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Boils or furuncle : Causes, features and diagnosis

Boils and carbuncle are the common skin infections found and is especially seen during summer where the environmental conditions support to spread infections. Both boils and carbuncle presents as a necrotic lesion and detail characteristics, causes and treatment are detailed here.

Causes and features of boils or faruncle

A boil also called a faruncle is an acute, necrotic and deep seated infection of the hair follicle and is caused by a bacterial infection called Staphylococcus aureus. It begins with an erythematous, tender follicular papule which rapidly develops into large putular form. It has a pointed end and discharges a core of necrotic material and heals with a scar. The infection usually occur through any cut, scratches or pimples. Furuncle is an extremely painful condition and there may be associated fever. The area is inflammed and raised with warm in touch. Cold and ice can give soothing effect. The pain gradually decreases in intensity when the pus is formed.

Sites of boils or carbuncle

The common sites where the boil can occur are face, the neck, the axillae and the buttocks. There are the area where there is more hairs, and the infection of hair follicle can occur more commonly. Other sites include pubic area in both male and female.

Factors associated with formation of boils or carbuncle

In children the major factors responsible for boils are poor nutrition, poor hygiene and any injury which is not maintained in a hygienic way.

In adults obesity, diabetes, lymphoma are the main factors associated with boils.

However treatment of corticosteroids, cytotoxic drugs, immunosuppresents are common pre disposing factors for this skin infection in both children and adults.

Diagnosis of a boil or furuncle

To daignose a boil or furncle is not a tedious job, a typical skin lesion with raised pustule and a point of pus is typical in boil. Constitutional symptoms like fever may or may not be present. The pus is sometimes cultured to recognise the bacteria and to know on which antiboitic it is sensitive as now most of the Staphylococcus are methicillin resistant.

Carbuncle is another form of skin infection more commonly present in diabetics having mutiple pus points. Read more at Carbuncles A skin infection in diabetics.

Treatment constitutes antibiotics and symtomatic. There are alternative medicines too. preventin can be done by maintaining hygiene. To know more refer to Treatment of Boils and Carbuncles.

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Diagnosis and treatment of enlarged adenoids

Enlarged adenoids the most common cause of snoring in children and may lead to mouth breathing and deafness with recurrent ear infection. It may even cause dangerous sleep apnoea syndrome. For detail features and symptoms one may refer to Enlarged adenoids - Cause of mouth breathing in children.

Diagnosis of enlarged adenoids

Diagnosis of enlarged adenoid is important as the features of adenoid facies is misnomer and the same features may be seen with a children having dental malocclusion problems. Thus to diagnose enlarged adenoids the most important diagnostic procedure is posterior rhinoscopy.

In posterior rhinoscopy a rhinoscope is inserted orally to visualize posterior part of pharynx where an enlarged adenoid is visible.

Careful digital examination should be done if needed. Ohter investigation include soft tissue x ray of the nasopharynx which is confirmatory and revels mass in the nasopharynx and also an obstruction in the airway caused by that mass.

Treatment of enlarged adenoids

There are three principles of treatment of adenoids namely medical. surgical and nasal exercise.

Medical treatment of adenoids

If the adenoid hypertrophy is not marked and nasal obstruction is mild then conservative or medical treatment is preferred. It constitutes antibiotics if there is any respiratory infection. If there is chronic nasal obstruction anti histaminic syrups and nasal decongestants can be used. Nutritious diet and fresh air breathing is another important steps to be taken.

Surgical treatment of enlarged adenoids

In cases where there is features of adenoid hypertrophy causing significant nasal obstruction, mouth breathing and evidence of snoring and sleep aponoea syndrome, surgery is indicated in the form of adenoidectomy or removal of adenoids. Adenoidectomy is done under general anaethesia. St. Clair Thomson's adenoid currete with cage is introduced into the oral cavity and passed behind soft palate keeping the instrument in the midline in relation to the posterior end of septum and swept down, the postero superior wall of naso pharynx curretting the adenoids.

While surgery the injury to eustachian tube should be avoided as it is very close to adenoids, there may be profuse bleeding so a temporary pack should be given to control it. One should ensure proper removal of adenoids by palpating nasopharynx.

Exercise for enlarged adenoids
Simple breathing exercise should be encouraged is the child can do. Breathing by nose in fresh air should be encouraged. These exercises may reverse the features of nasal obstruction and mouth breathing it is not severe enough.

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Adenoids : The disease causing respiration difficult in children

Adenoids literally means to enlarged or hypertrophied nasopharyngeal tonsil and this enlargement is due to repeated respiratory infections. This presents as a nasopharyngeal mass of lymphoid tissue present n postero superior wall of nasopharynx.

Causes of adenoids

The causes of adenoids is mainly the recurrent respiratory infections which lead increase in size of the adenoids. Adenoids are lymphoid organ and helps in fighting against foriegn bodies like infections and this is the reason why in gets enlarged due to recurrent infection. Allergy can also be a cause.

Features of Adenoids

Adenoids are the main reason for sleep apnoea syndrome in children. It is also responsible as a major cause of snoring in children.Thouh adenoids presents its effects in different ways -

Features of adenoids due to nasal obstruction

The children becomes a mouth breather, There may be recurrent sinusitis and nasal discharge. Voice becomes nasal and tone less. There may be noisy breathing and child may snore at night. It may cause periods of apnoea during sleep called sleep apnoea syndrome.

Features of adenoids due to eustachian tube blockage

There may be pain in the ears which may be on and off. There may be deafness and features of secretory otitis media in most of the cases. In some case there may be acute infection and acute otitis media may develop or the chronic disease of the ear may persist.

Features of mouth breathing

The child has difficulty in feeding or may take long time to finish his meals. He or she use to keep the mouth open and saliva may dribble from the mouth. Their teeth are crowded and palate may be high arched. They may have chronic irritation of the throat and there may be alteration of the voice due to breathing of the impure air and causing chronic pharyngitis and chronic laryngitis.

Generalized manifestation of adenoids

This may be due to the common effect of all the blockage and the child is generally low in nutrition and there may be frequent diarrhea. The chest is of pigeon shaped and the abdomen may be protuberant.

The nose of the child suffering from enlarged adenoids may be pinched and there is loss of naso labial furrow. The facial expression is dull and there may be saliva dribbling from the angle of the mouth. These features along with moth breathing is called adenoid facies.

The children suffering from enlarged adenoids may suffer from enuresis or night wetting. They often urinate on bed in the night even they feel the sensation of feeling to micturate.

The diagnosis of enlarged adenoids is not difficult and surgery by removing adenoids is the ultimate treatment. For details about diagnosis and treatment one may see Diagnosis and treatment of enlarged adenoids.

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Montignac diet : A popular weight loss diet of Europe

The Montignac diet is a popular weight loss diet in Europe and was formulated by Michel Montignac. Montignac diet recommends the carbohydrates with high glycemic index should not be consumed with lipids, since this combination encourages excess fat in food to be stored in the body as excess body fat.

The basic aim of this diet is to build a concept of nutrition which focus on person wanting to loose weight efficienly. Montignac diet target on the right combination of the diet and not limiting on the quantity what one eat. Thus it fulfils the satire to eat as well as solve the purpose of weight loss. Montignac diet also claims to benefit some diseases like diabetes, hypertension and other heart problems.

Principles of Montignac diet

The basis of Montignac diet is that carbohydrate with high glycemic index lead to a state of hyperinsulinism eventually resulting in insulin resistance, which leads to a vicious cycle, leading to weight gain and other adverse health events. This can be overcome by regulating the post prandial blood glucose levels, by consumption of carbohydrates with low glycemic index.

There are two principles on which Montignac diet is based.

The first principle is to overcome the conditioning that it is calories that make us weight gain. This belief, despite its proven failure is unfortunately still widespread and preached by many dietecians.

The second principle is to eat food that is nutritious, based on its nutritional value and metabolic potential. For example

Carbohydrates with the lowest glycemic indices.

Among fats, polyunsaturated omega 3 fatty acids like fish as well as monosaturated fatty acids like olive oil are the best choices. Saturated fatty acids like butter, fat meats should be avoided.

Proteins chosen on the basis of their origin whether vegetable or animal, depending on how they lead to weight gain by causing hyperinsulinism.

Methods of Montignac diet

French cuisine is the major inspiration for this diet plan and this diet permits consuming food items like choclate, cheese etc in limited quantity that is usually not allowed in other diet plans.

The diet is divided into two phases as

The weight losing phase

This phase of Montignac diet focuses on losing weight. Apart from choosing fat and protein wisely, this phase consists chiefly of eating the carbohydrates with a glycemic index of 35 or lower. The goal is to eat meals that do not provoke hikes in blood sugar levels. Right eating habit prevents lipogenesis and activate lipolysis by thermogenesis.

During this phase the pancreas is detoxified, thus encouraging glucose tolerance and preventing excessive insulin secretion. This phase is followed minimum for 2 months.

Stabilizing and prevention phase

This phase focusses on maintaining the weight lost during the first phase, the scope to chose from is wider than in phase 1. Carbohydrates with high glycemic index are also allowed.

Benefits of Montignac diet

The inventors of Montignac diet claims following benefits with this diet-

Consuming food with low glycemic index has numerous health benefits especially with people with diabetes and other diseases.

It reduces the risk of developing diabetes and heart problems and other weight related disease.

It permits consumption of food of ones choice and does not cut off any food item completely.

People on this diet do not get bored with the diet schedule due to wide variety.

This diet includes a lots of fiber which stimulates weight loss.

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Diagnosis and treatment of achalasia cardia or cardiospasm

Achalasia cardia or cardiospasm is a condition where there is dilatation of lowertwo third of esophagus leading to dysphagia or difficulty in swallowing. There are various thoeries to establish its cause and the main complain is dysphagia for liquid more to solid. The details of cause and clinical features is given at Causes and features of achalasia cardia.

Diagnosis of achalasia cardia or cardiospasm

A young patient coming with difficulty in swallowing that too more with liquid than solid leads to think about achalasia. There are certain investigations to confirm the diagnosis, these are -

Barium swallow x-ray

Barium swallow x-ray is diagnostic for achalasia cardia. A barium solution is given orally to the patient and an X ray is taken. There is marked dilatation of the oesophagus which is fusiform in shape and the lower end of esophagus shows smooth constriction. Lower end is tapering or rounded and there is no irregularity seen. A fluid level may be visible in the x ray.

On screening the barium solution is seen to be held up for a long time at the cardiac end as there is difficulty in swallowing the solution and remains at the end.

Oesophagoscopy

Oesophagoscope is a thin tube like instrument with a camera attached and is inserted orally to see the oesophagus. It reveals a dilated esophagus with smooth narrowing containing undigested food. Oesophagoscopy also differentiate achalasia from esophageal cancer.

Treatment of achalasia cardia or cardiospasm

Though a surgical operation is the definite treatment of achalasia cardia, but there are some medications used in the initial stage.

Some anticholinergic drugs is prescribed in the initial stage of achalasia cardia, this helps in reducing secretions and thus prevents regurgitation and may releive cardiospasm.

To get releived from dysphagia dilatation under direct vision by bougies is done and is effective. This process should be repeated and patients may themselves dilate using Hurst's mercury bougies.

The treatment of choice for achalasia cardia or cardiospasm is a surgical operation called cardio myotomy or Heller's operation. This is done through thoraco abdominal approachand the lower end of oesophagus is longitudinally incised upto the mucosa and mucosa sprouts out through the incision, relieving the spasm.

All queries are invited and I will be glad to short out.

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Achalasia cardia or cardiospasm : Causes and features

Achalasia cardia is an esophageal disease mimicking cardiac disease hence also called cardiospasm. It is a condition where there is marked dilatation of the lower two third of the esophagus without any demonstrable or detectable obstructive pathology at the cardiac end.

This is an important cause of dysphagia means difficulty in swallowing and the food is held up in the lower end of esophagus and does not pass readily into the stomach.

Causes of achalasia cardia or cardiospasm

Though thew actual cause of achalasia cardia is not known exactly, but there are some theories postulated for the aetiology of achalasia cardia of oesophagus.

* The motor nerve supplying oesophagus is vagus nerve which control the movement. It is assumed that any vagal disturbance may be a cause of achalasia cardia or cardiospasm.

* The pinch- cock action of diaphragmatic cruras may be responsible as it may lead to dilatation of lower end of esophagus.

* Aurebach,s myenteric plexus is a bunch of nerves supplying the oesophagus and degeneration of this aurebach,s plexus my lead to dilatation of esophagus causing achalasia cardia.

* Many persons having a habit of mouth breathing may suffer from achalasia thus it is assumed that air swallowing may have a role in causing cardiospasm or achalasia cardia.

* Hirschprung's disease or megacolon is a congenital gastrointestinal disease and achalaisa cardia may be due to primary dilatation like the same disease.

* Lack of integrated parasympathetic stimulation and non propulsive motility of the esophagus may lead to dilatation of the esophagus causing achalasia cardia.

These are the postulated theories for the aetiology of cardiospasm though none of the cause has been authenticated by the studies.

Features of achalasia cardia or cardiospasm

Achalasia cardia is mainly seen in young age groups. The incidence is almost equal in both male and female. It present with a symptom of increasing difficulty in swallowing and discomfort in the chest or epigastric region, thus also known as cardiospasm.

The characteristic feature of dysphagia in achalsia cardia is that there is difficulty in swallowing more to liquids than solids. There may be weight loss but that is not severe to be of much concern.

There is regurgitation of food containing undigested food taken several days back, thus may be foul smelling, regurgitation may also contain acid, which may be a cause of chest pain.

In long standing cases these reflux of undigested food of several days old may go to lung and may cause pulmonary complications, thus an early diagnosis and treatment is required.

For diagnosis and treatment of Achalasia cardia or cardiospasm refer to Diagnosis and treatment of cardiospasm.

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Natural process of weight loss

In our body there are some natural process or reaction causing weight loss. There are various theories or better to say processes going in our body which is responsible for wxcess fat loss. Some of these theories are

Lipolysis or breakdown of fat causes weight loss

Lipolysis is the metabolic process which results in freeing fats from the reserved stores of body thus causing weight loss. Low levels of insulin which activate the enzyme triglyceride lipase, which is responsible for evicting fatty acids from adipose tissues which is the storage of fats by bringing them in the bloodstream and there these fats are burnt in order to get energy for the body.

Thus due to the usage of stored lipids for the energy requirements of the body there is a weight loss. During starvation one can survive for few days due to this stored fats which provides energy for survival but person looses weight.

Calorie theory for weight loss

Calorie is not a new term as it is the amount of energy needed to raise the temperatureof one gram of water from 14 degree C to 15 degree C. Our body's temperature is maintained at 98.6 F and to maintain this temperature energy is required. Furhter for eating and digesting too energy is required. Energy requirement vary from person, sex and individual requirement according to their work.

In an individual for doing all the fuctions if 2800 calories ir required and the person is taking only 2000 calories, this 800 calories are compensated from fat reserves thus weight loss occurs due to lipolysis. This theory is based on assumption that there is no energy loss, also many person are there who consume heavy calories but less fat.

A study was held in United Stateswhich revealed that Americans were consuming 4% less calories and 11% less fats than previously. As concerns free fat foods, in 10 years, their consumption rose from 19 to 76%. In spite of this during the same period obesity in US increased by 31%.

In India, about 20% of the people have become obese in the past 20 years even if for the most part remained vegeterian, have moderate calorie consumption and have not really changed their lifestyles and eating habits.

All this concludes that although theoritically, the calorie theory might seem logical, but this does not mean to be true always practically.

Hyperinsulinism and weight loss

Hyperinsulinism or high blood sugar seems to be a functional cause of weight gain. Hyperinsulinism is the excessive pancreatic secretion of insulin hormone. Insulin lowers blood sugar levels during metabolic process and digestion.

In all cases of obesity, regardless of species and mechanism, hyperinsulinism is always preent, and this hyperinsulinism is directly proportional to body mass index (BMI)which measures the degree of excess weight. Excess insulin results in weight gain and conversely, reduced insulin results in weight loss.

Thus these are the general theories of weight loss, but these theories does not apply to certain conditions like ppostpartum weight loss or weight loss due to any illness.

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Misconceptions about cancer

Cancer is not a new disease and there have been many researches and still many researches are going on. Public awareness has increased significantly. Still there are many misconceptions about cancer.

I have narrated some of the misconceptions and tried to reveal the fact as per best of my knowledge and study.

Cancer means certain death

Still there is a common beleif that cancer means a certain death, however most of the cancers are curable and if detected at early stage can be cured 100%. Some cancers like cervical cancer and cancer of vocal cord are cured without any residual effects.

Mode and vaiety of treatments had improved a lot in last decade and many terminal cancer can also prolong their life.

Cancer is contagious and can spread

Baring a few cancers like cancer cervix which is caused by viral infection, cancer are not at all contagious. Cancer cervix certainly can spread by virus in multiple sex partners.

Cancer can occur or spread by undergiong biopsy

When ever a biopsy or any surgery is indicated in a tumor which is benign, most of the person gets confused as there is a common myth that biopsy or any form of surgery can lead to malignancy. Biopsy is done by taking the tissue with very fine needle and cannot spread the tumor, neither other invasive tests like FNAC.

Biopsy and FNAC (fine needle aspiration cytology) is extremely important as not all the lump or tumor are malignant and there is no need of chemotherapy or radiotherapy for benign tumors. Biopsy can diagnose and differentiate between benign and malignant tumors and treatment can be done accordingly.

Even in all malignant cancers treatment strategy may vary with type and form and stage of cancer which can be diagnosed by biopsy.

There are several other myths that chemotherapy is more dangerous that cancer itself, or radiotherapy is more harmful than beneficial but these are far from truth.

Healthy food and not heavy food is important for cancers and there is a myth of having high caloric foods like sugars, fats in diet which in fact is more dangerous as it feed more to cancer cells than healthy cells and stimulate them to grow and multiply faster.

Any query regarding cancers are invited.

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