Friday, August 26, 2011

Guillain Barre syndrome

Guillain Barre syndrome Also called as acute infective demyeliting polyradiculoneuropathy (AIDP)
Got few variant Include AIDP, AMAN (acute motor axonal neuropathy) ,AMSAN(acute motor sensory axonal neuropathy) ,acute ataxia and opthalnmoplagia (Fischer syndrome)
Presentation: acute onset paresthesia in distal upper and lower limb
Afebrile
After recovering from viral attack (such as diarrhea or URTI)
Absence of reflex
May got vent failure (1/3 pts)
Diagnosis:L electrodiagnostic, AIDP-demyelinating picture
CSF-albuminocytologic dissociation (increased protein without pleocytosis)
Management: Vent support if vital capacity < 15ml/kg
IV immunoglobulin or plasmaphresis

Wednesday, August 10, 2011

Role of IV immunoglobulin in sepsis

Sepsis is the inflammatory response of the body to severe infection, which can be caused by a variety of bacteria. Deaths due to sepsis and septic shock remain high despite giving antibiotics, especially if the lungs, heart and kidney are affected.

Intravenous immunoglobulin preparations contain antibodies that help the body to neutralize bacterial toxins.
There are two types of preparations, polyclonal immunoglobulins contain several antibodies and monoclonal immunoglobulins target a specific antigen.
The cochrane reviews found 24 trials of polyclonal immunoglobulins, with 17 in adults (1958 participants) and seven in newborn infants (338 participants); 18 trials (a total of 13,413 participants) were of monoclonal antibodies.
Both standard and IgM-enriched polyclonal immunoglobulins decreased the number of deaths in adults but not in infants.
In the monoclonal immunoglobulin trials, anti-endotoxin antibodies showed no benefit while the anti-cytokines showed a very small reduction in deaths among adults with sepsis.
h The reduction in deaths observed with polyclonal preparations needs to be confirmed in large studies that use high quality methods.
Most of the trials were small and the totality of the evidence is insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.

Wednesday, August 03, 2011

Management of Glucose during fasting month.

Yesterday marked the starting of Ramadan ( a fasting month) for all Muslim.
Here is the brief account for management of diabetes during fasting month.
First we classify the diabetes patient to low , moderate to high risk.
Briefly low risk patient is the well controlled diabetes without target organ damage.
Very high risk patients are those with poorly controlled diabetes, recurrent hypoglycaemia, previous DKA (ketoacidosis), HHS (hyperosmolar ,hyperglycemia states), dialysis or pregnant lady.

Followed by knowing the potential complication they may face.
1-hypoglycemia
2-hyperglycemia
3-DKA
4-dehydration and thrombosis


Hypoglycaemia is due to reduced food intake.
Then why hyperglycemia ? accoding to the extensive EPIDIAR study which showed a fivefold increase in the incidence of severe hyperglycemia (requiring hospitalization) during Ramadan in patients with type 2 diabetes (from 1 to 5 events/100 people/ month_1) and an approximate threefold increase in the incidence of severe hyperglycemia with or without ketoacidosis in patients with type 1 diabetes (from 5 to 17 events /100 people/month_1) .
Hyperglycemia may have been due to
1.excessive reduction in dosages of medications to prevent hypoglycemia.
2.Patients who reported an increase in food and/or sugar intake had significantly higher rates of severe hyperglycemia

DKA particularly for those diabetic type 1. Particularly increased for those who reduced insulin injection with assumption food intake reduced during the month.

Dehydration and thrombosis
The dehydration may become severe as a result of excessive perspiration in hot and humid climates like Malaysia .It also happens among individuals who perform hard physical activities.
In addition, hyperglycemia produces a osmotic dieresis which further exacerbate the dehydration.
contraction of the intravascular space can further exacerbate the hypercoagulable state that is well demonstrated in diabetes .Increased blood viscosity secondary to dehydration may enhance the risk of thrombosis and stroke. Arab study found increase retinal vein occlusion during fasting month but not stroke and IHD.

General considerations

Individualization.

Frequent monitoring of glycemia

Nutrition.
It most likely to arise from inappropriate diet or as a consequence of over-eating and insufficient sleep. Therefore,the diet during Ramadan for diabetic patients should not differ significantly from a healthy and balanced diet.
ingesting large amounts of foods rich in carbohydrates and fats, especially at the sunset meal, should be avoided.

Exercise.
Normal levels of physical activity may be maintained. However, excessive physical activity may lead to a higher risk of hypoglycemia and should be avoided

Breaking the fast.
All patients should understand that they must always and immediately end their fast if hypoglycemia (3.3 mmol)

The fast should also be broken if blood glucose reaches (3.9 mmol/l)
in the first few hours after the start of the fast,

Type 2 Diabetis
Patients treated with oral agents. The choice of oral agents should be individualized.
In general, agents that act by increasing insulin sensitivity are associated with a significantly lower risk of hypoglycemia than compounds that act by increasing insulin secretion.

Metformin. Patients treated with metformin alone may safely fast because the
possibility of severe hypoglycemia is minimal.
2/3 of the total daily dose with the sunset meal and the other third before the
predawn meal.

Sulfonylureas.
It has been suggested that this group of drugs is unsuitable for use
during fasting because of the inherent risk of hypoglycemia. However, severe or fatal
hypoglycemia is a relatively rare complication of sulfonylurea use.
glyburide or glibenclamide may be associated with a higher risk of hypoglycemia than other
second-generation sulfonylureas, specifically gliclazide, glimepiride, and glipizide

Short-acting insulin secretagogues.
Members of this group (repaglinide and nateglinide) are useful because of their
short duration of action. They could be taken twice daily before the sunset and
predawn meals.


Incretin-based therapy.
Therapies that affect the incretin system include glucagon-like peptide-1 receptor agonists
(GLP-1ras) exenatide and liraglutide and dipeptidylpeptidase-4 inhibitors (DPP-4is) alogliptin, saxagliptin, sitagliptin,and vildagliptin. These classes of agents
are not independently associated with hypoglycemia.
Exenatide in particular can be dosed before meals to minimize appetite and promote weight loss.
With its short half-life of 2 h, it is not associated with a substantial effect on fasting
glucose.
DPP-4is are among the best tolerated drugs for the treatment of diabetes.
They are moderately less effective in A1C lowering than GLP-1ras and do not require titration.

alpha-Glucosidase inhibitors.
Acarbose,miglitol, and voglibose slow the absorption
of carbohydrates wh
en taken with the first bite of a meal. Because they are
not associated with an independent risk of hypoglycemia,
particularly in the fasting
state, they may be particularly useful during Ramadan
Insulin
judicious use of intermediate- or long acting insulin preparations plus a shortacting
insulin administered before meals.

Good luck to Dr during fasting month. It poses great challenge to keep Hbaic in target.

Tuesday, August 02, 2011

advice for short case examination

In clinical exam and pathway towards becoming a real Dr or specialist. Undergraduate need to undergone several clinical exam. The most striking and scarring is short case exam or so called OSCE (objective short case exam)which takes about 10-15min (average 10 minutes). different stages of OSCE demanding different things from candidate eg, a 3 year OSCE candidate and specialist exit exam demanding different things although they may get similar case.

First and foremost, candidate need to be calm. A calm candidate is a way to achieve success. Saying is better than experiencing it. First, candidate need to stay calm . Take a deep breath before entering it (your hall) and before you approach patient after examiner give you the instruction.

second, listen the instruction properly. Make sure you open your own ear. Do not end up examine the wrong system. Get the hints and do whatever nessasary. If ask when straight to abdomen , do not check peripheral. If ask to skip then skip. the examiner try to make sure you finish in time!

Third, approach patient politely. Remember , patient is your best textbook for disease. In exam, patient is your Future! If he or she dislike, in pain or show unpleasant expression, examiner with no hesistation to fail you. Respect them, examine them as if they are your parents, grandparents and siblings. Do not cause pain -if they are pain then prepare to die. Give correct and clear instruction.

four, smooth examination. Do not sit patient then lie back then sit again. The obstucted exam means troubling patient means failure. The obstructed exam means not finish in time.

Fifth is thank the patient after finished then face yourselves completely to the examiner. Do NOT see back patient during preasentation. It showed inconfidence.

Sixth, do not argue with examiner. If you argue then prepare yourself to fail. if they ask to recheck certain findings, normally you are wrong in undergraduate stages.For postgraduate , it depends on nature of examiner.

Finally good luck to those taking examination.