Tuesday, December 13, 2016

Post-operative Anemia: Modern Approach

Up to 90% of patients undergoing major surgery may develop post-operative anemia. The term anemia refers to low hemoglobin level. The level of hemoglobin (Hb) varies across different races and age but as per the World Health Organization (WHO), Hb value below 13.0 g/dl in adult males and below 12.0 g/dl in adult females (who are not pregnant) should be considered a cut-off level for a diagnosis of anemia.

The cause of post-operative anemia is intra-operative blood loss. Patients with normal pre-operative Hb levels have been found to be anemic during post-operative follow ups. It has been observed that patients undergo down regulation of intestinal absorption of iron along with impaired mobilization of iron from body stores. Oral iron therapy is not generally recommended to increase Hb levels in post-operative patients.

Intra-operative and post-operative allogenic blood transfusions are generally done to overcome the anemia. The modern approach to overcome the post-operative anemia recommends pre-operative iron supplementation. Intravenous or infusible iron solutions like iron-isomaltoside 1000 solution has reduced the need for intra-operative allogenic blood transfusions.

The patients undergoing major surgeries should undergo following investigations:
·         Hemogram (including reticulocyte count)
·         Serum iron, ferritin and transferrin saturation
·         Carbohydrate Reactive Protein (C.R.P.) to rule out and active inflammation
·         Serum B-12 and Folic Acid levels should also be worked out in elderly patients

Available literature supports intravenous iron formulations in elective and non-elective major surgeries in patients with suboptimal Hb and/or inflammatory disease. Surgeons have a focus on “patient blood management”. Intravenous infusion of iron improves Hb concentrations and hematological response quickly and replenishes the iron stores. Subsequently also reduces treatment cost by decreasing blood transfusions and related complications.

Tuesday, December 30, 2014

Happy New Year - 2015

Dr. CS Rayat wishes his Followers & Friends “A Very Happy & Prosperous New Year-2015”.

“May every ray of the Sun fill your life with Success and Ultimate Happiness in 2015”

CS Rayat

Sunday, June 15, 2014

Management of Tuberculosis: Diagnostic Approach

Accurate and timely diagnosis of Tuberculosis (TB) is a prerequisite for the treatment and control of spread of infection to other family members of the patient and health professionals dealing with patients. In the recent past several advances in the diagnosis and management of Tuberculosis (TB) have come out. Tools and technology are of great help in understanding of pathogenesis, demonstration of Mycobacterium, drug sensitivity testing and evaluation of prophylaxis.
Tuberculosis is a major health problem requiring early management at diagnostic and treatment level to bring down the mortality rate. In the developing countries the current mortality rate is 1 death per 100,000 population. The global incidence rate of Tuberculosis (TB) reported in the year 2010 was 128/100,000/year. To sustain the control and elimination of Tuberculosis (TB) there is a need for efficient testing and treatment regimens.

Diagnosis of Tuberculosis (TB) has conventionally been relied upon sputum microscopy of Micobacterium tuberculosis (an Acid Fast Bacilli) by Ziehl-Neelsen Staining Technique. The technique is very specific but has a poor sensitivity (around 50%). More sensitive technique used for demonstrating Acid Fast Bacilli (AFB) is by culture on Lowenstein Jensen Medium. Isolation of mycobacteria by culture method is considered to be gold standard in-spite of being time consuming.

The scenario of multi drug resistant TB (MDR-TB) has given a challenge to biomedical scientists to develop new drugs and diagnostic methods. Advances in molecular techniques for the diagnosis of TB have revolutionized diagnostic approach to this public health problem. Various new diagnostic modalities are based on the DNA extraction from the mycobacterial isolates. The nucleotide sequences of DNA are amplified and multiplied millions of times by polymerase chain reaction (PCR) for comparative diagnosis through detection of amplified DNA.

The tests that detect Mycobacterium tuberculosis antigens in clinical specimens could provide rapid and direct evidence of infection. The major targeted antigen of Mycobacterium tuberculosis is Lipo-arabino-mannan (LAM). LAM is detected in the urine of patients suspected of having pulmonary TB (Tuberculosis of lungs) as well as extra-pulmonary TB (Tuberculosis of organs other than lungs).

Molecular Tests are very sensitive and specific for diagnosis of infection and monitoring of treatment as well as for evaluating drug resistance. Uniplex-PCR (single insertion sequence IS6110 of 38 kDa)) or Multiplex-PCR (for multiplex targeting like IS6110 and MPB 64) are of great help for detecting drug resistance. Multiplex-PCR is more sensitive than Uniplex-PCR. Multiplex-PCR is useful in early detection, species differentiation (Mycobacterium tuberculosis or Mycobacterium avium) and epidemiology.

Two Molecular Assays used for rapid diagnosis of a case of TB and drug-resistance testing are:  i) X-pert MTB/RIF, and ii) Line Probe Assay (LPA)

i)                    X-pert MTB/RIF: X-pert MTB/RIF detects Mycobacterium tuberculosis (MTB) and resistance to Rifampicin (RIF) using Real-Time PCR (RT-PCR) Assay by amplifying MTB-specific sequence of the rpoB gene (inherent of MTB genome) that is probed with molecular beacons for mutations within the RIF-resistance determining region. Diagnosis of TB can be determined within 2 hours from the sputum samples with minimal health hazard. X-pert MTB/RIF test has 99% sensitivity and 100% specificity.

ii)                  Line Probe Assay (LPA):  Rapid detection of anti-TB drug resistance by Mycobacterium tuberculosis is the need of the hour for effective treatment and management of patient care. Line Probe Assays have been developed for rapid detection of rifampicin resistance and/or MTB-DR (especially rifampicin in combination with isoniazid). The Line Probe Assay (LPA) employs the hybridization of labeled PCR products with oligonucleotide probe on a strip and reading by colorimeter. The genotype MTB-DRplus Assay also simultaneously detects specific mutations in the katG gene conforming high level isoniazid resistance as well as in the inhA gene conforming low level isoniazid resistance.

The Molecular Assays are labeled for use on isolates from solid and liquid culture as well as directly on sputum smear positive pulmonary specimens. Mycobacterium tuberculosisstrain typing’ is very important for the analysis of the spread of tuberculosis as well as for monitoring the evolution of antibiotic resistance. These assays are also used to assess the bacterial load for monitoring of anti-TB treatment (ATT).

Just click the following link to update your knowledge about Management of Tuberculosis through Therapeutic Approach: http://drugsense.blogspot.in/2014/06/management-of-tuberculosis-therapeutic.html

Tuesday, March 25, 2014

Tuberculosis of Lymph Glands: A common type of surgical tuberculosis.

The tuberculosis in general comes under the domain of physicians, but several of its local manifestations are regarded as surgical tuberculosis. However, with powerful and effective anti-tuberculosis therapy majority of these cases can be treated without surgery. The tuberculosis of lymph glands is very common type of surgical tuberculosis. The lymph glands (filtering units of lymphatic system) commonly involved are those in the region of the neck; on one or both sides, above the clavicle. The affected lymph glands appear like a small or big lump with nodules. Initially the swollen lymph glands are painless, but later on the swelling may become soft due to breaking down of gland into a cheesy material and termed as 'cold abscess'.

Unlike an abscess or a boil due to acute infection, the glandular abscess is not 'warm' to touch. The abscess may break down, develop into a sinus and start discharging pus. The discharging sinus refuses to heal for a long time unless the patient is treated properly. It is worth remembering that every form of tuberculosis, in any part of the body leads to signs and symptoms of 'tubercular toxemia'. The 'tubercular toxemia' causes evening rise of temperature, weight loss, loss of appetite (anorexia), general weakness and sweating of body at night. The consultation of physician is must for early diagnosis and treatment of tuberculosis of lymph glands if above mentioned symptoms are there.

Saturday, March 22, 2014

General Health & Mental Health: Role of Social Psychiatry

General health physicians should take into account the social milieu of the population. The social psychiatry plays a major role in the evaluation and management of mental health in addition to general health of a person. For example, we propagate compulsory immunization for children but at the same time we also educate our people for observance of sanitary principles; similar association exists between the general health and mental health. The practice of medicine is incomplete without the knowledge of social psychiatry. The social psychiatry has a unique place in the medical speciality of psychiatry.

Every psychiatric patient should not be considered a lunatic or insane person. Only severely regressed psychiatric patients are confined to custodial mental hospitals and 95% of psychiatric patients can be treated by general physicians having knowledge of social psychiatry. Psychiatry plays a vital role in social development. It has been established that economic and technological developments are not merely linear processes but extensions of individual personality factors.

For overall progress, the population will have to be motivated for achievement and guided for shedding traditional inhibitions to proceed on the path of industrialization and technological growth. Technological developments do have serious repercussions on mental health and quality of life. It is the universal truth that "Freedoms of life and pursuit of happiness can degenerate into a freedom to plunder, waste and pollute". Gene cloning, stem cell research, genetic engineering and organ transplantation are challenging and threatening the personal identity of one and all. Organs of underprivileged people are removed for transplantation in the elite and wealthy. The organ trade has denigrated the super-speciality of organ transplantation.

Mankind has developed and perfected the weapons of self destruction and annihilation. The entire issue of conflict between nations can only be solved through social psychiatry. To establish the world peace, nuclear disarmament is must and psychiatrists have a major role to play to format the mindset of international leaders.

Without mental health the life is meaningless. For meaningful life, coexistence of general health and mental health is must. We should never forget that general health adds years to life, whereas the mental health provides us purpose and meaning of living.