Asthma and surgery: Why asthma people need special care during surgery?

What is asthma? 

Asthma is reversible narrowing of the airways due to oedema of airway, increased airway secretions and due to constriction of the smooth muscle cells of bronchial walls.

What happens in asthma?

The respiratory tract of the people with asthma is very sensitive. Their airway gets narrowed as soon as it gets encounters with a noxious stimulus. In general the bronchioles of the respiratory tracts are composed of a mucosa, a smooth muscle layer and other types of connective tissue which contain secretary glands. These glands produce mucous which help in keeping the respiratory tract moist.

In asthma, as the noxious stimulus enters the respiratory tract following changes occur.

• The mucosa gets inflamed
• The smooth muscles constrict
• The glands start secreting more and more secretions

As a result of above effects the airways get narrowed.  As a result the person feels difficulty in breathing and a wheezing sound is produced when he/she breaths. 

What happens in surgery?

To many people surgery means a fearful experience. In one hand it is true, because it involves a lot of interventions that put the body in to a dangerous position. But, now as the Medical technology has advanced so much, the fear is minimal. To a normal healthy person it can be said that the risk is close to nothing. 

But people with other cormobidities, like asthma,   face an additional risk as their respiratory system is already compromised. Surgeries are done under local or regional anaesthesia. Out of these two, general anaesthesia cause profound changes in the respiratory system. Even some of the people with no respiratory tract disease start having respiratory problems after surgery.  Therefore, the risks for people with asthma are even higher.  

So, what will the doctor do about it?

If you present with asthma before surgery, he/she will make an assessment regarding your condition. In this case, he/she will assess the severity of the disease. This is usually done by clinical examination, because the clinical assessment is considered very important. 

There are other ways besides clinical assessment to assess the severity. It is done by doing some tests. They are listed below.

• Spirometry – This done by using a small device called the spirometer. This requires high Patient Corporation. 

 

A reduction in following values is seen in asthma.

• FEV1 (Normal value for women = >2L, for men = >3L)
• FEV1/FVC
• FEF 25-75%

• The Spirometry is also used to evaluate the response of the respiratory tract to bronchodilators.

• PEFR is measured at bedside by Wright peak flow meter. It is normally >200L/min

• An FEV1 or PEFR <50% of normal indicate moderate to severe asthma. 

• Apart from the above tests, the doctor will also do an arterial blood gases to find out any hypoxaemia and hypercapnia.

• Chest X-ray is often done to look for flattened diaphragm and hyperluscent lung fields indicating air trapping and hyperinflation.

• Sputum culture may also be done.

How the asthmatics are managed during surgery?

Elective surgeries will be postponed in patients presenting with exercebations of asthma. Other patients who undergo emergency surgeries are provided with intensive treatment. The treatment involves,

• Bronchodilators – Beta 2 agonists like salbutamol

• Steroids – Prednisolone

• Antibiotics are given in the presence of infections.

Regional analgesia is mostly preferred in asthmatic patients, since it does not involve any airway manipulation, but still high spinal or epidural can restrict respiration and produce an ineffective cough.

Diabetic Nephropathy

What is diabetic nephropathy?

Diabetic nephropathy also called Kimmelstiel-Wilson disease; Diabetic glomerulosclerosis; is a progressive kidney disease that occurs as result of long term uncontrolled diabetes mellitus. It is a complication of diabetes Mellitus with a significant mortality and morbidity rate.

Causes

Several factors play part in development of diabetes Nephropathy.

• Uncontrolled high blood sugar
• High blood pressure
• Afro-Americans (13%), Hispanic (9.5%) and people with an Indian origin are said to be in higher risk of developing the condition than others.  
• Genetics

Does everyone with diabetes develop this?

No. Most people with diabetes do not develop this condition. People with type one diabetes are said to be at a higher risk of developing the disease than those with Type two diabetes.

What Happens in Diabetes Nephropathy?

In this condition, abnormality is found in the kidney. That is why it is called diabetes nephropathy. Kidneys are the organs, which filters blood and remove the waste products and other substances which are present in excess amounts from the body. This process occurs in millions of small units called the nephrones. Each nephrone has a part called the glomerulus. The glomerulus is composed of a tuft of tiny capillaries, which brings in blood and another membrane called the Bowman’s capsule. Both membranes of capillaries and the Bowman’s capsule have tiny holes, so they can act as a filter.  Most of the blood constituents with small molecular weight are filtered in to the glomerular filtrate. But, the bigger molecules like plasma proteins like albumin are not filtered. 

In uncontrolled Diabetes Mellitus, there is persistently high blood sugar. These high concentrations of blood sugar damage the above mentioned filtering membrane causing them to thickened (glomerulosclerosis). The pores in those membranes become lager. As a result the bigger molecules like plasma proteins like albumin leeks in to the membrane. So, finally albumin is found in the urine. Initially as the damage is little, only small amount of albumin is found. Therefore, it is called microalbuminuria. 

How to find out whether you have Diabetes Nephropathy? What are the Symptoms and signs?

• The initial abnormality found is microalbuminuria, which will not usually be detected unless you specially looked for it. People with type 1 diabetes are said develop microalbuminuria typically after 5 years. At this stage there are no symptoms. Therefore the patient feels fine. It is very important to detect the disease at this stage, because the kidney damage might be reversible. Microalbuminuria will present in urine for 5-10 years before the major symptoms of the disease start to show. The glomerular damage is not reversible once the renal damage has progressed to a level that a lot of albumin is found in urine. Therefore, doing urine analysis in diabetes patients is very important. 

• As the damage progresses high level of protein is found in urine even by a normal urine analysis. The patient himself may be able to detect high level of protein in urine.  This is indicated by presence of froth in urine and its foamy appearance.

• As the body continues to loose protein, the blood albumin levels gradually falls. Albumin plays a major role in keeping water getting out of blood vessels in to the surrounding tissues. As the albumin concentration goes down, more water gets off from the vascular compartment. This ultimately leads to swelling off the body. The swelling will first appear around in the mornings. Later as the disease progressed the swelling will start appearing in the legs and the feet. 

• High blood pressure
• High cholesterol and triglyceride levels
• Leg cramps
• Nocturia – passing urine several times at night
• Less need for antidiabetic treatment

Rests of the symptoms are very non specific and could be due to any other illness. They are,

• Fatigue
• Frequent hiccups
• Gastrointestinal symptoms like nauseas and vomiting
• Poor appetite
• General ill feeling

How is it confirmed?

The following parameters are considered when diagnosing the disease.

• Presence of macroalbuminuria – 300 mg of albumin present in urine passed within 24 hours.
• Presence of abnormal renal function tests – serum creatinine

                                                                          Calculated creatinine clearance
                                                                          Abnormal glomerular filtration rate

•   Presence of diabetes retinopathy
• Renal biopsy can confirm the diagnosis, but it is not always necessary if the history and clinical findings points towards the disease.

              - early stages shows mesangial expansion and glomerular basement membrane thickening.

              - Later stages - nodular glomerulosclerosis, also referred to as Kimmelstiel-Wilson disease.

                                                                  

How the Condition is managed? What are the Treatments?

Treatment of this condition is pointed towards the slowing down of kidney damage and controlling the associated problems. In this case, controlling the blood pressure plays a major role. It helps both in slowing the renal damage as well as reducing the cardiovascular damage (e.g.: strokes) seen in diabetes patients. Currently it is recommended to maintain blood pressure less than 130/80 mmHg. Following drugs are used to meet this goal.

• ACE Inhibitors – Causes renal vasodilatation and thereby increases renal blood flow.
• Diuretics also play a major role.

• Angiotensin receptor blockers – but the combination therapy has shown to worsen the outcome.

Tight control of blood glucose level – This has lead to a significant reduction in the progression of the disease.

Diet control to reduce blood glucose level

Avoid renal toxins – NSAIDs, Cyclooxygenase 2 inhibitors, radio contrast media

How Smoking Affects Health

Smoking causes wide variety of diseases ultimately leading to death. It is a known fact for everybody that smoking is bad for health. There are thousands of articles, advertisements, and rules regarding bad effects of smoking. Even the cigarette itself has a label saying the bad health outcomes of smoking. But, still people remain to smoke.

This must be mainly due to socio-economic and cultural backgrounds of the people. On the other hand it could be due to lack of understanding about bad health outcome of smoking. The main aim of this article is to give a clear understanding about how smoking results in deadly health outcome. 

Can Effects of Smoking be reversed? 

Another important thing about smoking is that the most of the bad health outcomes of smoking can be reversed entirely after just within two years after cessation of smoking.  Out of them some can be reversed within several hours.  Therefore, tobacco smoking accounts for a whole list of preventable diseases in the world. Stop smoking now! Your body will be healthy as ever. 

Some of the toxic substances in tobacco

• Tar
• Nicotine – accounts for the addictive property of cigarette smoke.
• polynuclear aromatic hydrocarbons

 There are more tan 40 toxic chemicals in cigarettes

Mechanism of Effects of Tobacco Smoke

There are a lot of substances in cigarette that cause various alterations in the body. Following are the main organ systems of the body that face the greatest bad health outcome o tobacco smoking and ultimately lead to death.

• Cardiovascular system – involves the heart and the blood vessels.
• Respiratory system – Involves the whole respiratory tract starting from the nose to alveoli, the small chambers which make the lungs.
• Reproductive system

Even though many people think that most of the deaths related to smoking results from lung involvement, the truth is that it is due to cardiovascular effects.

Some of the major toxic substances in tobacco 

• Tar
• Nicotine – accounts for the addictive property of cigarette smoke.
• polynuclear aromatic hydrocarbons
• Carbon Monoxide

How Smoking Cause Respiratory Tract Diseases

When the cigarette smoke enters the respiratory tract, some of the toxic particles are trapped by lining mucosa of the respiratory tract. Normally such particles are expelled out by the action of cilia present on the luminal surface of lining epithelium of the respiratory tract. This process is called mucociliary escalator. 

But, when a person continues to smoke the action of cilia gradually declines. Finally as a result the particles in the smoke accumulate in the respiratory tract, giving more time for the carcinogenic substances in smoke to enter the cells and cause cancer. Along with these accumulated substances, the pathogenic organisms like bacteria get a chance to remain in the respiratory tract and multiply. This is the main cause for recurrent respiratory tract infections seen in smokers. Pneumonia and Tuberculosis are two of such infection with a significant mortality and morbidity rate. The blockage of respiratory tract leads to asthma and shortness of breath. When the person continues to smoke in long term the damage to bronchial tree and the alveoli gradually increases and finally leads to the development of Chronic obstructive Pulmonary Disease and Emphysema. 

How smoking effects the Cardiovascular System

When someone smokes the toxic substances in it diffuse through alveoli in the lungs in to the blood stream. In the blood stream, these substances, especially carbon monoxide enter the red blood cells. Red blood cells are the major oxygen carries vehicles of the blood stream. In the red blood cells carbon monoxide binds with the hemoglobin. Hemoglobin combined with carbon monoxide is called carboxy hemoglobin. CarboxyHb cannot bind with oxygen. As a result the oxygen carrying capacity of blood reduces. So, tissues suffer from lack of oxygen. 

Nicotine also enters the blood stream and stimulates the sympathoadrenargic system. This system accounts for the increase of heart rate and blood pressure. They also cause vasoconstriction of coronary vessels, which supply blood to the heart muscles leading to ischemia of the heart, which leads to angina and myocardial infarction. 

The substances in smoke also damage the vascular endothelium, which leads to the development of atherosclerosis, clot formation, and trigger vascular spasms. The important thing about these changes is that they are transient. 

Smoke free period o f12-18 hours decrease the CarboxyHb level by a significant proportion. But, the elimination is slower during sleep.

How Cigarette smoking cause cancers

Carcinoma or a cancer simply means a bunch of cells which divide uncontrollably and spread to various organs of the body. Normally the cell division is tightly regulates by the DNA of the cell. But, tobacco has substance that can go and bind to the cell’s DNA and cause uncontrollable cell division.

Following are the carcinogenic substances that are found in cigarettes.

•  Polynuclear aromatic hydrocarbons - They are tar components with potent carcinogenic properties. They are toxicated to mutagenic epoxides. E. g : tar, Benzopyrene,

• Aacrolein – Also responsible for irritating lachromatory effects of cigarettes. Also cause carcinoma by binding to DNA that leads to the production of mutations. In animals it is so much toxic that animals die even before they develop cancer.

• Lead 210 - A radioactive carcinogen.

• Polonium 210 – Another radioactive carcinogen.

These radioactive carcinogens go and deposit at places where bronchial tree bifurcates. This gives an opportunity for these substances to enter the cells and cause damage to DNA. 

 READ MORE ABOUT HOW CELLS TURN IN TO CARCINOMA CELLS

 Smoking is one of the most dangerous preventable health hazards. 

STOP SMOKING TODAY, YOU WILL BE DISEASE FREE FOR THE REST OF YOUR LIFE!                     

New Research Findings: Can Ovarian Cysts Recur After Sclerotherapy

Did you had Sclerotherapy for ovarian cyst? Then can it recur? Well, there is a study done by Kafali. H. et.al (2011), which supports that it can recur. The study was done to determine whether there is a chance of cyst recurrences after Sclerotherapy. It has been done using 52 subjects with simple ovarian cysts. That means the women had only non neoplastic ovarian cysts. They were subjected to sclerotherapy with alcohol and erythromycin. After that they were followed up for 12 months. Out of the 52 cases 12 recurrences were found. This implies that there is a relatively high recurrence rate.

References : Kafali. H. El (2011), Recurrence of ovarian cyst after sclerotherapy. Minerva Medica Journals Journals and Books on Medicine since 1909  [online] Available at <http://www.minervamedica.it/en/journals/minerva-ginecologica/article.php?cod=R09Y2011N01A0019>[Accessed 2 February 2011]


Ovarian Pain and Ovarian Cysts- Types, Causes, Symptoms, Diagnosis and Treatment

New Research Findings: Combined Oral Contraceptive Pills Can Reduce Acne

A study done in United States of America by Koltun. W et. al.(2011) has found that a low dose combined oral contraceptive can reduce acne, and in some they were able to cure acne totally.  The study was done using 893 healthy women with acne who took ethinylestradiol 20μg/drospirenone 3mg combined oral contraceptive. They were compared with 442 healthy women with acne who were given only a placebo. The Combined oral contraceptives (COC) and placebo pills were given for 6 cycles. The  COC group had three times better acne reduction.


References:

Koltun W, Maloney JM, Marr J, and Kunz M. (2011). Treatment of moderate acne vulgaris using a combined oral contraceptive containing ethinylestradiol 20 μg plus drospirenone 3mg administered in a 24/4 regimen: a pooled analysis. Pubmed. [online] Available at: <http://www.ncbi.nlm.nih.gov/pubmed/21288628>[Accessed 9 February 2011]

Research Findings: Most effective treatment for acne rosacea

Acne rosacea causes popular pustular lesions on the skin. This can be successfully treated with tropical metronidazole or azelaic acid. Most patients find it easy to tolerate Metronidazole than azelaic acid.  Other drugs which are also effective against acne are,

·        Oral doxycycline

·        Tetracycline

It is still to find out which one is the best among these drugs.

New Research findings: Vitamin D and disease Reduction, Vitamin D supplements

Several studies (vrant WB, Boucher BJ, 2011) have done regarding provision of adequate amounts of vitamin D and its association with disease reduction. It is a well known fact that vitamin D prevents rickets and osteomalacia. Apart from that, these studies have found that adequate vitamin D is also helpful in reducing the risks of following diseases.

• Various types of cancer
• Heart diseases and other vascular diseases
• Neurological disorders
• Diabetes Mellitus
• Autoimmune diseases
• Some of the bacterial and viral infections

These studies have used more than 400 IU/day of vitamin D. To avoid hypovitaminosis D-related diseases one should have serum 25-hydroxyvitamin D concentrations of 30-60 ng/ml. To achieve this target, one should get 1,000-4,000 IU/day of vitamin D either through ski production or oral intake. 

To get adequate skin vitamin D production, one should have adequate exposure to sunlight which provides ultra violate B rays, which is necessary for vitamin D production in the skin. Usually dietary supply of vitamin D is only adequate for the avoidance of vitamin D related bone diseases. Therefore, to have other disease protective effect, people should take vitamin D supplements.

Grant WB, Boucher BJ.,2011,Requirements for Vitamin D across the life span.Pubmed. [Online] Available at<http://www.ncbi.nlm.nih.gov/pubmed?term=serum%2025-hydroxyvitamin%20D%20concentrations%20of%2030-60%20ng%2Fml%201%2C000-4%2C000%20IU%2Fday%20of%20vitamin%20D>[Accessed 9 February 2011]

Warts on Your Skin? Apperarance, Cause, Diagnosis, and Management

Warts on your skin? How worried you should be?

If the warts are only on the face, there are minimal complications, because they are benign lesions. You may worry about it because of their cosmetic effects. But, if you have genital warts, you really should be worried, because there is a risk of cancer.

What are warts?

Warts are lesions on your skin, which are caused by a virus called a human papilloma virus.

How do they look like?


Warts are elevated areas of skin, which can range from several millimeters to centimeters. There top could be pappiliferous, dome shaped, or flat. Genital warts could appear like a cauliflower. Most often they take the same colour as the skin.

How are they transmitted?

Warts are transmitted by touch, sexual contact or swimming.

What are the places which warts can appear?

They can simply appear anywhere in the body. The most commonest places are face, hands, feet, and genital areas. Therefore, they are divided into four types according to the place they appear.

• Common warts

 These are common in hands and feet in children, but also can appear in face and genitalia. They are dome shaped with pappiliferous surface. Warts in the face may have digits like projections. There presence interupts the skin lines.

• Plane warts

 There top is flat and slightly brown in colour. They are commonly seen on face and dorsal aspects of the hands. They are often multiple and responds poorly to treatment. There is nothing to be alarmed, since they resolve spontaneously, often after getting inflamed.  These lesions show the Koebner Phenomenon.

• Plantar warts

These are painful and need medical attention.

• Genital warts

People with genital warts should be worried since they are in a risk of developing genital carcinoma. They  should also be screened for other sexually transmitted diseases.

Management/ Treatment of Warts

Warts are often treated with topical salicylic acid, lactic acid, formaldehyde, and phodophylotoxin. Others are cryotherapy or curettage.

Treatment for Acne

Acne is caused by a bacterium called Propinobacterium acne. Usually most people with acne have already tried over the counter creams. Most people with mild acne improve with this treatment and people with more severe condition are treated with systemic drugs. Benzoyl peroxide (Panoxyl, Acnecide, Brevoxyl) cream or gel are given for mild cases. They are given for local appliance twice a day. They can cause irritation and contact dermatitis in some people. These creams act by reducing the number of Propianobacterium acnes.

If you have more comedons(black heads) tretinoin is used. This is available as cream or gel. It also produces irritation as a side effect. Antibiotics like clindamycine and erythromycin is also given along or with zink or benzoyl peroxide for mild to moderate acne.

  

Psoriasis Treatment- Side Effects of Cyclosporine

Are you a psoriasis patient? Are you given psoriasis? Then you should know about the side effects of cyclosporine. This is a very effective drug in severe psoriasis, but it should be given under specialist care.

Side effects of long term treatment include,

• Hypertension
• Kidney damage
• Viral warts with risk of skin cancer
• Hypertriglyceridaemia
• Hersutism

Therefore the doctor will do the following tests before starting treatments.

• Blood pressure
• Serum creatinine

 

He will check serum creatinine 2 or three times before starting the treatment. Serum creatinine is a good indicator of renal function. Values more than the normal levels, indicate kidney damage.  This is to establish a baseline value for serum creatinine so subsequent values (every other week) after starting the treatments can be used to assess any kidney damage.

Fifty percent of patients who are on cyclosporine can develop systolic blood pressure >160mmHg and diastolic blood pressure >95mmHg. Such patients are given calcium channel blockers like Nifedipine or angiotensin converting enzyme inhibitors if not tolerated. 

A lipid profile will also be done to see any development of Hypertriglyceridaemia.