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THREE POINTS WORTH NOTING IN A PATIENT, IN WHOM YOU DETECT HYPERTENSION+

OP kapoor

 
1. White collar hypertension is present in one-third of the patients, in whom high blood pressure is detected incidentally. If such patients do self-recording of their blood pressure at home, the readings are normal. Twenty four hours ambulatory BP monitoring must be done in every case, to rule out this type of hypertension, which is normally known as white collar
hypertension.

2. Routine urine examination and routine blood count are a must in case of every patient, who is diagnosed as hypertensive. The presence of albumin in urine could mean secondary renal hypertension, especially if the kidneys are very small and contracted on sonographic findings. More often, it indicates that the patient has developed hypertensive nephropathy, which along with an associated low haemoglobin, should certainly remind you to rule out chronic renal failure due to hypertension, which is a silent disease.

If a patient of hypertension, shows presence of albumin in his urine and his routine blood count reveals anaemia, HBsAg blood test should be asked for, especially if the patient is young, or has joint pains or undiagnosed oedema of the legs. In such a situation, you should think of polyarteritis nodosa, which may have caused secondary hypertension.

 

PREVENTION OF VENOUS THROMBOEMBOLISM AFTER MAJOR ORTHOPAEDIC SURGERY : IS
FONDAPARINUX AN ADVANCE?


Osteoarthritis of the hip or knee, and hip fractures, are major causes of disability in older people. Orthopaedic surgery for these conditions is a major component of healthcare, relieving pain and restoring mobility and quality of life. Complications of surgery include infection, bleeding, and venous thromboembolism.

The better efficacy of the fondaparinux regimen over the enoxaparin regimen in the latest meta-analysis for the commoner surrogate endpoint (asymptomatic deep-vein thrombosis) masked the opposite finding for the less common, clinically relevant endpoint (symptomatic deep-vein thrombosis or pulmonary embolism) - i.e., that the point estimate was 47% higher in the fondaparinux group.

The Lancet, 2003; 362 : 504.


Symptoms/Sign/Obsolete/Evergreen New
THREE TYPES OF SYMPTOMS APPEARING SOON AFTER A PATIENT GOES TO BED AT NIGHT

OP KAPOOR


The following are the three conditions, which can be diagnosed very easily, if on direct questioning the patient confirms that the symptoms occur soon after he lies down in bed at night.

1. Cardiac cough : Patients of congestive cardiac failure, very often complain of cough soon after lying down in bed. The cough could be so bad, that the practitioners are tempted to diagnose an additional chest cause, even in non-smokers, in whom COPD is rare.

2. GERD syndrome (Gastro-Esophageal re.ux disease) : Patients of GERD complain about retrosternal burning in the chest very often, soon after going to bed at night, especially after a late heavy dinner.

3. Bronchial asthma and allergic bronchial cough : Although many patients of bronchial asthma and allergic bronchial cough, get the attack towards early morning, there are many patients, who complain that the wheezing in the chest
starts soon after lying down in bed at night. The situation is slightly similar in patients


THREE REWARDS WHICH I HAD IN MY PRACTICE WHILE DOING DARK ROOM FLUOROSCOPY

OP KAPOOR

Dark room .uoroscopy is becoming an old fashioned procedure in a consulting room because of radiation hazards, but doctors like me, who have been conducting this procedure, feel very much satis.ed with the results. I can quote
three occasions from my practice, when I felt elated on doing dark room .uoroscopy.

1. A patient presented with hiccups at my clinic. As usual, on examination, there was no obvious cause of the hiccups. But on fluoroscopic examination, I found that he was one of those rare patients, in whom the hiccups were due to
contraction of only one dome of the diaphragm. Such unilateral hiccups have been described in literature, but may never be diagnosed by the modern generation of doctors, who do not conduct routine darkroom .uoroscopy.

2. A middle aged patient presented with fever and left sub-costal chest pain of one week duration. I made a diagnosis of liver abscess of superior surface of left lobe, which was about to rupture into the pericardium. On .uoroscopy, I could
see an elevated immobile left dome of the diaphragm, a peculiar displacement of heart shadow and absence of any normal gastric air shadow in the fundus. Diagnosis was later con.rmed and liver aspiration was done before
the abscess could rupture into the pericardium. During my 40 years of private practice, I have made this diagnosis on more than half a dozenoccasions.

3. In the .rst 20 years of my practice, I diagnosed half a dozen patients with atrial septal defect because of radiographic .ndings of pulmonary hypertension with associated “Hilar Dance”. I feel sorry for doctors, who will never see this
dance on a chest X-ray. Ofcourse, in the last few years, I have seen such a patient only once, because most of the children having this defect, are being operated upon by cardiac surgeons or interventional specialists during

CORONARY ANGIOPLASTY VERSUS FIBRINOLYTIC THERAPY FOR MYOCARDIAL INFARCTION

Despite the time required for transfer, patients assigned to angioplasty had a better outcome than those assigned to
fibrinolytic therapy.

N Engl J Med 2003; 349 : 733.

 

AVOID USING ANTI-LEUKOTRIENES IN PATIENTS OF BRONCHIAL ASTHMA IN PRIVATE PRACTICE

OP KAPOOR


Anti-leukotriene drugs have been in the market for a few years. The p h a r m a c e u t i c a l companies have succeeded in persuading the GPs to use them in patients of bronchial asthma, who are not responding to the usual line
of treatment.

Unfortunately, the family physicians fall in to the trap of medical representatives, who show them all sorts of charts and articles printed in most of the unknown journals all over the world.

I have a large practice of bronchial asthma patients. My advice is based on my personal experience and articles published in standard medical journals. Some time back, the WHO advised the practitioners to avoid using this drug
till some more reports are available.

More than 90% of all bronchial asthma patients are controlled with a short course of oral steroids lasting for 2-3 weeks, along with broncho-dilators. Most of them, remain well on a maintenance dose of any of the steroid inhalers given in a proper dose (atleast 500 µg per day).

There are others, who might need a maintenance dose upto 800-1000 µg, depending on which steroid inhaler is used. The practitioners should not hesitate to give large doses to patients, in whom these are indicated, provided the patient gargles and rinsesreligiously, after using the inhaler.

If the patient still does not respond to the maintenance dose, what else can be done? The following is my advice in such a situation :

1. A small dose of theophyllin can be added in the evening. Even this is doubted by many medical pundits. I have stopped taking the help of this drug in the above patients.

2. Addition of inhalation of broncho-dilators two or three times a day.

3. In some patients, adding a very small dose of oral steroid (5 mg on alternate days) will have more or less no side effects in the long run. I avoid, even this, in many patients.

Finally, the most important point is to review your diagnosis of “resistant bronchial asthma”. According to my experience, one of the following three illnesses will be found in 90% of the patients of resistant bronchial asthma, who are put on
theophyllin, anti-leukotriene drugs, etc. by the family physicians. The rest of the 10% patients will have to be sent to a Chest Specialist ultimately.

The three illnesses are :-
1) ABPA : Allergic broncho-pulmonary aspergillosis is a very common condition, which mimics severe bronchial asthma. If a patient of resistant bronchial asthma has severe eosinophilia, first exclude this condition, which is the most common cause in the above type of patients. These patients have a past history of vague lung shadows seen on X-ray chest, off and on. Very high IgE levels, presence of aspergillosis in the sputum and very high levels of anti-aspergillosis antibodies should be looked for. Such patients respond dramatically to a very high dose of oral steroids and will need a large maintenance dose of oral steroids, which always cause some side effects and this should be explained to the patients.

2) Allergic Vasculitis or Angiitis : Churk Struss Syndrome : This condition should be thought of if a patient of resistant bronchial asthma also has systemic symptoms mimicking tuberculosis like fever, loss of appetite and additional symptoms of joint pains, skin lesions, non-speci.c oedema and X-ray chest showing lung shadows, which are of an unusual type and which go on changing unlike tuberculosis. Some of them will have associated systemic hypertension, presence of HBsAg (Australia antigen), mono-neuritis multiplex demonstrated on EMG examination- thus fitting into poly-arteritis nodosa. Again these patients respond to high dose of oral steroids but always in combination with cyclophosphamide or other immuno suppressive drugs, which have to be given for a very long time.

3) Tropical Eosinophilia : This is the rarest of the above three illnesses and the patients respond fairly well to a combination of Di-ethyl Carbamazine and steroids. The significant point to be noted is that in all the above three conditions, the patient's blood shows very high degree of eosinophilia and the X-ray chest can be abnormal in all the above three conditions.

The most important investigation is a routine blood count which is to be done in a leading laboratory because in all these conditions, there is moderate or severe eosinophilia, which should not be missed.

In conclusion, next time you see a patient of ‘resistant’ bronchial asthma, do not start antileukotriene drugs. These drugs are costly and have a lot of side effects. Besides, there is still a difference of opinion in the medical circles, regarding the
ef.cacy of these drugs, especially, if given for a long time. Instead, work up the patient as described above. Also make sure that the patient is not taking Betablockers, ACE Inhibitors or regular NSAID group of drugs and to treat associated allergic rhinitis and GERD, if present.

EARLY LUNG-CANCER DETECTION
`Spiral CT and selective PET effectively detects early lung cancer'

Low-dose spiral CT of the chest can detect early-stage lung cancer, but the introduction of screening programmes has been hampered by concerns about false-positive .ndings for benign nodules. Ugo Pastorino and colleagues screened a high-risk population of 1035 heavy smokers with yearly spiral CT and selective use of PET, for 2 years. These methods effectively detected early lung cancer. Very small lesions detected by CT could be followed up at 12 months without major risks of progression, reducing the problems associated with false-positive results. In a Commentary, Stefan Diederich notes that lung cancer is the most lethal malignant tumour in developed countries and, therefore, primary prevention would be preferred. Given the inherent dif.culties in this course of action, however, he points out that Pastorino and colleagues' make an important contribution to lung-cancer screening - simplification of the diagnostic algorithm for nodule classification.

Lancet Neurol, 2003; 2 : 588, 593.

Cost Effectiveness/Yield/Medical Economics
START DIAGNOSING DVT BY D-DIMER TEST

OP KAPOOR

Deep venous thrombosis (DVT) should be suspected clinically in any patient, who hasone or more of the following signs:-
1. Pain and swelling of a leg.
2. Increase in the calf diameter or presence of oedema of the leg.
3. Tenderness or feeling of a clot along a vein.
4. Presence of erythema, prominent veins or discolouration of the skin.

All the above signs are minimal when small veins of the calf are affected. Usually Doppler or Duplex sonographic studies of the veins con.rm the diagnosis, but these can be negated if small veins are involved when nuclear isotope scanning will be a superior method. Doppler studies are more reliable if major veins like ileo femoral are involved, but then in such cases the clinical diagnosis is much more easy and the physical signs, especially oedema are much more marked. Lately, I have switched over to the investigation of blood test, D-dimer, to diagnose DVT. This test was initially introduced to diagnose pulmonary embolism. In the last few years, it has been recognised that this test is often positive due to DVT and not due to pulmonary embolism. For the latter to be picked up, additional imaging studies, along with nuclear ventilation and perfusion scan and blood oxygen saturation levels have to be done.

Not only is this method of diagnosis for DVT more cost effective but the blood samples can

HEAD AND NECK CANCER TREATMENT

`Accelerated radiotherapy appiled to squamous-cell carcinoma of the head and neck yields better locoregional control than does a conventional schedule with identical dose and fractionation'.

Head and neck cancer can be cured by radiotherapy, but the optimum treatment time is unclear. Jens Overgaard and colleagues studied radiotherapy given as six fractions per week - an accelerated schedule - compared with the conventional .ve fractions per week, in a multicentre trial in Denmark. The 5 year locoregional control rate in the six-fraction group was signi.cantly better than that in the .ve-fraction group. Treatment bene.t was seen wholly in primary tumour control; none was seen in neck-node control. Although morbidity was significantly higher in the six fraction than in the five fraction per week group, the effects were transient. The researchers recommend shortening radiotherapy treatment time in head and neck cancer patients.

Lancet 2003; 3 : 933.


Symptoms/Sign/Obsolete/Evergreen New
THREE TYPES OF SYMPTOMS APPEARING SOON AFTER A PATIENT GOES TO BED AT NIGHT

OP KAPOOR

The following are the three conditions, which can be diagnosed very easily, if on direct questioning the patient confirms that the symptoms occur soon after he lies down in bed at night.

1. Cardiac cough : Patients of congestive cardiac failure, very often complain of cough soon after lying down in bed. The cough could be so bad, that the practitioners are tempted to diagnose an additional chest cause, even in non-smokers, in whom COPD is rare.

2. GERD syndrome (Gastro-Esophageal re.ux disease) : Patients of GERD complain about retrosternal burning in the chest very often, soon after going to bed at night, especially after a late heavy dinner.

3. Bronchial asthma and allergic bronchial cough : Although many patients of bronchial asthma and allergic bronchial cough, get the attack towards early morning, there are many patients, who complain that the wheezing in the chest
starts soon after lying down in bed at night. The situation is slightly similar in patients

Flower, BMJ, 2003; 327 : 572-73.

WHAT ARE ALL THE THINGS THAT ASPIRIN DOES?
The answer to the .rst part of this question is partly down to aspirin's unique mechanism of action that inhibits both COX 1 and COX 2 irreversibly. The effects of this are evident in platelets where cyclo-oxygenase cannot be replaced.

The currence interest in aspirin stems form the fact that many animal experiments and human epidemiological studies
now link aspirin (and other non-steroidal anti-in.ammatory drugs) with bene.cial effects in various cancers, including
breast, ovarian, oesophageal, and colorectal cancer.

What of the future of aspirin itself? Because of its profound effects on platelets it is unlikely to be supplanted as a cheap and effective prophylactic treatment for those patients at risk from excessive platelet aggregation, but in view of its venerable history, is surprising that aspirin is still the subject of ongoing medicinal chemistry effort.

Rod Flower, BMJ, 2003; 327 : 572-73.


Disease Pattern in India
NEUROCYSTICERCOSIS AND LEPTOSPIROSIS ARE MORE COMMON IN PRIVATE PRACTICE THAN WHAT AN AVERAGE PRACTITIONER THINKS

OP KAPOOR

1. Neurocysticercosis of the brain is so common in private practice that if an adult Indian patient complains of epilepticits, neurocysticercosis and tuberculoma of the brain have to be first excluded, before thinking of other conditions. Unfortunately, during olden days it was taught in medical colleges, that the disease occurs only in non-vegetarian patients and pork eaters. It is now clear that the disease can occur in a vegetarian or non-vegetarian patient because
the disease is transmitted by eating vegetable and food items, which are contaminated by the faeces of patients suffering from tinea solium infestation. Now that neurocysticercosis is easily treatable with a short course of drugs, more the reason that MRI of the brain should be done of every patient to exclude this disease in the above situation.

2. Leptospirosis : Old time practitioners think that this is a very rare disease. This is partly true also, .rst because till recently there were no effective diagnostic tests to diagnose it and secondly, the fact that the disease responds
so well to so many antibiotics including doxycycline. In olden days in medical colleges, we were asked to think of this disease in sewage workers. However, now we know that leptospirosis occurs due to consumption of foods and drinks, which are contaminated by urine of rodents, suffering from leptospirosis. Thus the disease should be thought of in every
patient, whether he is rich or poor, in a village or a city, or lives in a posh or dirty area of

ONCOLOGISTS MAY UNDERESTIMATE THE RISK OF THROMBOEMBOLISM

Many oncologists underestimate the risk of venous thromboembolism, despite the vulnerability of many patients with cancer to the condition. Kirwan and colleagues surveyed all oncologists in northern England. Over a quarter thought that their patients were not at risk of venous thromboembolism, independent of the type of tumour treated. Most reported not using prophylaxis routinely in chemotherapy, hormone therapy, or radiotherapy. Over a third of oncologists estimated that less than 1% of their patients were taking prophylactic therapy. The authors say that national guidelines on prophylaxis for venous thromboembolism during cancer treatment are needed.

BMJ, 2003; 327 : 597.
 


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