Diabetes Care Will Cost $336B by 2034

reference:

1) http://www.medpagetoday.com/Cardiology/Diabetes/17201

2) http://care.diabetesjournals.org/content/32/12/2225.full

Another good reason why you should breast feed

reference

http://www.medpagetoday.com/Cardiology/Diabetes/17278

Clopidogrel + Omeprazole = ???

Omeprazole inhibits CYP2C19 which "reduces the pharmacological activity of [clopidogrel] if given concomitantly or if given 12 hours apart.".

Following drugs chould not be used in combination with clopidogrel:-

esomeprazole,

cimetidine,

fluconazole,

ketoconazole,

voriconazole,

etravirine,

felbamate,

fluoxetine,

fluvoxamine, and

ticlopidine.

FDA suggested that patients who need an acid reducer should switch to "antacids (such as Maalox or Mylanta) and most acid reducers, such as Zantac (ranitidine), Pepcid (famotidine), or Axid (nizatidine).

reference:

http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/17058?utm_source=breaking-news&utm_medium=email&utm_campaign=breaking-news

Government to subsidise treatment at private clinics

Health Minister Datuk Seri Liow Tiong Lai says the public can soon seek medical treatment at private clinics without having to pay a hefty sum. The government is considering paying a portion of the bill under a proposed healthcare reform plan.

reference:

1)http://thestaronline.tv/default.aspx?vid=4735

new millenium stethoscope

Hear it
Record it
Send it
Confirm it (Zargis® Cardioscan™ software )

ref:
1) http://zargis.com/index-2_2.php
2) http://www.popsci.com/bown/2009/category/health

speeding really KILLS

Pandemic Flu 10 steps you must know as Medical Officer

10 Steps You Can Take: Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities

1) Develop a Business Continuity Plan

2) Inform employees about your plan for coping with additional surge during pandemic

3) Plan to operate your facility if there is significant staff absenteeism

4) Protect your workplace by asking sick employees to stay home

5) Plan for a surge of patients and increased demands for your services

6) Care for patients with novel H1N1 flu in your facility

7) Take steps to protect the health of your workforce during an outbreak of H1N1

8) Provide immunization against seasonal flu at no cost to your staff

9) Make sure you know about the pandemic planning and response activities of the hospitals, outpatient facilities and local public health in your community

10)Plan now so you will know where to turn to for reliable, up-to-date information in your local community

reference:

http://www.cdc.gov/h1n1flu/10steps.htm

source: http://www.cdc.gov/flu/weekly/

first wave H1N1 pandemic MedImmune nasal spray is a live attenuated vaccine recommended for 2 year-old till 49 year-old. Anticipated 3.4mil vaccine will be distributed in United States early October 2009. High risk groups will be vaccinate first. Children less than 10 year-old will need 2 doses. However, age recommended for 2 doses may varies; for MedImmune, 2 through 9 year-old, Norvatis 2 through 8 year-old and Sanofi Pasteur 6 months through 8 years. The 2 doses should be 21 days apart.

reference:

1) http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/sep1809update-jw.html

2) http://www.wmtw.com/news/21049473/detail.html

3) http://www.who.int/mediacentre/news/statements/2009/pandemic_vaccine_donations_20090918/en/index.html

Honda city (Honda Fit Aria) vs Toyota Vios (Toyota Belta)

2009 H1N1 Influenza Vaccine and Pregnant Women

Map: International Co-circulation of 2009 H1N1 and Seasonal Influenza

(As of September 4, 2009; posted September 18, 2009, 11:00 AM ET)

General Public

Q: Why does CDC recommend that pregnant women receive the 2009 H1N1 influenza vaccine?

A. It is important for a pregnant woman to receive the 2009 H1N1 influenza vaccine as well as a seasonal influenza vaccine. A pregnant woman who gets any type of flu is at risk for serious complications and hospitalization. Pregnant women who are otherwise healthy have been severely impacted by the 2009 H1N1 influenza virus (formerly called “novel H1N1 flu” or “swine flu”). In comparison to the general population, a greater proportion of pregnant women infected with the 2009 H1N1 influenza virus have been hospitalized. In addition, severe illness and death has occurred in pregnant women. Six percent of confirmed fatal 2009 H1N1 flu cases thus far have been in pregnant women while only about 1% of the general population is pregnant. While hand washing, staying away from ill people, and other steps can help to protect pregnant women from influenza, vaccination is the single best way to protect against the flu.

Q: Is there a particular kind of flu vaccine that pregnant women should get? Are there flu vaccines that pregnant women should not get?

A. There are two type of flu vaccine. Pregnant women should get the "flu shot"— an inactivated vaccine (containing fragments of killed influenza virus) that is given with a needle, usually in the arm. The flu shot is approved for use in pregnant women.

The other type of flu vaccine — nasal-spray flu vaccine (sometimes called LAIV for “live attenuated influenza vaccine)—is not currently approved for use in pregnant women. This vaccine is made with live, weakened flu viruses that do not cause the flu). LAIV (FluMist®) is approved for use in healthy* people 2-49 years of age who are not pregnant.

Q. Will the seasonal flu vaccine also protect against the 2009 H1N1 flu?

A. The seasonal flu vaccine is not expected to protect against the 2009 H1N1 flu. Similarly, the 2009 H1N1 influenza vaccine will not protect against seasonal influenza.

Q. Can the seasonal influenza vaccine and the 2009 H1N1 influenza vaccine be given at the same time?

A. It is anticipated that seasonal flu and 2009 H1N1 vaccines may be administered on the same day but given at different sites (e.g. one shot in the left arm and the other shot in the right arm). However, we expect the seasonal vaccine to be available earlier than the 2009 H1N1 influenza vaccine. The usual seasonal influenza viruses are still expected to cause illness this fall and winter. Pregnant women and others at increased risk of complications of influenza are encouraged to get their seasonal flu vaccine as soon as it is available.

Q: Is the 2009 H1N1 influenza vaccine safe for pregnant women?

A: Influenza vaccines have not been shown to cause harm to a pregnant woman or her baby. The seasonal flu shot (injection) is proven as safe and already recommended for pregnant women. The 2009 H1N1 influenza vaccine will be made using the same processes and facilities that are used to make seasonal influenza vaccines.

Q: What safety studies have been done on the 2009 H1N1 influenza vaccine and have any been done in pregnant women?

A: A number of clinical trials which test 2009 H1N1 influenza vaccine in healthy children and adults are underway. These studies are being conducted by the National Institutes of Allergies and Infectious Diseases (NIAID). Studies of 2009 H1N1 influenza vaccine in pregnant women are expected to begin in September.

Q: Does the 2009 H1N1 influenza vaccine have preservative in it?

A: There is no evidence that thimerosal (used as a preservative in vaccine packaged in multi-dose vials) is harmful to a pregnant woman or a fetus. However, because some women are concerned about exposure to preservatives during pregnancy, manufacturers will produce preservative-free seasonal and 2009 H1N1 influenza vaccines in single dose syringes for pregnant women and small children. CDC recommends that pregnant women may receive influenza vaccine with or without thimerosal.

Q. How many doses of the 2009 H1N1 flu vaccine will pregnant women need to get?

A. The U.S. Food and Drug Administration (FDA) has approved the use of one dose of 2009 H1N1 flu vaccine for persons 10 years of age and older.

In addition to protecting pregnant women from infection, infants less than 6 months old will not be able to be vaccinated so it is recommended that everyone who lives with or provides care for infants less than 6 months of age receive both the seasonal influenza vaccine and 2009 H1N1 influenza monovalent vaccine to provide protection for the infant. One recent study conducted in Bangladesh, assessed the effectiveness of influenza immunization for mothers and their young infants. Inactivated influenza vaccine reduced proven influenza illness by 63% in infants up to 6 months of age. This study confirmed that maternal influenza immunization is a strategy with substantial benefits for both mothers and infants.

Q: Should the 2009 H1N1 influenza vaccine be given to someone who has had an influenza- like illness since between April and now? Do I need a test to know if I need the vaccine or not?

A. There is no test that can show whether a person had 2009 H1N1 influenza in the past. Many different infections, including influenza, can cause influenza-like symptoms such as cough, sore throat and fever. In addition, infection with one strain of influenza virus will not provide protection against other strains. People for whom influenza vaccine is recommended should receive the 2009 H1N1 vaccine, even if they had an influenza-like illness previously. It is not necessary to test a person who previously had an influenza-like illness. People for whom the 2009 H1N1 influenza vaccine is recommended should receive it, even if they have had an influenza-like illness previously, unless they can be certain they had 2009 H1N1 influenza based on a laboratory test that can specifically detect 2009 H1N1 viruses. CDC recommends that persons who were tested for 2009 H1N1 influenza discuss this issue with a healthcare provider to see if the test they had was either an RT-PCR or a viral culture that showed 2009 H1N1 influenza. There is no harm in being vaccinated if you had 2009 H1N1 influenza in the past.

Q: What are the possible side effects of the 2009 H1N1 influenza vaccine?

A. The side effects from 2009 H1N1 influenza vaccine are expected to be similar to those from seasonal flu vaccines. The most common side effects following vaccination are expected to be mild, such as soreness, redness, tenderness or swelling where the shot was given. Some people might experience headache, muscle aches, fever, nausea and fainting. If these problems occur, they usually begin soon after the shot and may last as long as 1-2 days. Like any medicines, vaccines can cause serious problems like severe allergic reactions. However life-threatening allergic reactions to vaccines are very rare. In 1976, an earlier type of swine flu vaccine was associated with cases of a severe paralytic illness called Guillain-Barre Syndrome (GBS) at a rate of approximately 1 case of GBS per 100,000 persons vaccinated. Some studies done since 1976 have shown a small risk of GBS in persons who received the seasonal influenza vaccine. This risk is estimated to be no more than 1 case of GBS per 1 million persons vaccinated. Since then, flu vaccines have not been clearly linked to GBS. GBS has a number of different causes, and GBS can occur in a person who has never received an influenza vaccine. The potential benefits of influenza vaccination in preventing serious illness, hospitalization, and death substantially outweigh these estimates of risk for vaccine-associated GBS.

Anyone who has a severe (life-threatening) allergy to eggs or to any other substance in the vaccine should not get the vaccine. People should always inform their immunization provider if they have any severe allergies, if they’ve ever had a severe allergic reaction following flu vaccination, or if they have ever had GBS.

Q. Can the family members of a pregnant woman receive the nasal spray vaccine?

A. Pregnant women should not receive the live nasal spray influenza vaccine but family and household members and other close contacts of pregnant women (including healthcare personnel) who are 2 through 49 years old, healthy* and not pregnant may receive live nasal spray vaccine.

Q. Can a pregnant healthcare worker administer the live nasal influenza vaccine?

A. Yes. No special precautions are (such as gloves) are necessary. Hands should be washed or cleaned with waterless hand sanitizer before and after administering the vaccine or having any direct contact with patients in a health care setting.

references:

1) 2009 H1N1 Influenza Vaccine and Pregnant Women. http://www.cdc.gov/h1n1flu/vaccination/pregnant_qa.htm

2) http://www.cdc.gov/h1n1flu/updates/international/map.htm

Accutane - isotretinoin (not for sale)

Accutane - isotretinoin by roche sold to 13 million acne

sufferer worldwide since 1982 is stopped for

"business reasons". Another reason was the

serious side effects mental health problems

including depression, psychosis and suicide.

Besides that, if taken pregnant women,

miscarriage or birth defects

reference:

1) http://www.medscape.com/viewarticle/705547

SMART? symbicort maintenance and reliever therapy

chronic hypersensitive airway - bronchial asthma

hypersensitive airway aka bronchial asthma prevalence increasing worldwide especially amongst children.

environment vs genetic factors blamed for the rise.

various stimuli (allergen) can trigger bronchospasm of the hypersensitive airway.

May 5 annually is World Asthma Day

This year theme is " YOU CAN CONTROL YOUR ASTHMA"

lastest GINA guidelines 2008 showed the following:-

replacing the following, found in their GINA 2002 guidelines

reference:-

1) http://en.wikipedia.org/wiki/Asthma

2) http://www.who.int/respiratory/asthma/en/

3) http://www.nhlbi.nih.gov/health/public/lung/index.htm#asthma

4) http://www.nationalasthma.org.au/cms/index.php

5) http://www.nationalasthma.org.au/content/view/249/639/

6) http://www.asthma.org.uk/

7) http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2=1&intId=60

8) http://www.patient.co.uk/showdoc/40000622/

Curable infectious disease on the rise - tuberculosis

- 20mil active cases worldwide

- 50 to 100 mil children

- mortality 3mil annually

- 80% in developing countries

- since 1989 Malaysia detected average 11 to 12 thousand cases annually

- diagnosis: clinical + radiological + / - bacteriological

The tuberculin or Mantoux test has some role in the diagnosis of tuberculosis especially in paediatric cases and cases of extra-pulmonary tuberculosis.

The Mantoux test is used in Malaysia using the strength of 10 IU PPD. The result is read after 72 hours.

THE AIMS OF TREATMENT ARE:

1. To cure patients and render them non-infectious

2. To reduce morbidity and mortality

3. To prevent relapse and emergence of resistant tubercle bacilli.

Basic investigations:-

1.Sputum D/S x 3,

2.sputum culture AFB if D/S negative,

3.renal profile,

4.liver functions,

5.visual test (if ethambutol is used ),

6.blood sugar,

7.HIV test when indicated.

Treatment:-

isoniazid (H) 100mg / tab

rifampicin (R) /cap

pyrazinamide (Z) 250mg or 500mg/tab

streptomycin (S) im

ethambutol (E) 400mg/tab

1. daily intensive phase (at least 2/12) SHRZ or EHRZ

INH 5mg/kg/day (max 300mg daily)

rifampicin 10mg/kg/day (max 600mg daily)

pyrazinamide 25mg/kg/day (max 2000mg daily)

+/-

streptomycin 15mg/kg/day (max 1000mg daily; omit in elderly)

ethambutol 15 to 25 mg/kg/day (max 1200mg daily)

2. biweekly phase (4/12) eg S2H2R2

INH ] max 1000mg biweekly

rifampicin ] 15mg/kg/ biweekly max 600mg biweekly

streptomycin ] max 1000mg biweekly

reference:-

1) CPG on Management if Tuberculosis. Ministry of Health Malaysia.

heart defect at birth - congenital

heart defects at birth can be grouped into electrophysiological defects, structural defects or functional defects. It affects 1 in 125 births.

2types:

a) cyanotic heart disease

b) non-cyanotic heart disease

cyanotic heart disease:-

a) Triology of Fallot, Eisenmenger, Ebstein's anomaly (Right Ventricular enlargement)

b) Tricuspid atresia (Left Ventricular enlargement)

c) Transposition of the great vessels & truncus arteriosus (biventricular enlargement)

d) Tetralogy of Fallot ( no ventricular enlargement)

non-cyanotic heart disease

a) Atrial septal defects, pulmonary stenosis (Right Ventricular enlargement)

b) Patent ductus arteriosus, coarctation, Aortic stenosis (Left Ventricular enlargement)

c) Ventricular septal defect (biventricular enlargement

d) any mild lesion or dextrocardia ( no ventricular enlargement)

+Aortic stenosis, coarctation of the aorta and pulmonary stenosis are not associated with shunting of blood from the left side to the right.

Commonest : Ventricular Septal Defects (VSD) - 1/5 of all congenital heart defects

reference:-

1) http://www.doctorslounge.com/cardiology/diseases/congenital.htm

2) http://en.wikipedia.org/wiki/Congenital_heart_disease

3) http://en.wikipedia.org/wiki/Atrial_septal_defect

4) http://en.wikipedia.org/wiki/Atrioventricular_septal_defect

5) http://emedicine.medscape.com/article/890991-overview

6) http://emedicine.medscape.com/article/351705-overview

Cost of Living - how much money do you need worldwide 2008

1) the gap between the most expensive and least is widening.

2) Yvonne Traber, a principal and research manager at Mercer, commented: "Current market conditions have led to the further weakening of the US dollar which, coupled with the strengthening of the Euro and many other currencies, has caused significant changes in this year's rankings.

3) "Our research confirms the global trend in price increases for certain foodstuffs and petrol, though the rise is not consistent in all locations. This is partly balanced by decreasing prices for certain commodities such as electronic and electrical goods. We attribute this to cheaper imports from developing countries, especially China, and to advances in technology.

reference:

http://www.mercer.com/costofliving

pregnancy weight - gain does matters

Weight before, during and after pregnancy plays a vital role in pregnancy. Excessive weight gain is associated with risk of overweight child. - Dr. A. Baskaran

Maternal obesity found to be associated with gestational diabetes, proteinuric pre-eclampsia, induction of labour, delivery by emergency cesarean section, postpartum haemorrhage, genital tract infection, urinary tract infection, wound infection, birth weight above the 90th centile and intrauterine death. On the other hand, underweight mothers associated with miscarriages, anemia in pregnancy, pre-term delivery and infants with low birth weight (below the 5th centile).

reference:

1) BJOG 2001:108(1):61-6.

2) Wendy loo. Weight weighs heavily on pregnancy outcome, Medical Tribute 1-15May 2009.

21st century pandemic VS 1918 Spanish FLU - a reminder for "forgotten pandemic"

source: flu ward. http://www.slate.com/id/2127872/

1) A lapse of almost 9 decades of worldwide spread of a virulent influenza A H1N1. Once again influenza A H1N1 is making a come back. The spanish flu pandemic lasted from March 1918 to June 1920 (27 months). How long is this 16th April 2009 A H1N1 gonna last? 27 months, longer or shorter duration?

2) This time round, equipped with triple reassortment evolution (with pig + human + bird elements), are these viruses gonna make a big come back? or a smaller scale?

3) From history, we learned that, spanish flu 1918 killed approximately 2.5% to 5% world infected  population and infected more than 20% world population, ? 50millions. Also known as "the greatest medical holocaust in history". Till now, according to WHO, 5728 cases reported infected with AH1N1 in 33 countries. 

4) Another lesson we learned, it was initially misdiagnosed as cholera, dengue, typhoid. Are we gonna make the same mistake with such a massive advancement in medical technologies and knowledge as well as widespread of medical information that travels in the speed of light?

5) 2 genetic processes was postulated: genetic drift and antigenic shift has lead to this massive death toll. This was caused by an extremely high infection rate of up to 50% and severe complications of the infection due to cytokine storms. So which type of genetic mutation that as has lead to current influenza A H1N1? What are the factors that promotes these mutation to occurs? Fitness of survival theory?

6) Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses, and seals.

Influenza B viruses circulate widely principally among humans, though it has recently been found in seals.

7) Spanish flu infected young healthy adults predominantly. Why is that so? Explanation is cytokine storm. The stronger immune system would potentially have a stronger overreaction. Could this AH1N1 reacting the same?

8) Another oddity in spanish flu was that the outbreak was widespread in summer and fall (in the Northern Hemisphere) hwoever normally influenza is usually worse in winter. Thus this explain the seasonal flu vs AH1N1 pandemic flu. 

9) In spanish flu, 2nd wave infection was much more deadlier than 1st wave flu infection. During the 1st wave, which begins in early March, the epidemic resembled typical flu epidemics.  Those at the most risk were the sick and elderly, and younger, healthier people recovered easily. But in August, when the second wave began in France, Sierra Leone and the United States, the virus had mutated to a much more deadly form. This has been attributed to the circumstances of the first World War.

10) Was spanish flu a form of biological warfare? Is this AH1N1 a form of biological warfare? Or may be just due to fitness of survival theory.

reference:-

1) 1918 flu pandemic.  http://en.wikipedia.org/wiki/1918_flu_pandemic

2) Kobasa, Darwyn; et al. (2007). "Aberrant innate immune response in lethal infection of macaques with the 1918 influenza virus". Nature 445: 319–323.

3) Aoki, FY; Sitar, DS (January 1988). "Clinical pharmacokinetics of amantadine hydrochloride". Clinical Pharmacokinetics 14 (1): 35–51.

4) Carrington, Damian (2000-05-11). "Seals pose influenza threat". BBC.

5) Gladwell, Malcolm. "The Dead Zone". The New Yorker (September 29, 1997): 55.

flaky scalp - a hyperkeratosis disorder

Seborrheic Dermatitis Triad:

1) individual susceptibility

2) sebum

3) malassezia (Malassezia globosa, Malassezia restricta, Malassezia furfur)

Reference:

Dandruff/Seborrheic Dermatitis: A New Descriptive Model,Tom Dawson, Jim Schwartz. Procter & Gamble.

Are you burned out yet, DOC?

WSJ blog listed some causes of burnout among surgeons and other physicians:

• Length of training and delayed “gratification”
• Long working hours and enormous workloads
• Imbalance between career and family
• Feeling isolated / not enough time to connect with colleagues
• Financial issues (salary, budgets, insurance issues)
• Grief and guilt about patient death or unsatisfactory outcome
• Insufficient protected research time and funding
• Sex- and age-related issues
• Inefficient and/or hostile work environment
• Setting unrealistic goals or having them imposed on oneself

Reference:

http://blogs.wsj.com/health/2009/04/20/10-reasons-doctors-get-burned-out/

HOUSEMAN GUIDE

Going through house officer period may be one of the toughest part of a medical officer job in terms of massive physical demands & mental stress induced by patients as well as your superior (MO, Specialist, consultant and so forth). This is because, doctoring job is dealing with human lives and this leave no room for negligence or mistakes. Therefore our Medical Council, MMC came out with a guidelines for house officer. This guide explains on goals of intership in Malaysia, getting full registration, annual practicing certificate (APC), locums, fitness to practise, work and conduct.

reference:

http://mmc.gov.my/v1/docs/A%20Guidebook.pdf

Evidence-based management of CHF

when heart is failing its role

Evidence-based management of CHF

View more presentations from mauron.

Exploring A Medical Career

self evaluation before joining medical school & not after joinning medical school :-p

Exploring A Medical Career

View more presentations from LeslieHutchinsMD.

revised Chain of Survival

CPR meant to provide layperson as well as healthcare staff with the necessary skills to be the first responder in any case of collapsed patient.

*making sure you and patient not in danger zone

therefore DR should be added as suffix to ABC

D: danger

R: response

if everything alright, proceed with conventional

Airway : head tilt chin lift / jaw trust / oropharyngeal airway / making sure no foreign body

Breathing : rise and fall of the chest wall

Circulation : feeling / palpating the major vessel pulse ie carotid pulse

Defibrillation: Automated External Defibrillator

previously chest compression : breathing ratio was 15:2

latest changes in CPR guidelines is 100 chest compressions per minute. When doing rescue breaths, you should breathe into the victim for about one second, until the chest clearly rises. The current ratio is 30 compressions to 2 breaths.

Reference:

Personal Training

American Red Cross, CPR/AED tor the Professional Rescuer, 2007

p/s: (primary vs secondary survey)

1) identify whether this is shockable wave (VT/VF) or not (PEA)

2) remember your 6Hs & 5Ts for PEA.

3) after 1st shock continue with CPR, after 2nd shock give 1mg of iv adrenaline and continue with CPR. If still not reverted and shockable wave, shock and then give iv amiodarone 300mg bolus or lignocaine 1%. If torsades de pointes, give iv MgSO4.

4) maximum iv atropine can be given is 3mg.

heart pain

Acute Coronary Syndrome or better known as ACS consist of a spectrum of thrombotic coronary artery disease ranging from unstable angina to both STEMI and nonSTEMI.

ECG: T wave tenting or inversion, ST elevation or depression (including Jpoint elevation in multiple leads) and pathologic Q waves. 

Troponin I or T is the most sensitive determinant of ACS

Marriott's Criteria

Epicardial injury is diagnosed when Jpoint elevated by 1 mm or more in two or more limb leads or precordial leads v4 to v6 or by 2mm or more in two or more precordial leads v1 to v3. Serial cardiac marker determines confirm myocardial injury or infarction in more than 90% of patient with Jpoint elevation in the limb leads.

Significant Q wave = > 0.04 sec in duration & at least 1/4 of the corresponding R wave height.

Isolated small Q wave II, III and aVF & lead I and aVL frequently normal (these small Q waves are known as septal Q waves because of the origin of the initial vector in ventricular depolarization)

from 1 - 4% patients ultimately proven to have ACS are sent home from ED.