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Sunday, September 20, 2015

Better Prevention be the goal than the Treatment of Drug Resistant Gonorrhoea

It has been published in The Guardian that a multi-drug resistant Gonorrhoea strain has been detected in 15 cases by Public Health England since March; the British Association for Sexual Health and HIV reported. It has triggered an unprecedented national public health alert in England.
Gonorrhoea is caused by a bacterium called Neisseria gonorrhoeae. It has become resistant to penicillin, tetracycline, quinolones and many more groups of drugs, finally is being treated with Ceftrixone in combination with azithromycin.
Neisseria Gonorrhoeae

Now, it has been reported that several cases are not responding to azithromycin and some cases have become resistant to ceftrixone too.
News of the British cases comes less than a day after the European Centre for Disease Prevention and Control (ECDC) reported gonorrhoea rates in Europe had gone up by 79% since 2008, particularly among men. The UK reported 61% of all cases in Europe. It has risen by 19 per cent in 2014 amongst heterosexuals and a whopping 32 per cent in gay men.
There were almost 35,000 cases of gonorrhoea reported in England last year. It is the second most common bacterial sexually transmitted infection in the UK after Chlamydia, with the bacteria transmitted through discharge from the penis and vagina.
It’s a clever little bug that doesn’t always show symptoms and patients carry the infection without even realizing it, called carriers.
The main causes of resistance to the antibiotics are inadequate/inappropriate treatment and emergence of mutated strains of bacteria.
Hence, it is better to emphasize on prevention than to go for treatment of Drug Resistant Gonorrhoea.
Gonorrhea: Protect Yourself- According to the recommendations of CDC:

It is critical that individuals protect themselves against infection.
Prevention strategies include:
(1)                         Abstinence or mutual monogamy— The surest way  to avoid transmission of gonorrhea is to abstain from sexual intercourse, or to be in a long-term, mutually monogamous relationship with a partner who has been  tested and is known to be uninfected.
(2)                         Condoms— When used consistently and correctly, condoms can reduce the risk of transmission of gonorrhea.
(3)                         Regular screening— Screening for those at greatest risk is critical. CDC recommends that sexually active gay and bisexual men and high-risk sexually active women be tested for gonorrhea at least once a year.
(4)                         Prompt and effective treatment— Anyone who becomes infected should get treated with a ceftriaxone injection and either azithromycin or doxycycline right away to cure the infection and prevent transmission to others. Patients receiving a treatment other than dual therapy that includes ceftriaxone should be tested one week after completing treatment to confirm that the infection has been cured.
Prevention is better than cure, “A stitch in time prevents none.”


Sunday, September 13, 2015

DPP-4 Inhibitors Used to Treat Type 2 Diabetes Mellitus may cause Joint Pain

FDA Issues Warning for DPP-4 Inhibitors; published in ClevelanD Clinic on 08.09.2015, drugs like sitagliptin, saxagliptin, linagliptin, and alogliptin, used to treat Type 2 Diabetes Mellitus, may cause joint pain that can be severe and disabling. Nevertheless, FDA has not advised to stop the medications.

Friday, April 3, 2015

Exercise within Your Target Heart Rate, no Less, no more to Derive Maximum Benefit

Yes, many clinicians have forgotten to examine pulse of a patient; more so the clinical method that we used to regard as the best friend, in 1980s. Now, when patient comes to a doctor, advices flow, USG, ECHO, Doppler, ECG and MRI, and so on and so forth; and, why not? It is easier to know the parameters through machines. Still, one aspect remains crucial, should we advice all these tests to each patients! The clinician, within us says no; give a provisional diagnosis that is not rare; more common, much better; then advise for the required investigations, either to support the provisional diagnosis or to rule out other possibilities. If, this pattern is followed, perhaps, we have to go back to our Guru, the Hutchison’s Clinical Method and examine pulse.
On the other day, when I wanted to know about the some minimum 5 features of pulse, have to witness a blank face. So, where are we leading to?
We were taught to examine peripheral arterial pulse for the following features:
1.       Rate
2.       Rhythm
3.       Nature, that includes volume or wave form
4.       Symmetry
5.       Condition of the arterial wall

Certain terminologies coined to the pulse rate require clarification for performance of heart under stress.
What is Pulse?
Ordinarily, pulse is refection of heart rate or the number of times your heart beats in one minute in health; may not be same as heart rate in disease conditions of heart.
Pulse rates vary from person to person. Pulse is lower at rest and increases during exercise for increase demand for oxygen. It is essential to know pulse rate for planning out exercise program.
Normal Pulse
Normal Heart Rates at Rest:
  • Children (ages 6 - 15) 70 – 100 beats per minute
  • Adults (age 18 and over) 60 – 100 beats per minute
  • Below 60 beats/min- Bradycardia
  • Above 100 beats/min- Tachycardia

What is maximum heart rate?

The maximum heart rate is the highest heart rate achieved during maximal exercise. One simple method to calculate the predicted maximum heart rate is
220 – Age in years = predicted maximum heart rate per minute
Example: a 40-year-old's predicted maximum heart rate is 180 beats/minute.

What is target heart rate?

  • One must exercise in the target heart rate zone to derive maximum benefit; no less no more. This is usually, between 60 to 80 percent of maximum heart rate. Beginner is advised to start exercising within 50% of maximum heart rate.
  • It is not recommended to exercise above 85 percent of your maximum heart rate. Intensity at that level increases both cardiovascular and orthopedic risk with minimal, additional health-related benefit from the exercise.
  • Always check with health care provider before starting an exercise program. Health care provider can help to find a program and target heart rate zone that matches the need, goals and physical condition.
  • When beginning an exercise program, one may need to gradually build up to a level that is within the target heart rate zone. If the exercise feels too hard, slow down.
  • To find out if your are exercising in your target zone (between 60 and 80 percent of your maximum heart rate), stop exercising and check your 10-second pulse. If your pulse is below your target zone, increase your rate of exercise. If your pulse is above your target zone, decrease your rate of exercise. 
Age Target HR Zone 50-85% Average Maximum Heart Rate, 100%
20 years 100-170 beats per minute 200 beats per minute
30 years 95-162 beats per minute 190 beats per minute
35 years 93-157 beats per minute 185 beats per minute
40 years 90-153 beats per minute 180 beats per minute
45 years 88-149 beats per minute 175 beats per minute
50 years 85-145 beats per minute 170 beats per minute
55 years 83-140 beats per minute 165 beats per minute
60 years 80-136 beats per minute 160 beats per minute
65 years 78-132 beats per minute 155 beats per minute
70 years 75-128 beats per minute 150 beats per minute
There is your radial pulse;
Please note that some medications and medical conditions may affect your heart rate. If you are taking medications or have a medical condition (such as heart disease, high blood pressure or diabetes), always ask your doctor if your maximum heart rate/target heart rate will be affected. If so, your heart rate ranges for exercise should be prescribed by your doctor or an exercise specialist.


Sunday, March 29, 2015

Mutation in BRCA Gene substantially Increases the Risk of Breast Cancer in both Female and Male

An article published in Mail Online about the story of a young lady, who in spite of regular screening for breast cancer, preferring for prophylactic mastectomy before the age of 31, discovered that she is already harboring a 6 cm tumor in her breast. The article can be accessed here.
Emma Cunliffe has mutated BRCA (BReast CAncer) gene that dramatically increases the risk of cancers; breast and ovarian cancer in particular.
Her mother and grandmother both had been diagnosed in their early 30s for breast cancer. Now, she plans to have her ovaries removed after having a family.
Role of BRCA genes:
Faults or breaks develop in the DNAs (Deoxyribonucleic Acid) that house several genes, may be following repeated divisions or other environmental factors like radiation. The primary responsibility of the BRCA gene is to signal for a protein that can repair the defects in the genes in association with some other proteins. Both BRCA 1 and BRCA 2 protein interact with the protein produced by the RAD51 and PALB 2 gene to mend breaks in DNAs.
BRCA 1 gene encodes a nuclear phosphoprotein that acts as a tumour suppressor. The encoded protein combines with other tumour suppressors, DNA damage sensors, and signal transducers to form a large multi-subunit protein complex known as the BRCA1-associated genome surveillance complex (BASC). This gene product associates with RNA polymerase II, and through the C-terminal domain, also interacts with histone deacetylase complexes. This protein thus plays a role in transcription, DNA repair of double-stranded breaks, and recombination.
Mutated forms of the genes produce a protein that is not perfect; hence, cannot do the repair work. This leaves the cells multiply uncontrollably, without check.
Apart from breast cancer, mutations in the BRCA1 gene also increase the risk of ovarian cancer, prostate cancer, and colon cancer. The BRCA1 gene is located on chromosome 17q21 -- the long (q) arm of chromosome 17 at position 21.
BRCA 2 gene is located on the chromosome 13q12.3; on the long (q) arm of chromosome 13 at position 12.3.

Heredity - autosomal dominant (AD)
Heredity - autosomal dominant (AD) (Photo credit: Wikipedia)
Risk to Women having mutated BRCA 1 & 2 genes:
A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2.
·         Breast cancer: About 12 percent of women in the general population will develop breast cancer sometime during their lives. By contrast, 55 to 65 percent of women who inherit a harmful BRCA1 mutation and around 45 percent of women who inherit a harmful BRCA2 mutation will develop breast cancer by age 70 years.
These genes also increase breast cancer risk in men. 
·         Ovarian cancer: About 1.4 percent of women in the general population will develop ovarian cancer sometime during their lives. By contrast, 39 percent of women who inherit a harmful BRCA1 mutation and 11 to 17 percent of women who inherit a harmful BRCA2 mutation will develop ovarian cancer by age 70 years.
The first breast cancer gene faults to be found were BRCA1 and BRCA2.  There are other genes that significantly increase a woman's risk of breast cancer. They are called TP53 and PTEN. Tests are available for the following genes;
·     BRCA1
·     BRCA2
·     TP53
·     PTEN genes
Researchers have found other common genes that can slightly increase a woman's risk of developing breast cancer. No tests are available for these genes yet but they include
·     CASP8
·     FGFR2
·     TNRCP
·     MAP3K1
·     rs4973768
·     LSP1
Rare genes that can also increase breast cancer risk slightly include
·     CHEK2
·     ATM (ataxia telangiectasia mutated)
·     BRIP1
·     PALB2
No individual tests are available for these genes yet.
Who all need to be screened for defective genes?
·         Breast cancer diagnosed before age 50 years
·         Ovarian cancer
·         Cancer in both breasts
·         Both breast and ovarian cancers
·         Multiple breast cancers
·         Two or more primary types of BRCA1- or BRCA2-related cancers in a single family member
·         Cases of male breast cancer
·         Ashkenazi Jewish ethnicity
·         Triple-negative (estrogen receptor negative, progesterone receptor negative, and HER2/neu negative) breast cancer
·         Pancreatic cancer with breast or ovarian cancer in the same individual or on the same side of the family
·         Two or more relatives with breast cancer, one under age 50
·         Three or more relatives with breast cancer at any age
·         A previously identified BRCA1 or BRCA2 mutation in the family

In the instant case, MRI could not detect it as it was of a cotton-wool consistency; it was reported.
In these high risk women;
1.     Breast Self Examination (BSE) should start as age of 20
2.     Clinical Breast Examination (CBE) by a heath care person at the same age
3.      Contrast MRI and Mammogram, both, not anyone, should start from 25 years or 10 years before the age at which the breast cancer in family member is detected; but not before the age of 15.
Contrast MRI and Mammogram both act as complimentary, as MRI is more sensitive, but less specific, gives more unnecessary warnings; Mammography, can even detect some tumors which MRI cannot.
This information is not at all a substitute for the opinion of your consultant.
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