Medinews January 2010

Vol. 11, No. 1, January 2011

ISSN 0971-880X

Single Copy Rs. 100/-

Pages 16

Dr KK Aggarwal Gr. Editor-in-Chief, IJCP Group

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Member The Indian Newspaper Society

d i t o r i a l

Official Voice of Doctors of India

Smoking: An Enemy of Longevity • • •

Smoking contributes to heart disease, osteoporosis, emphysema and other chronic lung problems and stroke.

It makes breathing during exercise much harder and thus can make activity less enticing.

It appears to compromise memory, too.

Quitter Wins Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group Editor-in-Chief, eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http//twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

• • • •

After a smoker quits, the risk of heart disease begins to drop within a few months, and in five years, it matches that of someone who never smoked.

Stroke risk drops to equal that of a nonsmoker within 2 to 4 years after a smoker quits.

The death rate from colorectal cancer also decreases each year after quitting.

At any age, quitting progressively cuts your risk of dying from cancer related to smoking, although this drop is most marked in those who quit before age 50.

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‘‘ ‘‘

People who quit smoking can repair some, if not all, of the damage done.

It is not in the stars to hold our destiny but in ourselves.

—William Shakespeare

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Anger and intolerance are the twin enemies of correct understanding.

—Mahatma Gandhi

Make Sure

I

During Medical Practice

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Clinical Tips

A 11-year-old child with diarrhea had little response with the prescribed antibiotics.

OH My God! you should have added lactobacilli to the antibiotic Regimen

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© IJCP Academy

Top 22 Stories of the Year 2010 6

Make sure that lactobacilli are prescribed along with antibiotics because they restore the normal flora of the gastrointestinal tract and decrease the duration of diarrhea.

Dr KK Aggarwal

Photo Quiz

9

(Source HealthBeat)

Cystatin C Beats Creatinine at Predicting Complications of Kidney Disease Testing for cystatin C, a protease inhibitor made by most cells and a biomarker of renal function, more accurately identifies chronic kidney disease (CKD) patients who are at high risk for complications than creatinine testing does, according to a new study in the Journal of the American Society of Nephrology on Dec. 16.

ACR Hybrid Score More Sensitive than the ACR20 Response Criteria Results of a post-hoc analysis show that ACR hybrid is more sensitive than the ACR20 response criteria in detecting response to therapy in rheumatoid arthritis. The hybrid score - which combines the ACR20/50/70 scores with percent change from baseline in multiple disease domains. The study is reported in the January issue of Arthritis Care & Research.

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Clinical Tips Aspirin after Peptic Ulcer Bleeding: Is It Worth the Risk?

Background: Peptic ulcer bleeding is usually treated endoscopically, then followed by proton pump inhibitor therapy, and the discontinuation of aspirin or other antiplatelet agents until the ulcer heals.

The resulting risk of cardiovascular or cerebrovascular events and death is believed to be offset by reducing the risk of recurrent bleeding, but the true risk-benefit ratio is unknown. Sung and colleagues conducted a randomized, placebo-controlled trial to examine the effect of continuing aspirin therapy in patients being treated for peptic ulcer bleeding.

The Study: The authors recruited 156 patients with acute peptic ulcer bleeding who were already on lowdose aspirin (325 mg per day or less) for prophylaxis or treatment of cardiovascular disease. Within 24 hours of bleeding onset, all patients received endoscopic treatment with epinephrine and thermal coagulation, followed by pantoprazole (Protonix; 80-mg bolus intravenously, then 8 mg per hour intravenously for 72 hours, then 40 mg per day orally for the remainder of the study).

After endoscopic hemostasis was achieved, patients were randomized to receive 80 mg per day of aspirin or placebo for eight weeks and were monitored for episodes of recurrent peptic ulcer bleeding and cardiovascular or cerebrovascular events. Patients were excluded if they were using aspirin for primary prophylaxis; had gastric outlet obstruction or ulcer perforation; were taking corticosteroids, nonsteroidal anti-inflammatory drugs, or other anticoagulants; or if hemostasis could not be achieved.

Results: Although the 30-day incidence of recurrent ulcer bleeding was 10.3 percent in the aspirin group and 5.4 percent in the placebo group, the risk comparison was not statistically significant (hazard ratio [HR] = 1.9; confidence interval, 0.6 to 6.0).

Total number of units of blood transfused and duration of hospital stay were similar between the two groups.

However, the aspirin group had a significantly lower 30-day mortality rate than the placebo group (1.3 versus 9.0 percent; HR = 0.2), with similar estimates of eight-week mortality (HR = 0.2). Mortality caused by cardiovascular, cerebrovascular, or gastrointestinal complications was also lower in the aspirin group (HR = 0.2).

Conclusion: The authors conclude that continuing lowdose aspirin therapy after peptic ulcer bleeding may increase the risk of rebleeding, but it is also associated with a 12 percent reduction in all-cause mortality in comparison with placebo. The protective effect of aspirin (in combination with pantoprazole) seems to outweigh its potential gastrointestinal toxicity in these patients.

The authors of this study tentatively suggest that aspirin be stopped for three to five days after the index bleed and resumed after stabilization, because most observed deaths from gastrointestinal bleeding occurred within the first few days after index bleeding. However, confirmatory studies examining the optimal time to restart antiplatelet therapy are needed.

Source: Adapted from Am Fam Physician. 2010;82(11):1395-1396.

What is the Best Vasopressor for the Treatment of Shock?

Background: Consensus guidelines recommend that dopamine or norepinephrine be the first-choice vasopressor for patients in shock. Dopamine may increase splanchnic and renal perfusion more than norepinephrine, but observational studies have reported that it is also associated with a greater risk of death.

The true benefits of these agents compared with each other are unknown. De Backer and colleagues conducted a multicenter, randomized, double-blind trial to determine if using norepinephrine instead of dopamine could reduce the death rate among patients in shock.

The Study: The authors enrolled 1,679 adult patients in shock (i.e., signs of tissue hypoperfusion despite hydration, with a mean arterial pressure less than 70 mm Hg or systolic blood pressure remaining below 100 mm Hg) who received dopamine or norepinephrine.

If hypotension persisted with the maximal drug dosage (20 mcg per kg per minute for dopamine or 0.19 mcg per kg per minute for norepinephrine), open-label norepinephrine was added. Patients were excluded for serious arrhythmias (e.g., rapid atrial fibrillation [more than 160 beats per minute]) or if they had already received a vasopressor for more than four hours during the current episode of shock.

Cont’d on Page 10...

Doctor of the year awards Dr Subhash Arya eMedinewS Life Time Achievement Award

Dr Kaberi Banerjee eMedinewS Medical Doctor of the Year 2010 Award

Dr SC Tiwari eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Naresh Trehan eMedinewS Life Time Achievement Award

Dr Sudhir Gupta eMedinewS Medical Doctor of the Year 2010 Award

Dr NK Bhatia eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Praveen Chandra eMedinewS Medical Statesman of the Year the 2010 Award

Dr Sudhir Kumar Gupta eMedinewS Medical Doctor of the Year 2010 Award

Dr Anupam Sibal eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Ambrish Mithal eMedinewS Medical Statesman of the Year the 2010 Award

Dr Neelam Kler eMedinewS Medical Doctor of the Year 2010 Award

Dr AN Malviya eMedinewS Distinguished Speaker of the Year 2010 Award

Dr AS Soin eMedinewS Medical Statesman of the Year the 2010 Award

Dr HK Chopra eMedinewS Medical Doctor of the Year 2010 Award

Dr Anoop Sarya eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Ashok Seth eMedinewS Medical Statesman of the Year the 2010 Award

Dr Reshma Aggarwal eMedinewS Medical Doctor of the Year 2010 Award

Dr Rohini Honda eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Ranjit Roy Chaudhury eMedinewS Medical Statesman of the Year the 2010 Award

Dr Girish Tyagi eMedinewS Medical Doctor of the Year 2010 Award

Dr Sanjay Choudhary eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Mahesh Verma eMedinewS Medical Statesman of the Year the 2010 Award

Dr Vinay Sanghi eMedinewS Medical Doctor of the Year 2010 Award

Dr Praveen Bhatia eMedinewS Distinguished Speaker of the Year 2010 Award

Dr Yash Gulati eMedinewS Medical Singer of the Year Award

Dr Rajiv Parakh eMedinewS Medical Doctor of the Year 2010 Award

Dr Sheh Rawat eMedinewS Distinguished Speaker of the Year 2010 Award

Dr AK Aggarwal eMedinewS Medical Doctor of the Year 2010 Award

Dr Swati Bhave eMedinewS Medical Doctor of the Year 2010 Award

Dr Neelam Mohan eMedinewS Most Popular Doctor of the Year 2010 Award

Excellence Awards eMedinewS Life Time Achievement Award

Dr Ashok Rajgopal

Dr Sudhir Gupta

Dr Subhash Arya

Dr Rajvardhan Azad

Dr Naresh Trehan

Dr Sudhir Kumar Gupta

Dr Neelam Kler

Dr Veena Chowdhry

Dr HK Chopra

Dr Reshma Aggarwal

Dr Girish Tyagi

Dr Anoop Sarya

Dr Vinay Sanghi

Dr Rajiv Parakh

Dr Swati Bhave

eMedinewS Medical Statesman of the Year the 2010 Award

Dr Praveen Chandra

Dr Ambrish Mithal

Dr AS Soin

Dr Ashok Seth

Dr Ranjit Roy Chaudhury

Dr Mahesh Verma

eMedinewS Medical Singer of the Year Award

Dr N Subramanium

Dr Lalitha Subramanium

Dr Ramani Narasimhan

Dr Arti Pathak

Dr Praveen Khilanani

Dr Harjit Kaur

Dr Yash Gulati

eMedinewS Distinguished Speaker of the year 2010 Award

Dr Anil Goyal

Dr SC Tiwari

Dr DM Mahajan

Dr Awdesh Pandey

Dr NK Bhatia

Dr Anoop Gupta

Dr Anupam Sibal

eMedinewS Medical Doctor of the Year 2010 Award

Dr Jamal A Khan

Dr AN Malviya

Dr MK Pal

Dr Sanjay Choudhary

Dr AK Aggarwal

Dr Rajiv Khosla

Dr S Bhattacharjee

Dr Rohini Handa

Dr AC Dhariwal

Dr Praveen Bhatia

Dr Kaberi Banerjee

Dr Sheh Rawat

Dr Ajay Kriplani

Dr Vijay Trehan

eMedinewS Most Popular Doctor of the Year 2010 Award

Dr Yatin Mehta

Dr Neelam Mohan

Top 22 Stories of the Year 2010 1. Delhi Bug

A huge controversy arose when the Lancet Infectious Diseases broke a story where researchers reported a new gene called NDM-1, which stands for New Delhi metallo-beta-lactamase-1. The new bug is a gram negative bacteria showing resistance to all present antibiotics. The enzyme NDM–1 confers resistance to a broad range of beta-lactam antibiotics including the carbapenems, the mainstay of treatment of antibiotic– resistant bacterial infections. The gene for NDM–1 is one member of a large gene family that encodes beta–lactamase enzymes called carbapenemases.

Bacteria that produce carbapenemases are often referred to in the news media as “superbugs” because infections caused by them are difficult to treat. Such bacteria are usually only susceptible to polymyxins and tigecycline. NDM–1 was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008. It was later detected in bacteria in India, Pakistan, the United Kingdom, the United States, Canada, Japan and Brazil.

average blood glucose levels for a period of up to 3 months. An A1C >6.5% means diabetes.

6

New pill for HIV Prevention

A new pill is now available for HIV prevention along with condoms. It is to be used before the act and continues for seven days. In a trial of more than 2000 HIV-negative, but high risk, gay men in six countries, the combination antiretroviral pill (tenofovir and emtricitabine) reduced the risk of HIV infection by 44%, compared with placebo. Also, it was observed that the risk of contracting HIV was even lower, 73% lower than the placebo group. However, according to public health experts, safe sex and consistent use of condoms still remain as the best method of prophylaxis because the pre–exposure prophylaxis acts by loading up the high–risk individuals with the HIV–disabling antiretroviral drugs prior to exposure to the virus. This allows the drug to attack the virus as early as possible. But the drugs do not work as a vaccine would, by priming the immune system to actually prevent infection.

2

H1N1 Havoc

The H1N1 virus created great havoc, but in the end, proved to be just a ‘much hyped’ virus with mortality even lower than the regular human flu virus. The WHO declared the swine flu pandemic officially with the virus moving into the ‘post–pandemic’ phase.

The upside of this was an increased awareness of flu prevention practices.

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National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) Started in the Country

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The Chikungunya Epidemic

Chikungunya re-emerged and was the latest epidemic in North India with patients presenting with fever, rash and joint pains. The joint pains persisted after the fever was gone. It complicated pre-existing dengue epidemic in the society.

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Dengue with a Difference

The Ministry of Health and Family Welfare, Government of India has started the National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). The Non-Communicable Diseases (NCDs) are increasing in India and are a major cause of morbidity and mortality.

Dengue once again made its presence felt, especially in the national capital. However, this year dengue was different than other years. It presented with more GI symptoms, pancreas involvement, dengue hepatopathy and lot of skin reactions. The platelet count dropped to less than 10000 but most required no platelet transfusion.

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New Drug for Premature Ejaculation

A new drug for treatment for premature ejaculation is now available. Dapoxetine is a selective serotonin reuptake inhibitor that blocks the re-absorption of the neurotransmitter serotonin.

5

Diabetes Diagnosis

The year saw a new advancement when the American Diabetes Association (ADA) released its new clinical practice guidelines, which recommended use of A1C was recommended for the diagnosis of diabetes and pre diabetes and not fasting sugar. A1c measures

Premature ejaculation is the most common sexual problem aside from erectile dysfunction. While the currently existing drugs, which are not specific to treat premature ejaculation, need to be taken regularly, this new drug is an SOS drug and can be taken an hour or two before intercourse.

Top 22 Stories of the Year 2010 9

FDA Limits Access to Rosiglitazone

In September, the US FDA put new restrictions on rosiglitazone, a drug prescribed for type 2 diabetes due to concerns about increased risk of heart attacks and other cardiovascular problems.

It now requires patients to have a consent form to get the drug and has created new rules for doctors writing prescriptions for it. Now, doctors in the US will now have to attest and document each patient’s eligibility to receive rosiglitazone. In November this year, the Drug Controller General of India banned the much controversial drug “Rosiglitazone”

10 Revolutionary Tuberculosis Test

Patients with diabetes have 2 to 4 times higher mortality rates due to heart disease than those without diabetes.

New research from the ACCORD Study Group shed light on tailoring treatment to diabetic patients to reduce their risk of developing heart disease. In the first study, it was found that aggressive control of blood pressure with systolic blood pressure reading of less than 120 mm Hg versus less than 140 mm Hg did not cut down on the chances of heart disease in people with type 2 diabetes. Combining anti lipid treatment (stain plus fibrate) was beneficial in reducing chances of heart disease in those type 2 diabetes patients who had low HDL cholesterol and low triglycerides, reported another study.

12 Improving the Way We Reverse Sudden Cardiac Arrest

13 Research Supports Healthy Lifestyle Behavior

The World Health Organization endorsed a new rapid molecular diagnostic test for TB that is accurate nearly 99% of the time and reduces the diagnosis time by giving results in ≤2 hours. The test, called Xpert MTB/ RIF, was developed by Cepheid and the Foundation for Innovative and New Diagnostics (FIND), a non-profit group funded by the Bill & Melinda Gates Foundation.

Use of this test could lead to an increase in the diagnosis of patients with drug-resistant TB including the number of HIV-associated TB cases diagnosed in areas with high rates of both diseases.

11 Tailoring Treatment for People with Diabetes to Reduce Their Risk of Heart Disease

and Emergency Cardiovascular Care Science in October. The highlight of these new guidelines was the Change from “A-B-C” to “C-A-B.” i.e. change from the traditional approach of airway-breathingchest compressions (“A-B-C”) to first establishing good chest compressions (“C-A-B”). Significant studies now report that chest compression only, or ‘Hands Only CPR’ for adults by bystander lay rescuers improves survival outcome. It is important to note that using conventional chest compressions with rescue breathing is still important for children stricken with sudden cardiac arrest

The American Heart Association issued updated Guidelines for Cardiopulmonary Resuscitation

New research has supported the benefits of altering one’s diet and physical activity in conditions like obesity and hypertension. Results from the HEALTHY study showed that the earlier one starts to adopt healthy behaviors the better the effect on health outcomes. The HEALTHY study was a school-based intervention program and involved 42 middle schools in seven regions of the US. Another study showed that diet together with physical activity resulted in clinically significant weight loss and favorable changes in cardiac risk factors in individuals who were severely obese.

14 “Time is Brain”: Treatment of Acute Ischemic Stroke

A combined analysis of eight trials of clotdissolving treatment for acute ischemic stroke again emphasized that every effort should be taken to shorten delay in initiation of clot-dissolving treatment in order to get maximum benefit. The trial reported in the Lancet also showed for the first time that treatment given beyond the first 4.5 hours after onset carried the risk of increased mortality due to delay in treatment.

15 CREST Trial Directly Compared Carotid Endarterectomy and Carotid Artery Stenting

The large CREST trial compared carotid endarterectomy (open surgical repair) and carotid stenting (endovascular placement of a stent), the two major methods to reopen narrowed carotid arteries carrying blood flow to the brain. On the whole, both techniques had similar rates of success and complication, but among younger patients, under

Top 22 Stories of the Year 2010 70 years of age, stenting appeared advantageous while among older patients endarterectomy appeared advantageous.

16 The INTERSTROKE Study Identifies the Ten Major Risk Factors for Stroke

The worldwide INTERSTROKE study identified the top 10 risk factors for stroke namely High blood pressure, smoking, waist-to-hip ratio (abdominal obesity), diet, physical activity, blood lipids, diabetes mellitus (type 2), alcohol intake, stress and depression and heart disorders. Put together, these risk factors were found to be associated with 90 percent of the risk of stroke. This study analyzed risk factors for stroke in 22 countries and showed that 10 risk factors are associated with 90% of the risk of stroke. Hypertension was the most important of these modifiable risk factors for all strokes including brain hemorrhage. The most important message from the study was that controlling the blood pressure can reduce the chances of stroke.

calcium would seem appropriate. The study raised many questions, such as why calcium could have this effect during a relatively short period of time. Some experts recommend eating a calcium-rich diet rather than taking supplements.

19 Physical Activity, Even Moderate in Degree, Reduces Stroke risk

20 FDA Warns Against Quinine for Cramps

17 New Guidelines for Prostate Cancer Screening

The American Cancer Society (ACS) updated its prostate cancer screening guidelines, which called upon physicians to spend more time counseling patients about their informed about the benefits and risks of PSA testing. PSA testing should be individualized rather than be taken as an annual test for any man aged 50 and over. The group’s newly revised guidelines make it clear that prostate specific antigen (PSA) blood testing should not occur unless this discussion happens. Screening can in some cases save lives with early treatment; but, it also picks up benign disease in addition to cancer, and it can’t distinguish between aggressive and mild forms of the disease.

18 Calcium Boosts Heart Attack Risk

A meta–analysis of 15 randomized trials study reported in BMJ noted that calcium supplements taken without vitamin D may increase the risk for heart attack as much as 30%. Most osteoporosis guidelines currently recommend calcium supplements, despite relatively small benefits in bone health. Senior author Dr. Ian R. Reid, from the University of Auckland, New Zealand stated that in most cases, stopping

A study reported in the journal Stroke concluded that leisure-time physical activity, even in modest degree, is associated with lower stroke risk in women.

Walking, in particular, was generally associated with lower risks of total, ischemic, and hemorrhagic stroke.

The FDA re-issued guidelines on the use of quinine taking note of the fact that most of the quinine being prescribed in the United States is not for the approved indication i.e. uncomplicated malaria but, for leg cramps. Taking quinine may result in serious and life–threatening hematologic adverse effects.

21 Task Force Revises Mammography Guidelines

The American College of Radiology and the Society of Breast Imaging directly contradicted the US Preventive Services Task Force and recommended routine mammography for women at age 40 years and older. In 2009, the Task Force had asked for an end to routine mammography for women younger than 50 years, citing a lack of evidence for benefits in women of this age group, which sparked off a great controversy

22 The 1st Synthetic Cell

J. Craig Venter, co-mapper of the human genome, this year took another step toward creating life in the laboratory when scientists created a synthetic cell that can survive and reproduce itself according to an artificial DNA sequence. Generated from a process of carefully stitching together the chemicals that compose DNA, the entire genome of a bacterium was synthesized, which was inserted into a cell and was able to replicate. This represents a major step towards applications in biofuels and chemical synthesis through synthetic biology.

Photo Quiz Unusual Case of Pharyngitis A 22-year-old woman presented to the emergency department five days after eating lettuce that she said had scratched her throat. She had seen two physicians in the outpatient setting and was given pain medication. However, she was now unable to tolerate oral fluids. She had an intact airway with moderate trismus and mild anterior cervical lymphadenopathy.

She was afebrile. Computed tomography (Figure 1) and radiography (Figure 2) were performed.

Question Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

Figure 1.

A. Angioedema.

B. Epiglottitis.

C. Laryngotracheobronchitis (croup).

D. Peritonsillar abscess.

E. Retropharyngeal abscess.

Discussion The correct answer is E: retropharyngeal abscess.

Although the condition is commonly described as a childhood disease, it can occur in adults.1,2 Even with the use of antibiotics, mortality in patients with retropharyngeal abscess

Figure 2. can be as high as 50 percent.2 The retropharyngeal space is a potential area of infection, but normally regresses by six years of age.3 In adults, retropharyngeal abscess commonly causes sore throat, fever, dysphagia, odynophagia, neck pain, and dyspnea. However, most patients also have a history of trauma, such as from endotracheal intubation, endoscopy, or a foreign body in the hypopharyngeal area.

The patient’s computed tomography scan demonstrates fluid collection and abscess formation in the retropharyngeal space (Figure 3). There is also significant soft tissue swelling anterior to the abscess (Figure 4).

Summary Table Condition

Characteristics

Angioedema

Painless nonpitting edema most pronounced in the head and neck

Epiglottitis

Fever, difficulty swallowing, drooling, stridor; infection usually confined to the epiglottis

Laryngotracheobronchitis (croup)

“Barking” cough, stridor, possibly dyspnea; usually occurs in children three months to three years of age

Peritonsillar abscess

Unilateral sore throat, tender lymphadenopathy on the affected side, fever

Retropharyngeal abscess

Sore throat, fever, dysphagia, odynophagia, neck pain, dyspnea; patients usually have a history of trauma; posterior pharyngeal edema and lymphadenopathy; abnormal lateral neck radiography

and stridor. The infection is usually confined to the epiglottis. Occurrence of this disease has decreased dramatically since the introduction of Haemophilus influenzae type b vaccine.

Laryngotracheobronchitis (croup) usually occurs in children three months to three years of age. Symptoms include a “barking” cough, stridor, hoarseness, and potentially dyspnea.

Anteroposterior radiography may show subglottic narrowing (steeple sign).

Figure 3.

A peritonsillar abscess may lead to similar symptoms as retropharyngeal abscess. Typically, patients with peritonsillar abscess have unilateral sore throat and tender lymphadenopathy on the affected side.

Figure 4.

Potential complications of retropharyngeal abscess are airway obstruction, mediastinitis, aspiration pneumonia, epidural abscess, jugular venous thrombosis, necrotizing fasciitis, sepsis, and erosion into the carotid artery. In the outpatient setting, protection of the airway is crucial, with emergent surgical consultation for drainage of the abscess.4

References

With angioedema, painless and nonpitting soft tissue edema would be evident on clinical examination and imaging. The edema is most pronounced in the head and neck.

4.

Epiglottitis causes fever, difficulty swallowing, drooling,

1.

2.

3.

Abdel-Haq NM, Harahsheh A, Asmar BL. Retropharyngeal abscess in children: the emerging role of group A beta hemolytic streptococcus.

South Med J. 2006;99(9):927-931.

Tannebaum RD. Adult retropharyngeal abscess: A case report and review of the literature. J Emerg Med. 1996;14(2):147-158.

J Echevarria. Deep neck infections. In: Schlossberg D, ed. Infections of the Head and Neck. New York, NY: Springer; 1987:172-174.

Nwaorgu OG, Onakoya PA, Fasunla JA, Ibekwe TS. Retropharyngeal abscess: a clinical experience at the University College Hospital Ibadan. Niger J Med. 2005;14(4):415-418.

Source: Adapted from Am Fam Physician. 2010;82(12):1523-1525.

...Cont’d from Page 3

The primary end point was the rate of death at 28 days. Secondary end points included the rates of death in the intensive care unit and in the hospital, and the duration of stay in the intensive care unit.

Results: Septic shock (62.2 percent) was the most common etiology, followed by cardiogenic shock (16.7 percent) and hypovolemic shock (15.7 percent). Baseline characteristics were similar between groups, as were initial mean arterial pressure and the mean time to achieve a mean arterial pressure of 65 mm Hg. Overall mortality rates were similar; however, subgroup analysis found that dopamine was associated with a higher risk of death in patients with cardiogenic

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shock. Arrhythmias were nearly twice as common in the dopamine group compared with the norepinephrine group (24.1 versus 12.4 percent), with atrial fibrillation being the most common arrhythmia with either agent. There was nearly a fourfold greater discontinuation rate with dopamine because of severe arrhythmias, compared with norepinephrine (6.1 versus 1.6 percent).

Conclusion: The authors conclude that although there is no overall difference in the rate of death between patients treated with dopamine or norepinephrine, dopamine is associated with more arrhythmias and increased mortality among patients with cardiogenic shock.

Source: Adapted from Am Fam Physician. 2010 Dec 1;82(11):1395.

Dr. Good and Dr. Bad Pioneer in Medical Journalism

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Situation: A diabetic patient was found to have higher baPWV.

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It is normal

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Lesson: Brachial-ankle pulse wave velocity (baPWV) is a marker for

arterial stiffness and may be a risk stratification index for short-term prognosis in clinical practice, suggesting the need for further aggressive treatment and strict follow-up in coronary artery disease (CAD) patients with diabetes and higher baPWV. In a multivariate analysis, a higher baPWV was independently associated with poorer short-term prognosis (hazard ratio, 1.97;95% CI, 1.01-3.84) in diabetic CAD patients.

Hypertens Res 2010;33(10):1018-24.

Dr KK Aggarwal

Illusion

Say aloud the ink color of each word.

How quickly can you do it?

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