Dr KK AggArwAlGr. Editor-in-Chief, IJCP Group

MemberThe Indian Newspaper Society

Official Voice ofDoctors of India

Pages 12

Dr KK AggarwalPadma Shri and Dr BC Roy National Awardee

Sr. Physician and Cardiologist, Moolchand MedcityPresident, Heart Care Foundation of India

Group Editor-in-Chief, IJCP Group and eMedinewS

Chairman Ethical Committee, Delhi Medical CouncilDirector, 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/DrKKAggarwalKrishan Kumar Aggarwal (Facebook)

E d i t o r i a l

ISSN 0971-880X Single Copy rs. 100/-Vol. 11, No. 8, August 2011

I n s I d eMAKe Sureduring MEdical PracticE

A patient developed high altitude cerebral edema while traveling to Leh.

Make sure that all high-risk patients are given acetazolamide before they go to mountains.

KK Aggarwal

©IJ

CP

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Oh my God! Why was acetazolamide not started before the journey?

News & Views 3

Fitness Update 4

Legal Column 5

Research Review 6

Photo Quiz 7

Expert Opinion 8

Clinical Algorithm 9

Local Practice Patterns Drive Diagnostic Angios

There is wide variation among US institutions in the rate of positive findings of obstructive coronary artery disease (CAD) when patients undergo diagnostic angiography, a retrospective study found. Among hospitals, the rate of positive findings (≥50% obstruction) varied from 23 to 100%, reported Pamela S Douglas, MD, from Duke University Medical Center in Durham, NC, and colleagues. Hospitals with lower rates of obstructive CAD findings performed coronary angiography more often in younger patients, women, blacks and outpatients (all p < 0.001), researchers reported in the August 16 Journal of the American College of Cardiology. (Source: Medpage Today)

This Gadget Helps Stop Overeating

Mindless snacking is a problem for many weight-watchers. Now, scientists have developed a new device which they say could help stop people from overeating by monitoring how many mouthfuls they eat. Developed by researchers at Clemson University in South Carolina, the Bite Counter is worn like a watch and tracks a pattern of wrist-roll motion to identify when the wearer has taken a bite of food. Then this data can be used to monitor how many calories people are eating long-term. People can also set a bite limit so if they snack too much an alarm will go off. The researchers have described the innovative device as a pedometer for eating, the Daily Mail reported. Lead scientist Eric Muth said: “At the societal level, current weight-loss and maintenance programs are failing to make a significant impact. Studies have shown that people tend to underestimate what they eat by large margins, mostly because traditional methods rely upon self-observation and reporting. Our preliminary data suggest that bite count can be used as a proxy for caloric count.” (Source: TOI, August 8, 2011)

Aminophylline 0.5% Paste for Burning

Local FatA cream made of the asthma drug aminophylline at 0.5% concentration applied locally can burn local fat, according to results of two published studies. The first study from UCLA demonstrated it on thigh fat in 1995 and was published in the journal Obesity Research.1 A series of clinical trials were done using one thigh as the test and the other as the control.

The second study from Louisiana State University in Baton Rouge addressed waist circumference and was published in 2007 in the journal Diabetes, Obesity and

Metabolism.2 In the study, all participants were placed on a diet of restricted calories and required to exercise. There was a significant reduction in waist circumference in the aminophylline cream group at 12 weeks compared to controls. The waist to hip ratio, a measure of fat distribution also declined.

ReferencesGreenway FL, Bray GA, Heber D.Topical fat reduction. Obes Res 1995;3(Suppl 4):561S-568S.

Caruso MK, Pekarovic S, Raum WJ, et al. Topical fat reduction from the waist. Diabetes Obes Metab 2007;9(3):300-3.

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Dr KMK MasthanDr Hasmukh J Shroff

IJCP Publications Pvt. ltd.E - 219, Greater Kailash, Part - 1, New Delhi - 110 048Tel.: 40587513 E-mail: editorial@ijcp.com, emedinews@gmail.com, drveena@ijcp.comSubscription Office: Flat 5E, Merin Estate, Geetanjali, 25/8 diamond Harbour Road, Kolkata - 700 008 Mob.: 9831363901, E-mail: subscribe@ijcp.com, Website: www.ijcpgroup.com

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News & ViewsA Blood Test to Detect

Alzheimer’s EarlyA new blood test that is 96% accurate at identifying Alzheimer’s disease and can perhaps detect it even before symptoms such as memory loss, poor judgment or erratic behavior appear has been developed by scientists from Durin Technologies, Inc. and the University of Medicine and Dentistry of New Jersey (UMDNJ)–School of Osteopathic Medicine. The test that uses human protein microarrays to detect the presence of specific antibodies in the blood has a specificity of 92.5% and has the potential to spot Alzheimer’s in its earliest stages. (Source: TOI August 2, 2011)

Sentinel Nodes Reliable in Head and Neck Melanoma

Sentinel lymph node biopsy for head and neck melanomas appears both prognostic and safe despite debate on both counts, researchers argued. A positive sentinel lymph node finding was the single most predictive factor for a poor outcome, with hazard ratios of 4.23 for recurrence or death and 3.33 for all–cause mortality (both P<0.0001), Carol R. Bradford, MD, of the University of Michigan Health System in Ann Arbor, and colleagues found. (Source: Medpage Today)

Now, a Software to Prevent Stampedes

Scientists have developed a new software which can accurately detect when crowds are starting to build up to dangerous levels - a feat they say could help prevent stampede deaths that often occur during festivals and mass celebrations. German researchers who developed the new software said that it will give security staff the chance to disperse crowds to safety by pre-empting the problem. Lead researcher Barbara Krausz, from the Fraunhofer Institute for Intelligent Analysis and Information Systems, Germany, said when people become trapped in a congested area, they sway slowly from side-to-side in an effort to keep their balance. (Source: TOI, August 5, 2011)

New Nerve Cells Made from Skin

For the first time, human skin cells have been directly transformed into functional nerve cells, opening a way for cell replacement therapies for neurodegenerative conditions such as Alzheimer’s disease, researchers reported. Transduction using a lentivirus vector that carried the transcription-regulating genes Ascl1, Brn2 and Zic1 resulted in conversion of 62% of human fibroblasts into neuronal cells, according to Asa Abeliovich, MD, PhD, of Columbia University in New York City and colleagues. (Source: Medpage Today)

FOBT not Fooled by Upper GI Bleeds

Bleeding in the upper gastrointestinal (GI) tract did not alter the accuracy of immunochemical fecal occult blood testing (FOBT) for lower-GI lesions, according to results of a large prospective cohort study. FOBT had a sensitivity of 24.3% and specificity of 89% for lower-GI bleeding, and twice as many patients with endoscopy-confirmed lower-GI lesions had positive FOBT results compared with patients who had negative tests. In contrast, a similar proportion of patients with positive and negative FOBT results had endoscopy-confirmed upper-GI lesions, as reported online in CMAJ. (Source: Medpage Today)

Air Cleaners do not Thwart Most Effects of Secondhand

SmokeAir cleaners significantly reduce particulate matter (PM) levels but are not enough to reduce exposure to secondhand smoke in inner-city children with asthma residing with a smoker, a new study has found. Arlene M Butz, ScD, MSN, CPNP, with the Division of General Pediatrics at The Johns Hopkins University School of Medicine, in Baltimore, Maryland, and colleagues reported the findings in the August issue of the Archives of Pediatrics & Adolescent Medicine. (Source: Medscape Medical News)

Antidepressant Scripts Often Lack DiagnosisAlmost three-quarters of the antidepressant prescriptions written by nonpsychiatrists had no documentation of psychiatric diagnoses, an analysis of recent prescribing trends showed. Prescriptions without psychiatric diagnoses accounted for a majority of nonpsychiatrists’ antidepressant prescriptions from 1996 to 2007, according to an article published online in Health Affairs. (Source: Medpage Today)

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Obesity is Baby Boomers’ Main Health ProblemA higher percentage of baby boomers are obese than in any other group in the USA, a poll carried out by LifeGoesStrong has revealed. Findings revealed that while approximately 36% of baby boomers are obese, the figure for the two generations directly above and below them is about 25%. A baby boomer is somebody born during a baby boom, which in this text refers to US citizens born between 1946 and about 1965. When World War II was

over, birth rates worldwide increased significantly - this explosion of new babies became known as the baby boom. This rise in population produced a considerable increase in demand for consumer goods, which stimulated the post-war economy. Baby boomers make up almost 20% of the US population and have a significant impact on the economy. They are frequently the focus of marketing, business and health campaigns.

Fitness Update

Study Finds Personality Plays Role in Body WeightPeople with personality traits of high neuroticism and low conscientiousness are likely to go through cycles of gaining and losing weight throughout their lives, according to an examination of 50 years of data in a study published by the American Psychological Association. Impulsivity was

the strongest predictor of who would be overweight, the researchers found. Study participants who scored in the top 10% on impulsivity weighed an average of 22 lbs. more than those in the bottom 10%, according to the study.

A Rich New Source of Heart-healthy Food Ingredients - SeaweedIn an article, that may bring smiles to the faces of vegetarians, who consume no dairy products and vegans, who consume no animal-based foods, scientists have identified seaweed as a rich new potential source of heart-healthy food ingredients. Seaweed and other ‘macro algae’ could rival milk products as sources of these so-called ‘bioactive peptides,’ they conclude in an article in ACS’s Journal of Agricultural and Food Chemistry. Maria Hayes and colleagues Ciarán Fitzgerald, Eimear Gallagher and

Deniz Tasdemir note increased interest in using bioactive peptides, now obtained mainly from milk products, as ingredients in so-called functional foods. Those foods not only provide nutrition, but have a medicine-like effect in treating or preventing certain diseases. Seaweeds are a rich but neglected alternative source, they state, noting that people in East Asian and other cultures have eaten seaweed for centuries: Nori in Japan, dulse in coastal Europe, and limu palahalaha in native Hawaiian cuisine.

Chew More, Eat Less?Nutritionists in China found when both lean and obese young men chewed more at a meal, they ingested fewer calories and had more favorable levels of gut hormones in their blood, lending credence to the old Swedish proverb that says, among other things, ‘Eat less, chew more,’ and ‘all good things will be yours’. You can read about the

study by Jie Li and colleagues from the School of Public Health at Harbin Medical University, in the August issue of the American Journal of Clinical Nutrition. Li and his team invited 16 lean and 14 obese young men to take part in two studies. In the first study, they observed the differences in chewing habits between the lean and the obese group.

—Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com

Eating Fat when Sad Really does Lift MoodThere may be more to the term comfort eating than we realize. However, consuming fat appears to be the mood-lifter, rather than any other food ingredient. Researchers from University of Leuven, Belgium, reported on a study in the Journal of Clinical Investigation. The authors explained that humans have an intimate relationship between their emotional state and what they eat. When we feel tired, stressed, anxious or overworked we tend to grab the chocolate bar, rather than an apple - in other

words, comfort foods. Lukas Van Oudenhove, MD, PhD and team charted areas of the brain with functional magnetic resonance imaging (MRI) scans - specific areas of the brain are seen to light up when a person is sad.

They recruited 12 healthy individuals, none of them was obese. They were then given an infusion of fatty acid or saline via a feeding tube. Fatty acid was used because most comfort foods have high fatty acid content.

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The organic compounds contain arsenic either in trivalent or pentavalent combination.

The chief toxic manifestations are anaphylactic reaction; later on, skin reactions, hepatitis, jaundice, encephalitis may occur. The less soluble compounds cause local tissue necrosis.

Salvarsan and its derivatives are generally administered intravenously and occasionally intramuscularly. Arsenic is found in the blood soon after an intravenous injection of one of these preparations and is rapidly eliminated by the kidneys and bowels but may be retained in the tissues for a longer time after an intramuscular injection.

Arsenic is used homicidally much more frequently in India than in any other country, as it is cheap, easily available and can be easily concealed in the food. A very small quantity of arsenic is sufficient to produce

Arsenic Poisoning and its Medicolegal Importance

Legal Columnfatal effects, although cases have occurred where much larger quantities were given for homicidal purposes. Mass homicidal poisoning in which persons have been affected has sometimes occurred from arsenic having been administered by an individual in some article of food.

Arsenic may also be administered along with some other poisons like powdered glass, copper sulfate, mercury, opium, nux, etc.

Instead of administering a single fatal dose of arsenic at once, the murderer in western countries usually administers small doses over a long period in order to produce the symptoms simulating gastroenteritis and thus to conceal the crime.

Arsenic is sometimes employed as an abortifacient, both as an internal administration and as a local application in the form of paste or ointment to abortion sticks.

Conference CalendarPrimary Care: Mental Health Issues with a Focus on Drugs and BehaviorSeptember 4-11, 2011 Venue: 7-Night Western Mediterranean Cruise Conference, Barcelona, SpainWebsite: http://www.continuingeducation.net/coursedetails.php?program_number=878

Medical Ethics and Legal MedicineSeptember 5-15, 2011 Venue: 10-Night Western Mediterranean Cruise Conference, Civitavecchia, ItalyWebsite: http://www.continuingeducation.net/coursedetails.php?program_number=886

10th Global Conference: Making Sense of: Health, Illness and DiseaseSeptember 6-8, 2011 Venue: Mansfield College, Oxford, United KingdomWebsite: http://www.inter-disciplinary.net/probing-the-boundaries/making-sense-of/health-illness-and-disease/call-for-papers/

Pediatric Review 2011September 11-18, 2011Venue: 7-Night Mediterranean Cruise Conference Rome, ItalyWebsite: http://www.continuingeducation.net/coursedetails.php?program_number=854

22nd International Congress of the Israel Society of AnesthesiologistsSeptember 13-15, 2011 Venue: David InterContinental, Tel Aviv, IsraelWebsite: http://www.ICISA.co.il

FDI Annual World Dental Congress: New Horizons in Oral Health CareSeptember 14-17, 2011 Venue: Centro Banamex Convention and Exhibition CentreMexico City, SwitzerlandWebsite: http://www.fdicongress.org/

Current Problems of Gastroenterology and Abdominal SurgerySeptember 15-16, 2011 Venue: Congress Hall, Kiev, UkraineWebsite: http://www.nbscience.com/22.html

Clinical Pediatrics Conference15 to 17 September 2011 Vancouver, British Columbia, CanadaWebsite: http://clinicalpeds.com

Advances in Nephrology, Dialysis, Kidney TransplantationSeptember 29-30, 2011 Venue: Congress Hall, Odessa, UkraineWebsite: http://www.nbscience.com/25.html

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Weight Loss as Treatment for Knee Osteoarthritis Symptoms in Obese Patients: 1-year Results from a

Randomized Controlled Trial Objective: To evaluate 1-year symptomatic improvement in obese patients with knee osteoarthritis (OA) on an intensive low-energy diet (LED) maintained by frequent consultations with a dietician compared to minimal attention. Methods: The LED program consisted of group therapy with dietary consultations and two periods of a low-calorie diet of 810 kcal/day during Weeks 0-8 and Weeks 32-36. The control group only received dietary instruction and attention for 2-hour at baseline, and at Weeks 8, 32, 36 and 52. The primary endpoint (total Western Ontario and McMaster Universities [WOMAC] index) was assessed as the mean group difference during and after 1-year. Results: The study population consisted of 89 patients, 89% women, average age 63 years. After 1-year, mean weight loss in the LED group was –10.9 kg (11%) versus –3.6 kg (4%) in the control group (p < 0.0001). There was no difference between the groups in total WOMAC index (p = 0.11), although both groups improved. However, the LED intervention resulted in less WOMAC pain (7.7 mm), with a group mean difference of 7.2 mm (95% CI 1.0-13.4, p = 0.022). After one year 14 (32.8%) responded to LED versus 7 (15.6%) to control, with an absolute benefit of 16.3% (–1.1 and to 33.6%, p = 0.066). Conclusion: Continuous reinforcement of a weight loss program can be successful over a year in obese knee OA patients. Weight loss was statistically reflected only by a reduction in pain. However, the overall clinical benefits of the intervention on health should lead to a strong recommendation of weight loss in this group of patients.

Bliddal H, Leeds AR, Stigsgaard L, et al. Ann Rheum Dis 2011 August 5. [Epub ahead of print]

The Banishing Obesity and Diabetes in Youth Project: Description and Feasibility of a Program to Halt Obesity-associated Disease among Urban High School Students

Type 2 diabetes (T2DM) and cardiovascular disease (CVD) are rising dramatically in adolescents in parallel with excess weight. The Banishing Obesity and Diabetes in Youth (BODY) Project, is a school-based intervention that medically screens overweight and obese high school students, provides personalized feedback and connects to appropriate healthcare. Body mass index (BMI) was determined for 1,526 students in one New York City public high school with a school-based health center (SBHC). Overweight and obese students (n = 640) were invited to complete a medical evaluation that included a survey, blood pressure and blood tests. 328/640 (51%) eligible students returned signed parental consent and participated. All participants received a personalized report detailing their results along with specific recommendations on how to improve their health. Parents of participants with results outside healthy ranges (82%; 270/328) were called and mailed referral letters to connect with healthcare services. Project staff reached by telephone 74% (199/270) of those families and 29% (58/199) stated that the report led them to make arrangements to see a healthcare provider. Most students (83%; 273/328) were registered at the SBHC, and we shared their medical results with them so they could follow-up with the students. The BODY Project is a feasible program for urban schools with a SBHC. This may allow effective prevention of T2DM, and CVD from dyslipidemia and hypertension.

Sweat V, Bruzzese JM, Albert S, et al. J Community Health 2011 August 9. [Epub ahead of print]

Research Review

How COPD Disease Persists Even after Smoking Cessation?Australian researchers have found why chronic obstructive pulmonary disease (COPD) continues long after patients have quit smoking, the primary cause of the disease. They said cigarette smoke exposure fundamentally alters airway tissue from people with COPD at the cellular level, laying the groundwork for airway thickening and even precipitating precancerous changes in cell proliferation that may be self-perpetuating long after cigarette smoke exposure ends.

“We have demonstrated for the first time that the extracellular matrix (ECM) produced by fibroblasts following stimulation with cigarette smoke extract is functionally different than nonexposed ECM, and that the cigarette smoke itself may prime the airways in such a way to create an environment whereby airway remodeling is encouraged,” wrote lead researcher David Krimmer of the University of Sydney in Australia. The researchers examined the response of human lung tissue from donors with and without COPD to cigarette smoke extract (CSE). They found that CSE exposure-induced a significant increase in fibronectin deposition from the tissue of donors with COPD over the tissue of individuals without COPD. Similarly, they found that CSE upregulated the expression of perlecan - an ECM protein that is associated with tumor growth and angiogenesis - in COPD lung tissue.

Source: http://www.thehindu.com/health/medicine–and–research/article2302451.ece. July 28, 2011.

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Blistering Eruption on the Leg of an Adult

A 62-year-old white man presented with blistering of the skin on his lower extremity. The rash began two

weeks prior on the anterior surface of his right ankle and did not improve with a one-week course of ciprofloxacin. A similar rash subsequently developed on the lateral surface of his right thigh. He denied any foreign travel, trauma, or insect bites. He had a history of hypothyroidism, for which he took levothyroxine. He had no known medication allergies. He worked as a truck driver and had no pets. The patient did not have fever, gastrointestinal symptoms, or joint pain. Apart from the skin changes and swelling of the leg, the review of systems was unremarkable.

Physical examination revealed large, confluent, erythematous patches with clusters of clear and hemorrhagic vesicles, bullae, and sporadic ulcerations over the right lateral leg and anterior ankle (see accompanying figure). There was no mucosal involvement or inguinal lymphadenopathy. The rash was pruritic, but there was no pain or numbness. The examination was negative for Nikolsky sign (i.e., epidermal detachment from minimal pressure applied to normal skin adjacent to the lesion).

QuestionBased on the patient’s history and physical examination, which one of the following is the most likely diagnosis? (For Answer and Discussion, see page 10...)

Photo Quiz

Lab UpdateC-reactive Protein Test C-reactive protein (CRP) test measures the amount of a protein called CRP in blood. CRP test measures general levels of inflammation in the body. High levels of CRP are caused by infections and long-term diseases. CRP test is done to:

Check for infection after surgery. Its levels normally rise within 2-6 hours of surgery and then go down by the third day after surgery. If levels stay elevated three days after surgery, an infection may be present.

To check for infections and diseases that cause inflammation, such as:

Diseases of the immune systemPainful swelling of the blood vessels in the head and neckRheumatoid arthritisSwelling and bleeding of the intestines (inflammatory bowel)Bone infection

—Dr Arpan Gandhi and Dr Navin Dang

A. Bullous pemphigoid.

B. Dermatitis herpetiformis.

C. Erythema multiforme.

D. Pemphigus vulgaris.

E. Porphyria cutanea tarda.

South Asians more Vulnerable to Diabetes, Coronary

Artery DiseaseA new study led by an Indian-origin scientist has revealed that South Asians are more likely to add dangerous organ-hugging fat that can lead to diabetes and coronary artery disease (CAD). The team at McMaster University led by Dr Sonia Anand found that these ethnic groups tend to add dangerous fat onto their internal organs like their liver when they gain weight, while others just add it to their waistline. “The new study showed South Asians have less space to store fat below the skin than white Caucasians,” said Dr Anand, a professor of medicine and epidemiology at McMaster University. “Their excess fat, therefore, overflows to ectopic compartments, in the abdomen and liver where it may affect function,” she said. This visceral fat, she added, is associated with metabolic problems such as elevated glucose and abnormal lipids, which are risk factors that ultimately lead to CAD.

Source: http://www.newstrackindia.com/newsdetails/ 232949. 31 July 2011.

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Expert OpinionPediatric Update

What are the effects of CMV infection in older children/adults?In older children and adults, cytomegalovirus (CMV) causes only a mild flu-like illness. When clinical manifestations are present, they include:

MalaiseFeverGeneralized lymphadenopathyHepatosplenomegaly

Patients who are immunocompromised may develop extremely serious sequelae of infection, including chorioretinitis and pneumonitis.—Dr Neelam Mohan, Director, Pediatric Gastroenterology Hepatology

and Liver Transplantation, Medanta - The Medicity

Infertility Update

What is unexplained infertility?Upto 26% of infertile couples have unexplained infertility. In such cases, abnormalities are likely to be present but not detected by current methods. Possible problems could be: The egg is not released at the optimum time for fertilization, it may not enter the fallopian tube, the sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization. Also, polymorphisms in folate pathway genes could be one reason for fertility complications in some women with unexplained infertility.

—Dr Kaberi Banerjee, Infertility and IVF Specialist

When should you Start the DMARDs in RA?Once a diagnosis of rheumatoid arthritis (RA) has been made, the next step in the management would be to gauge the disease activity. This serves two important functions:

Enables the treating rheumatologist to decide on the disease-modifying antirheumatic drug (DMARD) therapy-based on the extent of disease activity

Enables the treating rheumatologist to gauge improvement or otherwise in disease activity, on follow-up.

Disease activity can be assessed in terms of clinical activity; functional impairment or joint damage. A number of clinical measures of clinical disease activity have been developed over the years, that take into account the number of inflamed joints (indicated by the number of swollen and tender joints); plus a patient’s or physician’s overall assessment of disease activity and one inflammatory measure (either ESR or CRP). Some of the initial activity measures were rather cumbersome as they involved assessment of upto 80-90 peripheral joints. With the realization that assessing fewer joints may convey the same information, three measures of clinical disease activity that take into consideration 28 peripheral joints (mainly upper limb and knees) are used regularly. They are:

Clinical Disease Activity Index (CDAI)

Simplified Disease Activity Index (SDAI)

Disease Activity Score on 28 joints (DAS-28). Each of these measures grades the extent of disease activity and allows an assessment to be made regarding mild, moderate or high disease activity as well as identifying clinical remission.1,2

Initiating DMARD Therapy The next step in management, after making a diagnosis and assessing disease activity, is to commence DMARD therapy

without delay. However, appropriate counseling should be undertaken so that the nature of the disease and therapy can be explained to the patient and his/her relatives. DMARDs can be introduced one at a time in a sequential manner or as a combination, with more than one DMARD. Evidence indicates that eventually, all these methods are effective in controlling disease activity. However, some evidence also suggests that initial therapy with a combination of more than one DMARD may help in earlier control of disease activity and therefore, better long-term effect.

The conventional DMARDs that have stood the test of time are: Hydroxychloroquine, sulfasalazine, methotrexate and leflunomide. Therefore, unless there are contraindications, initial therapy is commenced with one or more amongst these, either alone or in combination. The other DMARDs that may be used are: Minocycline, azathioprine, cyclosporine and thalidomide. It is important to emphasize that appropriate monitoring of DMARD therapy is mandatory, depending upon the drug(s) being used. Regular and periodic assessment of disease activity needs to be undertaken to gauge response to the treatment regime and therapy should be escalated rapidly if appropriate control is not achieved. In addition to DMARD therapy, two further measures need to be undertaken as part of the initial treatment regime.

ReferencesSmolen JS, Aletaha D. Activity assessments in rheumatoid arthritis. Curr Opin Rheumatol 2008;20(3):306-13.

Prevoo ML, van’t Hof MA, Kuper HH, et al. Modified disease activity scores that include 28 joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38(1):44-8.

—SJ Gupta, Senior Consultant, Dept. of Rheumatology Apollo and Sant Parmanand Hospitals, New Delhi

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Evaluation for Sensorineural Hearing Loss

Clinical Algorithm

An Inspirational Story

The Value of Sincerity of PurposeA story is told of a man who approached three workers who were doing the same job. ‘What are you doing?’ he asked each one of them separately and got different answers. ‘I am cutting the stones’ replied the first. ‘I am earning my livelihood,’ replied the second. ‘I am building a mosque’ replied the third. Each of the three workers saw himself linked to a different purpose each, one was to that extent, different from others, although all worked alike and were engaged in the same task. Our two hands with which we work are in no sense different from the hands of any other person.

The value of what we do depends upon the quality of the inner purpose in our heart with which we do our work.

History, physical examination, audiologic work-up

Diagnosis uncertain

Appropriate treatment

Severe-to-progressive Moderate-to-severe Mild-to-moderate

CT scan, Preferential seating

and Serial audiograms

Genetic testing

Genetic counseling

CT scan

ECG

Lab tests as indicated

CT scan

Appropriate treatment

Genetic testing

Lab tests as indicated

–+–+

Source: IJCP’s ENT Clinical Decision Charts. p:10.

Bilateral Unilateral

Diagnosis apparent

10

(...Cont’d from page 7)

Summary TableCondition CharacteristicsBullous pemphigoid Tense bullae with clear or hemorrhagic

fluid; may begin as urticaria or pruritus with bullous formation over weeks to months; mucosal involvement rare; Nikolsky sign absent; onset typically between 60 and 80 years of age

Dermatitis herpetiformis

Clusters of pruritic and erythematous papules, excoriations, or vesicles symmetrically distributed on extensor surfaces; associated with celiac sprue; onset typically between 20 and 40 years of age

Erythema multiforme Acute type IV hypersensitivity reaction characterized by macules, papules, and “target” lesions; begins on distal extremities and spreads proximally; minimal involvement of mucous membranes

Pemphigus vulgaris Flaccid blisters located on head, trunk, and intertriginous areas; mucosal involvement; Nikolsky sign present; onset typically between 40 and 60 years of age

Porphyria cutanea tarda

Blistering of the skin occurring on sun-exposed areas; may exhibit hypertrichosis of the forehead and cheeks, hyperpigmentation, and urine discoloration; associated with hepatitis C, hemochromatosis, and alcoholism

DiscussionThe correct answer is A: bullous pemphigoid.

The autoimmune condition is characterized by tense bullae on normal or erythematous skin.1 Typical age of onset is between 60 and 80 years; however, cases of juvenile bullous pemphigoid occur. Incidence of the disease increases with age.1,2 Patients may present with pruritus or urticaria with bullous formation occurring over weeks to months.3 Fluid contained in the bullae may be clear, or hemorrhagic if the base is bleeding. Rupture of the bullae results in erosions and crusting.1 Skin involvement can be localized, with lesions confined to the lower extremities, abdomen, and forearms; or generalized, with a widespread distribution of bullae.1,2 Mucosal involvement occurs in 10 to 25 percent of affected patients.3

The diagnosis is based on histologic examination, which reveals separation of the epidermis and dermis. Direct immunofluorescence testing shows deposition of immunoglobulin G autoantibodies targeting two hemidesmosomal proteins on the basement membrane of the epidermis.1,3 Serum antibody titers for the two antigens may also be performed. Prednisone, alone or in combination with a steroid-sparing agent, is the cornerstone of treatment.2,3 Topical corticosteroids may be sufficient for mild cases. The prognosis is good for most patients.2

Dermatitis herpetiformis is an autoimmune condition typified by clusters of erythematous papules, excoriations, and vesicles that arise as a consequence of gluten sensitivity. The lesions are extremely pruritic and tend to be distributed symmetrically along extensor surfaces.2,4 Dermatitis herpetiformis is associated with celiac sprue, but it can occur with other autoimmune disorders and malignancies. Most patients are between 20 and 40 years of age, but the condition may occur at any age.2,4

Erythema multiforme is an acute type IV hypersensitivity reaction to certain medications, herpes simplex virus or mycoplasma infection, and other triggers.5,6 It is a self-limited condition characterized by macules, papules, and “target” lesions that may contain a small bulla or vesicle.5 The rash begins on the distal extremities and spreads proximally.6 The skin lesions are usually symmetric, and there is minimal involvement of mucous membranes. Diagnosis is based largely on history and clinical presentation.5

Pemphigus vulgaris is an autoimmune disease that affects the skin and mucous membranes. The predominant skin lesions are flaccid blisters. The blisters are located on the head, trunk, and intertriginous areas, and onset is typically between 40 and 60 years of age. Pemphigus vulgaris is associated with Nikolsky sign and has a mortality rate of 5 to 15 percent.2,7 It is associated with other autoimmune diseases, including myasthenia gravis and thymoma.2

Porphyria cutanea tarda results from a deficiency in a heme-synthesizing enzyme. Blistering of the skin occurs on sun-exposed areas, especially the hands and forearms, and occasionally the face. Patients may also exhibit hypertrichosis of the forehead and cheeks, skin hyperpigmentation, and urine discoloration. Risk factors for the disease include hepatitis C, hemochromatosis, and alcoholism.8

ReferencesWolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008.

Southwell B, Riaz F, Khachemoune A. Bullous pemphigoid: a short review. Dermatol Nurs. 2009;21(6):322-326.

Patrício P, Ferreira C, Gomes MM, Filipe P. Autoimmune bullous dermatoses: a review. Ann N Y Acad Sci. 2009;1173:203-210.

Alonso-Llamazares J, Gibson LE, Rogers RS III. Clinical, pathologic, and immunopathologic features of dermatitis herpetiformis: review of the Mayo Clinic experience. Int J Dermatol. 2007;46(9):910-919.

Lamoreux MR, Sternbach MR, Hsu WT. Erythema multiforme. Am Fam Physician. 2006;74(11):1883-1888.

Volcheck GW. Clinical evaluation and management of drug hypersensitivity Immunol Allergy Clin North Am. 2004;24(3): 357-371, v.

Ahmed AR, Moy R. Death in pemphigus. J Am Acad Dermatol. 1982;7(2):221-228.

Thadani H, Deacon A, Peters T. Diagnosis and management of porphyria. BMJ. 2000;320(7250):1647-1651.

Source: Adapted from Am Fam Physician. 2011;84(2):231-232.

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Humor

I l l u s I o n

Dr. Good and Dr. BadSituatiOn : A 24-year-old female suffered migraine attacks after

physical exertion.

Dr KK Aggarwal

LeSSOn : Migraines can be triggered by stress, worry, menstrual periods, birth control pills, physical exertion, fatigue, lack of sleep, hunger, head trauma and certain foods or drinks that contain chemicals such as nitrites, glutamate, aspartate and tyramine.

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