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 Medcity, New DelhiPresident, Heart Care Foundation of India

Group Editor-in-Chief, IJCP Group and eMedinewSChairman 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.comhttp//twitter.com/DrKKAggarwal

Krishan Kumar Aggarwal (Facebook)

E d i t o r i a l

ISSN 0971-880X Single Copy rs. 100/-Vol. 11, No. 9, September 2011

I n s I d eMAKe Sureduring MEdical PracticE

A patient with acute chest pain died before reaching the hospital.

Make sure that at the onset of acute heart attack and chest pain, give the patient water-soluble aspirin to chew in order to reduce chances of sudden death.

KK Aggarwal

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Oh my God! Why was water–soluble aspirin not given?

Cover Story 3

Case Report 5

Fitness Update 6

Legal Column 7

Expert’s Opinion 8

News & Views 9

Conference Calendar 10

Predicting Perioperative Risk of Heart AttackA patient with diabetic stable nephropathy came for gallbladder surgery. What is his risk of peroperative heart attack? The 2007 ACC/AHA guidelines (not changed in the 2009 focused update) has summarized clinical predictors of increased perioperative risk for myocardial infarction, heart failure (HF) and cardiac death.1

ACC/AHA guideline summary: Clinical predictors of increased perioperative cardiovascular risk (myocardial infarction, heart failure, death)2

Major predictors that require intensive management and may lead to delay in or cancelation of the operative procedure unless emergent

Unstable coronary syndromes including unstable or severe angina or recent MI

Decompensated HF including NYHA functional Class IV or worsening or new-onset HF

Significant arrhythmias including high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with ventricular rate >100 bpm at rest, symptomatic bradycardia and newly recognized ventricular tachycardia

Severe heart valve disease including severe aortic stenosis or symptomatic mitral stenosis

Other clinical predictors that warrant careful assessment of current statusHistory of ischemic heart disease

History of cerebrovascular disease

History of compensated heart failure or prior heart failure

Diabetes mellitus

Renal insufficiency

Hospital-acquired Infections Costly, Preventable

A program to reduce hospital-acquired infections can save an average of $1.1 million a year, according to results of a new study. In 2002, one in every 20 hospitalized patients developed a healthcare-associated infection (HAI), making HAIs one of the leading causes of death and illness in the US, and costing upto $33 billion dollars, according to the Dept. of Health and Human Services (HHS). The 1.7 million reported HAIs resulted in an estimated 99,000 deaths in that year, wrote Hugh Waters, MS, PhD, of Johns Hopkins Bloomberg School of Public Health, and colleagues in the September/October issue of the American Journal of Medical Quality. (Source: Medpage Today)

ReferencesFleisher LA, Beckman JA, Brown KA, et al. Circulation 2009;120(21):e169-276.

J Am Coll Cardiol 2007;50(17):e159-241.

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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

A BASE OF 1 LACREADERSHIP

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Evaluation of Creatine Kinase as a Diagnostic Tool for Thyroid Function

Thyroid gland is located in the neck, anterior to trachea. It consists of two lobes that are connected by an

isthmus. The gland produces hormones which play a great role in control of basal metabolic rate (BMR), general body metabolism, growth, development and tissue differentiation. Thyroid dysfunction is one of the most common endocrinological disorders. Consequently, abnormalities of these hormones frequently involve many organ systems producing diverse clinical signs and symptoms which are generally nonspecific. Thus confirmation of a provisional diagnosis of thyroid disorder rests largely upon biochemical parameters.1

The commonly used parameters for assessment of thyroid function are estimation of thyroid stimulating hormone (TSH), total tri-iodothyronine (T3), total thyroxine (T4), free T3 (FT3) and free T4 (FT4). Out of these, TSH has been accepted as the initial screening test. This is because serum level of TSH has been documented to reflect the integrative action of thyroid hormone on the tissue most sensitive to circulating thyroid hormones, the pituitary.2

However, the abnormal TSH level necessitates the use of other indicators of thyroid status including total and free T3 and T4. None of these parameters have proven to be ideal as their measured levels tend to vary in conditions like pregnancy, use of oral contraceptives, protein wasting diseases, liver disease, certain drugs and heparin, etc.3 The inherent limitations of these parameters necessitate the establishment of alternate markers and enzymes like transaminases, lactate dehydrogenase (LDH) and creatine kinase (CK). Among these, CK has shown promising results as a diagnostic tool for thyroid disease.

Serum CK was first used as a diagnostic aid in progressive muscular dystrophy.4 It has since then become an important clinical marker for muscle damage. The serum CK levels in healthy individuals depend on age, race, lean body mass and physical activity.4-6 Musculoskeletal disorders often accompany thyroid dysfunction. In addition to well-known observation that musculoskeletal disorders are common

KMDS Panag, Gitanjali, Sudeep Goyal

Cover Story

in patients with hypothyroidism, they are also observed in thyrotoxicosis and level of CK is altered in both these conditions.7 In recent years, studies have been conducted to establish a relationship of CK levels in thyroid diseases.8 Skeletal muscle is affected by hypothyroidism more profoundly in cases of overt hypothyroidism and less so, when subclinical hypothyroidism is present.9,10

Thus, it follows that assay of CK activity in serum may prove to be valuable in screening of thyroid disorders and in the present study, we tried to evaluate the role of CK as an alternative diagnostic tool in patients of thyroid disorder.

Material and MethodsThe study was done at GGS Govt. Medical College, Faridkot. The study group comprised of 100 patients randomly selected from patients coming for thyroid function tests in the biochemistry diagnostic laboratory. There were 60 hypothyroid cases and 40 hyperthyroid cases. Fifty age, sex and socioeconomic status-matched persons were taken as controls. Exclusion criteria was taken to rule out other diseases which can alter the results of study like cardiovascular, neuromuscular involvements, recent cerebral stroke, gross hepatic or renal dysfunction and pulmonary infarction. All patients were screened for any drug history, especially drugs which can affect CK or thyroid hormone levels. Recent history of intramuscular injections, strenuous exercise was ruled out. Informed written consent was obtained for venepunture. Venous blood was withdrawn for investigations taking all aseptic precautions. Serum was separated and investigated either immediately or it was preserved at 2-80 C for upto three days for CK measurement.

FT3 and FT4 were measured by competitive enzyme-linked immunosorbent assay (ELISA). TSH was measured by quantitative ELISA using Monobind kits.

CK was measured by modified IFCC method-based on the principle that ATP formed by reaction of CK with creatine phosphate and ADP reacts with glucose to form glucose

AbstractThyroid disorders are very commonly affecting the general population, even the persons residing in nongoitrous areas are no exception. Currently used tests for the assessment of thyroid functions (TSH, T3 and T4) are not sometimes sufficient to clearly make out the diagnosis as T3 and T4 levels are affected by so many other nonspecific conditions. The present study was done to evaluate the role of alternative biochemical parameter, creatine kinase (CK), in diagnosing thyroid disorders. Sixty hypothyroid and 40 hyperthyroid patients were compared with fifty age, sex and socioeconomic status-matched healthy controls. FT3, FT4 and TSH levels were measured by ELISA method and CK levels were measured by modified IFCC method. In hypothyroid patients, significant increase in CK levels was found as compared to control group (190 ± 40 IU/l in hypothyroid patients and 100 ± 70 IU/l in control group). A negative correlation was also found between FT3 and CK (r = –0.51; p < 0.005). In patients of hyperthyroidism, the levels of CK were found to be on the lower side. It was concluded that CK measurements may be useful as an alternative diagnostic tool for the diagnosis of thyroid function disorders, which may be not only because of prevalence of muscular dystrophies in thyroid disorders but also due to role of FT3 in gene expression.

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6 phosphate, which reduces NADP to NADPH. The rate of reduction of NADP to NADPH is measured at 340 nm.

ResultsThe present study was conducted to evaluate the levels of CK in hypothyroid and hyperthyroid patients. The study and control groups were compared according to age, sex distribution and routine investigations were done which showed insignificant results. Table 1 shows the levels of the four parameters TSH, FT3, FT4 and CK in control and study groups.

The mean values of FT3 and FT4 in hypothyroid patients were 1.4 ± 0.41 pg/dl and 0.82 ± 0.20 ng/ml, respectively. TSH levels were 20.11 ± 13.57 mIU/l. The mean values of FT3 and FT4 in hyperthyroid patients were 5.82 ± 2.39 pg/dl and 3.5 ± 1.80 ng/ml, respectively. TSH level was 0.18 ± 0.18 mIU/l. The mean value of FT3 and FT4 in control patients was 2.8 ± 0.64 pg/dl and 1.3 ± 0.17 ng/ml, respectively. TSH level was 2.50 ± 0.80 mIU/l.

The CK values in the three groups were 190 ± 40, 60 ± 30 and 100 ± 70 IU/l in hypothyroid, hyperthyroid and normal individuals, respectively.

level of over 29,000 IU/l. Such a high serum CK level in a patient with hypothyroid underscores the importance of assessing thyroid function in patients with weakness, regardless of serum CK levels, even when systemic symptoms and signs of hypothyroidism are minimal or absent.13 In case studies, patients with hypothyroidism solely presented with symptoms of myositis and very high levels of CK which resolved after treatment for hypothyroidism14 and in a patient of Grave’s disease, patient developed myalgia with high level of CK after total thyroidectomy, the features were normalized after treatment and again reappeared after treatment was stopped.15 These studies clearly show that muscular involvement was there in thyroid disorders. In hypothyroid patients with decrease in serum T3, there is significant increase in CK and this may be in fact used as a parameter for screening hypothyroid patients.16

In the present study, similar results were found showing increased levels of CK in hypothyroid patients and decreased CK in hyperthyroidism. Also, there was a negative correlation between FT3 and TSH.

Some authors suggest direct role of T3 at the regulation of gene expression. It has been shown to induce or repress production of different proteins by increasing or decreasing transcription.17,18 Authors have studied thyroid hormone-dependent gene expression in differentiated embryonic stem cells which were induced or repressed in response to T3.Very high levels of FT3 have been documented to inhibit protein synthesis.19

It is concluded from these findings that measurement of CK may act as a good tool to diagnose hypothyroidism not only because of well-documented muscular dystrophy in thyroid patients but also because of negative correlation between FT3 and CK possibly-mediated at the level of gene expression.

ReferencesSaha M, Sarkar P, Chattopadhyay R, Mukhopadhyaya M, Bhowmick K. Role of creatine kinase and its coenzymes as surrogate markers of thyroid function. IJMB 2009;13(2):10-4.

Spencer CA. Strategy for use of serum thyrotrophin vs. free thyroxine measurement in thyroid testing. AACC Endo 1991;10:9-17.

Whitley RJ. Thyroid functions in Burtis CA, Ashwood ER (Eds.) Teitz Fundamentals of Clinical Chemistry. 5th edition, WB Saunders, 2001:842.

Ebashi S, Toyokura T, Momoi H, Sugita H. High creatine phosphokinase activity of sera of progressive muscular dystrophy patients. J Biochem 1959;46:103-4.

Rosalki SB. Enzyme assays in diseases of the heart and skeletal muscle. J Clin Pathol (Assoc Clin Pathol) 1970;4:60-70.

Meltzer HY. Factors affecting creatine phosphokinase levels in the general population: the role of race, activity and age. Clin Chim Acta 1971;33(1):165-72.

Cakir M, Samanci N, Balci N, Balci MK. Musculoskeletal manifestations in patients with thyroid disease. Clin Endocrinol 2005;59(2):162-7.

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Parameter Control Hypothyroid HyperthyroidFT3 (pg/dl) 2.8 ± 0.64 1.4 ± .41 5.82 ± 2.39

FT4 (ng/ml) 1.30 ± 0.17 0.82 ± 0.20 3.5 ± 1.8

TSH (mIU/l) 2.50 ± 0.80 20.11 ± 13.57 0.18 ± 0.18

CK (IU/l) 100 ± 70 190 ± 40 60 ± 30

(Cont’d on page 10...)

A negative correlation was found between FT3 and CK (r = –0.51; p<0.005).

DiscussionThe study was done to evaluate the role of CK as a supportive parameter for diagnosing hypothyroid or hyperthyroid individuals. The levels of CK are found to be significantly higher in patients of hypothyroidism as compared to normal individuals which may be because of skeletal muscle involvement in thyroid disorders. Hekimsoy et al, in a study conducted in 2005, found that skeletal muscle is affected by hypothyroidism more profoundly in cases of overt hypothyroidism as compared to subclinical hypothyroidism. Also, there was positive correlation between CK and TSH (r = 0.432; p = 0.04), a negative correlation was found between FT3 and CK (r = –0.556, p = 0.002).11 Giampietro et al in 1984, found myoglobin and CK to be the best indicators of hypothyroid myopathy, since they are sensitive for the early detection of muscle involvement due to metabolic disorder and are closely correlated to the metabolic condition of patients.12

Scott et al in a study conducted in 2002, showed that thyroid hormone replacement therapy resulted in resolution of clinical symptoms and a marked reduction in CK levels in a patient with progressive proximal weakness and serum CK

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Case ReportCarcinoma of Esophagus in Young

Carcinoma of esophagus in young is not common. Till now only five cases have been reported in the world,

in pediatric age group. Squamous cell carcinoma and adenocarcinoma are the most common types. Squamous cell carcinoma is the most commonest, usually affects the upper two-third of the esophagus. Adenocarcinoma affects the lower one third. Carcinoma esophagus occurs probably due to a combination of fungal contamination of food with the production of a carcinogenic mycotoxin, together with nutritional deficiencies, tobacco and alcohol. Only 5-10% of those diagnosed will survive for five years. Despite this gloomy prognosis, there are some encouraging signs of change. The poor prognosis of esophageal cancer is due to its local and systemic spread.

Case HistoryA 12-years-old female came with c/o difficulty in swallowing for six months - gradual in onset, progressive in nature, both for solids and liquids. History of regurgitation of food. History of loss of appetite and loss of weight was also present. No history of voice change/blood in vomitus. Constipation was present. Bladder habits were normal.

ExaminationOn general examination, patient was found to be emaciated, conscious, oriented and afebrile. Vitals were found to be stable. Pallor was present. She was not cyanosed. There was no significant lymphadenopathy. Systemic examination was found to be within normal limits. Local examination of ear, nose and throat using headlight was normal.

InvestigationsHemoglobin was found to be low. TC, DC, ESR, platelet count and urine routine examination were found to be normal. Smear study showed microcytic hypochromic anemia. Video laryngoscopy of hypopharynx was found

to be normal. Barium swallow demonstrated irregular, persistent, intrinsic filling defect in the upper esophagus. Foreign body impaction was suspected due to the age of the patient. Patient was prepared for esophagoscopy for the removal of foreign body. On esophagoscopy a mass was seen at about 5-6 cm from the cricopharynx. It was whitish to grey in color occluding the lumen but for a small passage on the left side. Biopsy was taken from the mass and sent for histopathological examination in two centers. One reported fungal elements (branching fungi). Another reported as infiltrative squamous cell carcinoma with typical keratin pearls. For confirmation third biopsy was planned. which confirmed infiltrating squamous cell carcinoma. CT scan - chest and abdomen, bronchoscopy was planned but it could not be done due to platypnea. USG abdomen was done to rule out liver secondaries, and lymphadenopathy but it was found to be within normal limits. Liver function tests were also found to be normal. Chest X-ray showed mediastinal widening.

ManagementSupportive treatment was given in the form of intravenous fluids, nasal oxygen and high protein liquid diet. Though, she was planned for thoracotomy and debulking of tumor, she died due to respiratory distress.

InferenceOut of the five cases2-,6 reported in the internet on squamous cell carcinoma of esophagus in young i.e. below 16 years, three cases are from India. It is therefore important that any young patient coming with typical progressive dysphagia should not be ignored and has to be evaluated thoroughly irrespective of the age of the patient.

ReferencesAllam AR, Fiaz M, Fazili FM, Khawaja FI, Sultan A. Esophageal carcinoma in a 15-year-old girl: a case report and review of the literature. Ann Saudi Med 2000;20(3-4):261-4.

Aryya NC, Lahiri TK, Gangopadhyay AN, Asthana AK. Carcinoma of the esophagus in childhood. Pediatr Surg Int 1993;8(3):251-2.

Shahi UP, Sudarsan, Dattagupta S, Singhal S, Kumar L, Bahadur S, et al. Carcinoma esophagus in a 14-year-old child: report of a case and review of literature. Trop Gastroenterol 1989;10(4):225-8.

Soni NK, Chatterji P. Carcinoma of the oesophagus in an eight-year old child. J Laryngol Otol 1980;94(3):327-9.

Tampi C, Pai S, Doctor VM, Plumber S, Jagannath P. HPV- associated carcinoma of esophagus in young. Int J Gastrointest Cancer. 2005;35(2):135-42.

Hedawoo JB, Nagdeve NG, Sarve GN. Squamous cell carcinoma of esophagus in a 15-year-old boy. J Indian Assoc Pediatr Surg 2010;15(2):59-61.

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6.Figure 1. Showing squamous cell carcinoma with typical keratin pearls.

Figure 1. Showing branching fungi.

M Prakash, AP Sambandham

AbstractCarcinoma of esophagus in young1 is a rare clinical entity. A case of carcinoma esophagus in young is being presented here. A high index of suspicion is required for its diagnosis.

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Fitness UpdatePlease Don’t Stop the Music

Do you listen to music while you exercise? New research published in the Journal of Clinical Sport Psychology suggests that you should, in order to reap maximum benefits from your workouts. Many researchers have found that music enhances exercise, and this study summarized all the relevant research on the benefits of listening to music during exercise. The authors of the article reviewed a total of 20 previous studies that examined the effects of adding music to exercise in different populations, and the results were clear: music benefits exercisers. Among the most prominent benefits of listening to music were increased motivation to exercise as well as improvement in exercise capacity and intensity. Some studies found that music was exceptionally helpful for patients undergoing cardiovascular or pulmonary rehabilitation or treatment for diseases such as Alzheimer’s and Parkinson’s. Other studies found that adding music to exercise increased elderly exercisers’ confidence and life satisfaction. The study concluded that music is most effective when it coincided with people’s own personal preferences.

Now, you have a great excuse to buy some new music for your mp3 player!

Exercise Decreases the Risk of Cancer RecurrenceA new report shows that although many doctors admit to advising their cancer patients and survivors to take it easy, this may not be the best advice. The report from Macmillan Cancer Support, the largest charity foundation in Great Britain, shows that exercising after a diagnosis or treatment for cancer may be an effective way to prevent recurrence and aid recovery. As long as exercise programs are low-impact and designed with the particular needs of the individual patient, they are safe and beneficial for cancer survivors. The report reviewed 60 studies and surveyed over 400 health professionals who work closely with cancer patients and found that lack of physical activities might be putting as many as 1.6 million cancer survivors in the UK at greater risk of long-term health problems with some at greater risk of cancer recurrence. The report also found that women with breast cancer who exercise for 150 minutes a week at moderate intensity are 40% less likely to experience disease recurrence, as compared to women who were active for less than an hour a week.

The report concludes by recommending that doctors and other health professionals prescribe exercise to all cancer survivors.

Studies Show 15 minutes of Daily Exercise Makes a Big DifferenceIt’s still no excuse to slack off. Regular exercise strengthens muscles, reduces the risk of some diseases and promotes mental well-being. The more exercise, the better. But not everyone has the time or willpower. So researchers set out to find the minimum amount of physical activity needed to reap health benefits. The findings by a study in Taiwan suggest just 15 minutes of moderate exercise a day can lead to a longer life.

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

One couldn’t get a taxi.

The one that struck me was the man who put on a new pair of shoes that morning, took the various means to get to work but before he got there, he developed a blister on his foot. He stopped at a drugstore to buy a Band-Aid. That is why he is alive today.

Now when I am stuck in traffic…Miss an elevator…Turn back to answer a ringing telephone…All the little things that annoy me…I think to myself…

This is exactly where God wants me to be at this very moment. The next time your morning seems to be going wrong, the children are slow getting dressed, you can’t seem to find the car keys, you hit every traffic light…Don’t get mad or frustrated; God is at work watching over you.

May God continue to bless you with all those annoying little things - and may you remember and appreciate their possible purpose.

An Inspirational Story

Appreciate Life’s Annoying Little Things

Lessons from 9/11:As you might know, the head of a major company survived the tragedy of ‘9/11’ in New York because his son started kindergarten.Another fellow was alive because it was his turn to bring doughnuts.One woman was late because her alarm clock didn’t go off in time.One was late because of being stuck on the NJ Turnpike because of an auto accident.One of them missed his bus.One spilled food on her clothes and had to take time to change.One’s car wouldn’t start.One went back to answer the telephone.One had a child that dawdled and didn’t get ready as soon as he should have.

An Inspirational Story

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Legal ColumnIndian hemp, hashish, ganja, pot, dope and grass, is made from the Indian hemp plant Cannabis sativa

Cannabis is often abused and, in some countries it is used almost as much as alcohol or tobacco and considered as aphrodisiac agent. It makes people feel relaxed and makes colors and sounds seem brighter and louder. The dried plant is made into cigarettes or put in a pipe and smoked. Sometimes it is taken with food also however some people inject it too.Cannabis adversely affects the brain, however it does not cause much harm to adults, unless it is injected. The signs and symptoms start within 10 minutes of smoking the drug and last for about 2-3 hours.When the drug is eaten, the effects start within 30-60 minutes and last for 2-5 hours. The main effects are a feeling of well-being, happiness and sleepiness, but high doses may cause fear, panic and confusion, the person cannot balance when standing up, hallucinations, drowsiness, slurred speech, coughing if the drug is breathed in, as when smoking cigarettes.

Cannabis is also Known as Marijuana If the drug is injected it may cause more serious problems severe headache, dizziness, irregular breathing, fever, low blood pressure and unconsciousness.If the patient is unconscious or drowsy, lay him or her on one side in the recovery position. Check breathing every 10 minutes. A patient who is anxious or confused should be kept in a quiet, warm room. If the cannabis was swallowed: There is no need to make the patient vomit. If the patient is fully awake, breathing normally and not vomiting, gives activated charcoal and water to drink.If the patient is hallucinating or violent, give chlorpromazine, 50-100 mg an adult dose, intra-muscularly.If cannabis has been injected, monitor breathing, pulse, blood pressure, temperature. Supportive care, including oxygen and mechanical ventilation, should be given as needed: Low blood pressure should be treated by keeping the patient lying with the feet higher than the head; intravenous fluids can be given.

—Dr Sudhir Gupta, Additional Professor, Forensic Medicine & Toxicology, AIIMS)

Mean blood sugar = A1C (1) × 25 sugar value (mg/dl)

For example: Mean A1C = 5%

Blood sugar = 25 × 5

= 125 mg/dl

Sugar mg/dl = Sugar (mmol/l) × 18

For example:

Sugar = 5 mmol/l × 18

= 90 mg/dl

Sugar (mmol/l) = For example:

Sugar = 180 mg/dl

mmol/l =

= 10 mmol/l

Sugar (mg/dl)18

180 18

Diabetology Lab Formulae Conversion Formulae Hyperammonemia

Ureterosigmoidostomy

Shock

Severe muscle exertion/heavy exercise

Cigarette smoking

Reye’s syndrome

Gastrointestinal bleeding

Renal disease

Urinary tract infection with a urease-producing organism (e.g. Proteus mirabilis)

Any cause of portasystemic shunting of blood

Parenteral nutrition

Transient hyperammonemia in newborns

Certain inborn errors of metabolism (urea cycle defects and organic acidemia)

After high-dose chemotherapy

Drugs such as:Valproic acidBarbituratesNarcoticsDiureticsAlcohol

Salicylate intoxication

Differential Diagnosis

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Expert ’s OpinionGastro Update

What is the nutritional management of IBD?Nutrition is an integral part of the management of children with IBD, and nutritional status should be assessed at presentation and at follow-up. Exclusive enteral nutritional therapy modifies disease in children with Crohn’s disease (CD). There are two types of enteral feeding: Elemental (amino acids + short-chain fatty acids + short-chain carbohydrates + vitamins) and polymeric (whole protein). Elemental diets are very useful but are unpalatable, so polymeric diets are preferred in children. Therapy lasts for six weeks followed by gradual re-introduction of normal diet. Nutritional support should be considered as an adjunctive therapy for any patient with CD or ulcerative colitis (UC) with malnutrition. Nasogastric/gastrostomy tube feeding can be considered.

—Dr Neelam Mohan, Director, Pediatric Gastroenterology,

Hepatology and Liver Transplantation, Medanta – The Medicity

Can ondansetron be used for gastro-enteritis in children? A large retrospective study from two pediatric emergency departments showed the use of oral ondansetron to reduce vomiting in children with presumed gastroenteritis. It does not increase the risk of missing other serious alternate causes of vomiting. Alternate diagnoses included appendicitis, intussusception, bacteremia, pyelonephritis, small bowel obstruction and intracranial tumor. This study also confirmed previous observations that ondansetron therapy reduced the rate of hospital admissions for gastroenteritis (3.7 vs 6.4%).

Ann Emerg Med 2010;55:415.

Lab UpdatePlasminogen This test is used to evaluate thromboembolic disorders, including ligneous conjunctivitis (a type of mucous membrane abnormality).This test is normally prescribed when searching for the following diseases:

Disorder involving the fibrinolytic systemLigneous conjunctivitis

High levels of plasminogen can be seen in:Pregnancy (peak of 165% of normal in third trimester)Increased triglyceride and/or cholesterol levels

Low levels of plasminogen can be seen in:Liver diseaseConsumptive coagulopathiesFibrinolytic therapyDICAdvanced age

—Dr Arpan Gandhi and Dr Navin Dang

Rabies UpdateWhat does Humanizing Your Dog Mean?

Talking to your dog like he/she is a person.

Treating your dog like he/she is a person.

Allowing dogs to do what they want as otherwise it would hurt their ‘feelings.’

My personal favorite - dressing them up in little doggie clothes.

Remember, humanizing your dog is fulfilling your own human needs, not your dogs.Humanizing dogs does more harm than good. Dogs are dogs - not humans!

—Dr AK Gupta, Author of “RABIES – The worst death”

A man goes to his doctor for a complete check-up. He hasn’t been feeling well and wants to find out if he’s ill. After

the check-up the doctor comes out with the results of the examination.

“I’m afraid I have some bad news. You’re dying and you don’t have much time,” the doctor says.

“Oh no, that’s terrible. How long have I got?” the man asks.

“10...” says the doctor.

“10? 10 what? Months? Weeks? What?!” he asks desperately. “10...9...8...7...”

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News & Views

FDA to Test New Ways to Trace Food

The FDA has announced the start of two pilot programs to help develop new tracking systems that will allow investigators to identify sources of foodborne disease outbreaks more quickly than is now possible. One of the programs focuses on processed foods, while the other targets raw fruits and vegetables. They mainly emphasize more detailed recordkeeping in the food production and distribution industries. (Source: Medpage Today)

FDA Panel Waffles on Limiting Duration of Bisphosphonate UseAn FDA advisory committee wants the agency to limit the duration of bisphosphonate therapy for treatment of osteoporosis, but the committee could not agree on what that time limit should be. (Source: Medpage Today)

Nocturnal ACS Linked to Belly Fat, Disordered Sleep

Night-time acute coronary syndrome (ACS) occurred significantly more often in patients with visceral fat accumulation and sleep-disordered breathing, investigators reported. Among 25 patients with night-time onset of ACS, two-thirds of those with ≥100 cm2 of visceral fat accumulation also had sleep-disordered breathing as compared with a fourth of patients with less visceral fat. In contrast, sleep-disordered breathing occurred in a similar proportion of patients with and without visceral fat and daytime-onset ACS. ACS during sleep occurs infrequently, and predisposing factors remain unclear but could include disordered sleep and obstructive sleep apnea (OSA). Patients with OSA have an increased risk of sudden cardiac death with night-time onset, the authors noted in their introduction. (Source: Medpage Today)

Bird Flu Back Again, UN Agency Warns

A new vaccine-resistant strain of avian H5N1 influenza has begun circulating in poultry flocks in Vietnam and China, posing ‘unpredictable risks to human health,’ the Food and Agriculture Organization (FAO) warned on Monday. “In Vietnam, which suspended its springtime poultry vaccination campaign this year, most of the northern and central parts of the country - where H5N1 is endemic - have been invaded by the new virus strain, known as H5N1 - 2.3.2.1,” the FAO said in a statement. No cases of human infection with the novel strain have yet reported by the FAO or its sister group, the World Health Organization. Vietnam has remained free of human infections with any avian H5N1 strains this year, according to WHO. (Source: Medpage Today)

Infant UTI Guidelines Include Ultrasound

Updated guidelines from the American Academy of Pediatrics (AAP) recommend urinalysis and culture when a urinary tract infection (UTI) is suspected or when antibiotic treatment will be started empirically in children 2-24 months. In first UTI the new guidelines recommend renal and bladder ultrasound with no voiding cystourethrogram (VCUG) unless the ultrasound is suggestive of anatomic abnormalities, and follow-up but no antimicrobial prophylaxis. The guidelines were published in Pediatrics.

In-school Screening Picks up Mental Health Issues

School-based mental health screening identifies troubled kids and helps get them into care, researchers found. A screening program in Wisconsin high schools found that nearly 20% of those assessed had mental health conditions, and about three-quarters of these students weren’t currently receiving treatment, Mathilde Husky, MD, of Columbia University, and colleagues reported in the September issue of the Journal of the American Academy of Child & Adolescent Psychiatry. This “highlights the extent of unmet need and reinforces the importance of proactive screening as a means of uncovering previously unidentified individuals at risk,” they wrote. (Source: Medpage Today)

FDA Approves Icatibant for Rare Swelling Condition

The FDA has approved the injectable drug icatibant (Firazyr) to treat acute hereditary angioedema (HAE) attacks, making it the first such medication available in the US that patients with the rare genetic condition can administer themselves. Patients with HAE suffer periodic, painful attacks of severe swelling in various parts of the body including hands, feet, face, abdomen and sometimes the throat, which can cause airway restriction. It is caused by a deficiency in the C1 esterase enzyme, which regulates inflammatory and coagulation responses. Defective C1-inhibitor can cause a biochemical imbalance that can produce unwanted peptides, which, in turn, induce the capillaries to release fluids into surrounding tissues, causing the swelling. (Source: Medpage Today)

FDA Update

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Conference Calendar1st Global Forum on Bacterial Infections: Balancing Treatment Access and Antibiotic ResistanceOctober 3-5, 2011 Venue: India Habitat Centre, New Delhi, IndiaWebsite: http://www.globalbacteria.org

10th European Federation of Internal Medicine Congress (EFIM 2011)October 5-8, 2011 Venue: Athens Hilton Hotel, Athens, GreeceWebsite: http://www.efim2011.org

Seventh International Conference on Sustainable DevelopmentOctober 5-6, 2011 Venue: Ebitimi Banigo Auditorium, University of Port Harc, Port Harcourt, NigeriaWebsite: http://www.irdionline.org

V Congress of TransplantologistsOctober 5-7, 2011 Venue: Congress Hall, Kharkiv, UkraineWebsite: http://www.nbscience.com/26.html

VII Congress of PediatriciansOctober 11-12, 2011 Venue: Congress Hall, Kiev, UkraineWebsite: http://www.nbscience.com/27.html

EUFEP Congress 2011 - Focus: Cancer PreventionOctober 12-13, 2011 Venue: Kloster Und, Krems, Lower Austria, AustriaWebsite: http://eufep.at

American Association of Integrative MedicineOctober 12-14, 2011 Venue: Branson Convention Centre, Branson, Missouri United StatesWebsite: http://www.aaimedicine.com/conference/

EAACI Pediatric Allergy and Asthma MeetingOctober 13-15, 2011 Venue: Convention Centre, Barcelona, SpainWebsite: http://www.eaaci-paam2011.com

7th Asia Pacific Congress in Maternal Fetal MedicineOctober 14-16, 2011 Venue: Kuala Lumpur Convention Centre, Kuala Lumpur, MalaysiaWebsite: http://www.apcmfm.hk

2nd International Conference on Stem Cells and Cancer (ICSCC-2011)October 15-18, 2011 Venue: Yashada Auditorium Pune, Maharashtra, IndiaWebsite: http://www.stemcells.org.in/?page_id=37

New TB vaccines for the futureOctober 17-18, 2011 Venue: Salón de ActosFundación Ramón ArecesVitruvio, 5 . 28006 MadridVenue: Madrid, SpainWebsite: http://www.tbvi.eu/news-agenda/events/event/symposium-new-tb-vaccines-for-the-future-17-18-october-madrid.html

Autoimmune Rheumatic Diseases: Current Areas of Early Diagnosis and Treatment Monitoring of Patients and Prevention of ComplicationsOctober 20-21, 2011 Venue: Congress Hall, Kiev, Ukraine Website: http://www.nbscience.com/28.html

2011 Connected Health Symposium: Driving Quality Up and Costs Down: New Technologies for an Era of AccountabilityOctober 20-21, 2011 Venue: Oston Park Plaza Hotel & TowersBoston, MA, United StatesWebsite: http://connected-health.org/events/symposium-2011.aspx

Acute and General Medicine for the PhysicianOctober 24-26, 2011 Venue: Royal College of Physicians, London, United KingdomWebsite: http://events.rcplondon.ac.uk/details.aspx?e=2213

The Canadian Conference on DementiaOctober 27-29, 2011 Venue: Hyatt Regency Hotel, Montreal, Ontario, CanadaWebsite: http://www.canadianconferenceondementia.com

Finsterer J, Stellberger C, Grossege C, Koroiss A. Hypothyroid myopathy with unusually high serum creatine kinase. Horm Res 1999;52(4):205-8.

Hekimsoy Z, Oktem IK. Serum kinase levels in overt and subclinical hypothyroidism. JPN Heart J 2004;45(6):1071-7.

Sakaki T, Fujioka Y, Akagami T, Masai M, Shimizu H, Sakoda T. Cardiac wall motion abnormalities observed in a patient with transient hyperthyroidism. Clin Endocrinol (Oxf) 2003; 59(2):162-7.

Hekimsoy Z, Oktem IK. Serum creatine kinase levels in overt and subclinical hypothyroidism. Endocr Res 2005;31(3):171-5.

Carpi A, Giampietro O, Clerico A, Buzzigoli G, Del Chicca MG, Beni C, Capri A. Detection of hypothyroid myopathy by measurement of various serum muscle markers - myoglobin, CK, LDH and their isoenzymes. Correlation with thyroid hormone levels (free and total) and clinical usefulness. Horm Res 1984;19(4):232-42.

Scott KR, Simmons Z, Boyer PJ. Hypothyroid myopathy with a strikingly elevated serum creatine kinase level. Muscle Nerve 2002; 26(1):141-4.

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Madhu SV, Jain R, Kant S, Parkash V, Kumar V. Myopathy presenting as a sole manifestation of hypothyroidism. J Assoc Physicians India 2010;58:569-70.

Shaheen D, Kim CS. Myositis associated with decline of thyroid hormone levels in thyrotoxicosis: a syndrome. Thyroid 2009;19(12):1413-7.

Prakash A, Lal AK, Negi KS. Serum creatine kinase activity in thyroid disorders. J K Sciences 2001;9(1):25-6.

Tsai MJ, O’ Malley BW. Molecular mechanism of action of steroid/thyroid receptor super-family members. Annu Rev Biochem 1994; 63:451-86.

Liu YY, Brent GA. Thyroid hormone-dependent gene expression in differentiated embryonic stem cells and embryonal carcinoma cells: identification of novel thyroid hormone target genes by deoxyribonucleic acid microarray analysis. Endocrinology 2005; 146(2):776-83.

Granner DK. Thyroid hormones. In: Harper’s Biochemistry, 25th edition, Murray RK, Granner DK, Mayes PA, Rodwell VW(Eds). Appleton & Lange 2000:565.

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Humor

I l l u s I o n

Dr. Good and Dr. BadSItuAtION : A 25-year-old male with normal body mass index

(BMI) came with mild abdominal obesity.

Dr KK Aggarwal

leSSON : Indians are susceptible to diabetes at a younger age and at a relatively lower BMI compared to the white Caucasians. This is partly explained by the fact that the thin-looking Indians are quite adipose (higher body fat percent).

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