Presentation includes an account on overview about oral anti diabetics, toxicity of sulfonylureas, biguanides, alpha-glucosidase inhibitors, DPP4 inhibitor, SGLT2 inhibitor and its managemnt.
Exercise Testing in Cardiology : Dr. Akif Baigakifab93
The testing modality and protocol should be selected in accordance with the patient’s estimated functional capacity based on age, estimated physical fitness from the patient’s history, and underlying disease
Several exercise test protocols are available for both treadmill and stationary cycle ergometers
Patients who have low estimated fitness levels or are deemed to be at higher risk because of underlying disease (e.g., recent MI, heart failure) should be tested with a less aggressive exercise protocol
Treadmill and cycle ergometers may use stepped or continuous ramp protocols
Work rate increments (stages) during stepped protocols can vary from 1 to 2.5 METs
Ramp protocols are designed with stages that are no longer than 1 minute and for the patient to attain peak effort within 8 to 12 minutes
The natriuretic peptide system works antagonistically to the RAAS and has favorable effects on the pathogenesis of heart failure
Natriuretic peptides are broken down by an enzyme called neprilysin
Neprilysin is also responsible for the breakdown of other substances, including bradykinin and angiotensin II
Sacubitril/valsartan is a combination product
Sacubitril is a pro-drug that, upon activation, acts as a neprilysin inhibitor
It works by blocking the action of neprilysin, thus preventing the breakdown of natriuretic peptides
This leads to a prolonged duration of the favorable effects of these peptides
Coronary heart disease (CHD) remains a leading cause of death worldwide, accounting for 16% of total deaths globally .
Atherosclerosis plays a central role, with early fatty streaks progressing to late complex atheromas
Vascular calcification, the pathogenic and process of ectopic bone production, specifically was shown to strongly correlate with degree of atherosclerosis (both calcified and noncalcified)
Vascular calcification was shown independently to predict cardiovascular morbidity and mortality
These associations, combined with the radio-opaque appearance of calcium hydroxyappatite on CT images, have led to extensive investigation of the quantification, or scoring, of coronary artery calcium (CAC).
CAC scoring has emerged as a widely available and powerful tool for stratifying cardiovascular risk, predicting patient outcomes, and guiding preventive therapy
A coronary bifurcation consists of a flow divider (carina) and three vessel segments:
The proximal main vessel (PMV)
The distal main vessel (DMV) and
The side branch (SB).
A bifurcation lesion is a major epicardial coronary artery stenosis next to and/or including the ostium of a significant side branch
A significant SB is a branch whose severe narrowing or acute occlusion before or during intervention can cause considerable ischemia or a new infarction area that will worsen the clinical course of a particular patient.
Other important elements to consider that are not inherent in the bifurcation classifications include:
Extent of disease on the SB (limited to the ostium or involving the vessel beyond the ostium)
Its size (over 2.5mm in reference diameter)
Bifurcation angle, and
Disease distribution
Left ventricular (LV) dysfunction remains one of the
best prognostic determinants of survival in patients
with coronary artery disease (CAD)
⚫ It was originally thought that dysfunctional
myocardium after an infarction was irreversibly
damaged
⚫ However, it was later recognized that some of the
involved tissue remained viable and contractility may
be restored with revascularization
HCM is a common genetic heart disease reported in populations globally
Inherited in an autosomal dominant pattern
The distribution of HCM is equal by sex, although women are diagnosed less commonly than men
The prevalence of unexplained asymptomatic hypertrophy in young adults has been reported to range from 1:200 to 1:500
Tetralogy of Fallot (TOF) is a congenital heart defect, which has four anatomical components:
Anterior malalignment ventricular septal defect (VSD)
Aortic override over the muscular septum
Variable degrees of subvalvar, valvar, and supravalvar pulmonary stenosis
Right ventricular (RV) infundibular narrowing and RV hypertrophy
Ventricular septal defects occur either as an isolated defect or as a component of a more complex lesion
It occurs in 50 percent of all children with CHD and in 20 to 30 percent as an isolated lesion
Most common congenital cardiac anomaly in children
Second most common congenital abnormality in adults, second only to bicuspid aortic valves
They are more common in premature infants and those born with low weight
VSDs are slightly more common in females (56%)
Patients with peripheral artery disease who have undergone lower-extremity revascularization are at high risk for major adverse limb and cardiovascular events
The efficacy and safety of rivaroxaban in this context are uncertain
Most common cyanotic heart defect seen in children beyond infancy, accounting for a third of all congenital heart disease (CHD) in this age group
Tetralogy of Fallot (TOF) is a congenital heart defect, which has four anatomical components:
Anterior malalignment ventricular septal defect (VSD)
Aortic override over the muscular septum
Variable degrees of subvalvar, valvar, and supravalvar pulmonary stenosis
Right ventricular (RV) infundibular narrowing and RV hypertrophy
Bentracimab (also known as PB2452) is a neutralizing recombinant human immunoglobulin G1 monoclonal antibody antigen-binding fragment that binds ticagrelor and its major active circulating metabolite with high affinity and specificity
Chlorthalidone for hypertension in advanced ckdakifab93
Chlorthalidone, a thiazide-like diuretic, reduces cardiovascular morbidity, such as the incidence of stroke and heart failure, and cardiovascular mortality
However, its efficacy and safety among patients with advanced chronic kidney disease remain poorly understood
An acute illness caused by an autoimmune response to infection with group A Streptococcus, leading to a range of possible symptoms and signs affecting any or all of heart, joints, brain, skin and subcutaneous tissues
Amyloidosis is a group of protein-folding disorders in which >1 organ is infiltrated by proteinaceous deposits known as amyloid. Amyloid involvement of the heart (cardiac amyloidosis) carries the worst prognosis of any involved organ, and light-chain (AL) amyloidosis is the most serious form of the disease
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
2. Chloroquine
sensitive malaria
Chloroquine 10mg/kg bw stat dose followed by
10mg/kg on 2nd day
f/b
5mg/kg bw on 3rd day
or
Chloroquine 10mg/kg bw
f/b
5mg/kg at 6hr,24 hrs & 48hrs
Add Primaquine 0.25-0.5mg/kg bw/ day for 14 days only if
G6PD levels are normal
This chloroquine level resides for about 2-3 weeks in blood, thus prevents the first
Relapse of P.vivax which generally occurs at 3wks after onset of primary illness.
So relapses begin after 5-6wks of illness if not treated with Primaquine.
3.
4.
5. CHLOROQUINE
S/E:
- It is generally well tolerated in therapeutic doses of malaria
- Large doses used in treatment of Rheumatoid Arthritis are usually associated
with higher frequency of side effects
- Pruritis is a common side effect and is more severe in darkly skinned
individuals.
- Other rare side effects : 1) elevated liver enzymes
2) GI disturbances
3) convulsions, retinopathy and arrhythmias
Overdosages can be dangerous and can lead to death within hours.
Pt. may progress from feeling dizzy and drowsy with headache and gi upset to
sudden visual loss, convulsions, hypokalemia, hypotension and cardiac
arrhythmias
6. The most important side effect of Primaquine is hemolysis in G6PD deficient
Patients
Amount of hemolysis depends on dosage, duration of exposure and degree
of G6PD Deficiency
Primaquine is rapidly eliminated from the body. So hemolysis will stop once
the drug is stopped.
So Pt. being treated with Primaquine should be looked for anemia, red or black
urine and should be stopped immediately if present.
A single dose of 0.25mg/kg bw Primaquine as Gametocidal will not lead to
hemolysis even in G6PD deficient pt.
So it is not necessary to check G6PD status for single dose administration as
given in Falciparum malariae.
18. ARTESUNATE > ARTEMETHER > QUININE irrespective of whether patient is
A infant or pregnant or a lactating female.
Mortality from untreated severe malaria is almost 100%.
With effective treatment mortality reduces to 10-20%
If a pt. presents with severe anemia , there are more chances of survival as
compared to acidosis
Therapeutic objective : is to prevent the patient from dying
Artesunate Dosage : 2.4mg/kg
Studies have shown that artesunate dosage between 1.5-4mg/kg dose is not
associated with any toxicity
19.
20.
21. Artesunate and Post Treatment Hemolysis
- Starts 7days after treatment with Artesunate
- Between 2010 and 2012, there were 6 reports involving a total of 19 European
travellers with severe malaria who were treated with artesunate injection
and developed delayed hemolysis. Out of 6 , 1 was adult
Artesunate rapidly kills ring stages parasites
Taken out of RBCs by Spleen
This infected RBCs have a shorter life span
Leads to hemolysis
22. ARTESUNATE ARTEMETHER QUININE
- Water soluble and can
be given Intavenously
- Oily solution
- Should be given only
I.M
I.V or I.M both are
equally effective
Rapidly converts into
Dihydroartemisnin, the
active form.
Converts slowly Loading dose : 20mg/kg
f/b
10mg/kg every 8hrly
Artesunate powder is
diluted with 5ml of 5%D
and given I.V or I.M
Only I.M / Oral If no improvement in
48hrs, dose reduced to
10mg/kg every 12hrly
2.4mg/kg bw / dose 3.2mg/kg stat
f/b
1.6mg/kg daily
Shouldn’t be infused
rapidly.
- Dilute in 5%D and
infuse over 4hrs ( not
>5mg/kg/hour)
Dose adjustment is not required for Artemisnin derivatives in Liver or Kidney
diseases.
23. FOLLOW ON TREATMENT
- 24hrs parenteral f/b complete ACT
- In ACT, Artemisnin + Mefloquine should be avoided in Pt. presenting with
unconsciousness or altered consciousness.
- If ACT not available : Artesunate/Quinine + Doxycycline(7d)
or
Artesunate/Quinine + Clindamycin(preferred in Pregnancy)
24. MANAGEMENT OF COMPLICATIONS OF
SEVERE FALCIPARUM MALARIA
Coma
Hypoglycemia
Convulsions
Hyperpyrexia
Pulmonary edema
Severe anemia
Acute kidney injury
Coagulopathy
Metabolic acidosis
shock
25.
26. TREATMENT OF
SEVERE FALCIPARUM MALARIA
IN PREGNANCY
- Artesunate > artemether > quinine
- 2nd & 3rd trimester > 1st trimester
- Hypoglycemia and pulmonary edema
- Risk of mortality 50% more in pregnant > non pregnant
- Fetal demise and premature labor
- Teratogenic effects : decreases embryonic erythroblasts, cardiac myopathy
delay in limb and tail development
27. SEVERE VIVAX MALARIA
- Very rare
- Anemia, thrombocytopenia , acute pulmonary edema are common
TREATMENT
Parenteral Artesunate > Artemether > Quinine for 24hrs
f/b
ACT or Chloroquine
28.
29. 1) There is no liver stage since parasite directly enters blood
2) Hypnozoites are not found
3) Hence there is no relapse
4) No need for Primaquine
30. 1) Infective form to man = Sporozoites present in salivary glands of
Mosquito
2) Infective form to man in case of
blood transfusion
3) Infective form to mosquito = Gametocytes
- To infect mosquito, Gametocyte must be mature, viable, count >12per cubic mm.
merozoites
32. Recrudescence is due to persistence of drug resistant parasite.
In Falciparum : Disease appears after 2-3weeks of completion of treatment
In Malariae ; Disease appears very late almost after 60yrs.
-due to hypnozoites
-May reappear after2-3yrs
-Seen in P.vivax and ovale.
34. Plasmodium spcies Type of RBC
P.Vivax Young RBCs
P.Falciparum RBCs of all age
P.Ovale Reticulocytes /Young RBCs
P.Malariae Old RBCs
35. Sickle cell trait Protective from P.falciparum
Thallasemia trait Protective from P.falciparum
Fetal Hb Protective from P.falciparum
G6PD deficiency Protective from P.falciparum
Ovalocytosis Protective from P.falciparum
Duffy negative RBCs Protective from P.vivax
36. -It is a parasite of monkey but can also affect humans
-Early trophozoite resembles to P.falciparum
-Late trophozoite resembles to P.malariae
-Quotidian malariae
37. P.Vivax P.Falciparu
m
P.Malariae P.ovale
Forms seen
in
peripheral
blood smear
Early and late
trophozoites,
gametocytes
and schizonts
Ring forms
(early
trophozoites)
and
gametocytes
Similar to that
of vivax
Ring forms are
known as
Band forms.
Similar to that
of vivax
Gametocye Spherical,
almost
occupies RBC
Banana
shape, larger
than RBC
Similar to that
of vivax
Similar to that
of vivax
RBC size Enlarged Normal Normal enlarged
Stippling Schuffner’s
dots ( small
red dots)
Maurer’s
cleft( large
red spots)
Ziemann’s
dots
James dots
44. -Most potent and fastest acting schizonticidal drugs
-But have short duration of action, hence cant be used singly and has to be
combined with slower acting drugs
- Acts by producing free radicals and toxic heme products
-Since they produce free radicals, free radicals have teratogenic effect. Hence C.I
in 1st trimester. Can be given in 2nd and 3rd trimester
-Oral drugs : Artesunate, Artemether, Dihydroartemisnin
-Only i.v drug : Artesunate
ARTEMISNISNIN GROUP DRUGS
45. -I.V Artesunate is DOC in severe falciparum malaria
-Oral artesunate 200mg for 3 days is preferred in Chloroquine resistant malaria
-Not used for prophylaxis since it has short duration of action
-S/E:
GI side effects: Nausea, vomiting, Diarrehea
ARTEMISNISNIN GROUP DRUGS
46. -Enters vacuole of plasmodium and binds with haem and produces toxic heme
products which is cidal for plasmodium
-Resistance is due to efflux of drug from vacuole
-DOC for treatment and prophylaxis of malaria except falciparum
-It has high volume of distribution and hence loading dose has to be given.
-Other uses : Giardiasis
Amebiasis,
Infectious mononucleosis,
SLE,
RA
CHLOROQUINE
47. S/E:
C - Convulsions
H - Hemolysis in G6PD deficient pt.
L - Low blood pressure
O -Ocular : Bull’s eye maculopathy
R - qRs and T wave abnormalities
CHLOROQUINE
48. •Fast acting schizonticidal drugs
•Used in severe falciparum malaria and chloroquine resistant malaria
•Derived from bark of cinchona plant
QUININE and QUINIDINE
49. •Cinchonism : headache + tinnitus +Visual disturbance
•Hypotension : Due to Alpha-1 blocking effect
•Hypoglycemia : Due to insulin release. Hence given with
dextrose
•Black water fever : Inadequate therapy leads to
hypersensitivity
QUININE and QUINIDINE
S/E
50. •Used in treatment and prophylaxis of vivax
•Used along with artesunate in severe falciparum malaria
•S/E : Neuropsychiatric
MEFLOQUINE