Refeeding syndrome with Parenteral Nutrition in ESRDVishal Bagchi
After a sustained state of malnutrition or under-nutrition patients tend to exhibit symptoms of refeeding syndrome secondary to nutrition support received from oral or parenteral nutrition.
Define refeeding syndrome
Identify causes of refeeding syndrome with subjective and objective analysis
Acquire skills to manage refeeding syndrome during and after oral and/or parenteral nutrition support
Daily minimum nutritional requirements of the critically illRalekeOkoye
Critically ill patients have nutritional needs that are essential in their management. This is a synopsis with specific calculable applications for the daily recommended components of nutrition in critical care.
Refeeding syndrome with Parenteral Nutrition in ESRDVishal Bagchi
After a sustained state of malnutrition or under-nutrition patients tend to exhibit symptoms of refeeding syndrome secondary to nutrition support received from oral or parenteral nutrition.
Define refeeding syndrome
Identify causes of refeeding syndrome with subjective and objective analysis
Acquire skills to manage refeeding syndrome during and after oral and/or parenteral nutrition support
Daily minimum nutritional requirements of the critically illRalekeOkoye
Critically ill patients have nutritional needs that are essential in their management. This is a synopsis with specific calculable applications for the daily recommended components of nutrition in critical care.
A review of the investigation and management of diabetic ketoacidosis in newly diagnosed type I diabetes. Patient details have been changed and anonymised to protect the identity of the individual.
A review of the investigation and management of diabetic ketoacidosis in newly diagnosed type I diabetes. Patient details have been changed and anonymised to protect the identity of the individual.
Measurement for Improvement - Management of Acute Kidney Injury in primary c...Renal Association
Charlie Tomson, Consultant Nephrologist at theFreeman Hospital Newcastle upon Tyne and Chair of the Intervention Workstream, NHS England/UKRR Think Kidneys Programme
presented at a Measurement for Improvement event on 16th March.
This talk was delivered by Dr. Shashikiran Umakanth on 10 Jan, 2016 as part of CME on Infectious Diseases conducted by the Indian Medical Association, Udupi-Karavali branch, Karnataka, India.
Ulcerative Colitis: Case Presentation & Disease Overviewfarah al souheil
patient presenting with bloody stools and systemic signs with no previous medical complaints was diagnosed with amoebiasis on top ulcerative colitis (sigmoid-proctitis)
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
DISSERTATION on NEW DRUG DISCOVERY AND DEVELOPMENT STAGES OF DRUG DISCOVERYNEHA GUPTA
The process of drug discovery and development is a complex and multi-step endeavor aimed at bringing new pharmaceutical drugs to market. It begins with identifying and validating a biological target, such as a protein, gene, or RNA, that is associated with a disease. This step involves understanding the target's role in the disease and confirming that modulating it can have therapeutic effects. The next stage, hit identification, employs high-throughput screening (HTS) and other methods to find compounds that interact with the target. Computational techniques may also be used to identify potential hits from large compound libraries.
Following hit identification, the hits are optimized to improve their efficacy, selectivity, and pharmacokinetic properties, resulting in lead compounds. These leads undergo further refinement to enhance their potency, reduce toxicity, and improve drug-like characteristics, creating drug candidates suitable for preclinical testing. In the preclinical development phase, drug candidates are tested in vitro (in cell cultures) and in vivo (in animal models) to evaluate their safety, efficacy, pharmacokinetics, and pharmacodynamics. Toxicology studies are conducted to assess potential risks.
Before clinical trials can begin, an Investigational New Drug (IND) application must be submitted to regulatory authorities. This application includes data from preclinical studies and plans for clinical trials. Clinical development involves human trials in three phases: Phase I tests the drug's safety and dosage in a small group of healthy volunteers, Phase II assesses the drug's efficacy and side effects in a larger group of patients with the target disease, and Phase III confirms the drug's efficacy and monitors adverse reactions in a large population, often compared to existing treatments.
After successful clinical trials, a New Drug Application (NDA) is submitted to regulatory authorities for approval, including all data from preclinical and clinical studies, as well as proposed labeling and manufacturing information. Regulatory authorities then review the NDA to ensure the drug is safe, effective, and of high quality, potentially requiring additional studies. Finally, after a drug is approved and marketed, it undergoes post-marketing surveillance, which includes continuous monitoring for long-term safety and effectiveness, pharmacovigilance, and reporting of any adverse effects.
1. Developing people for health and healthcare
Update in
Gastroenterology for
the Acute Take
Kingston Hospital NHS
Foundation Trust
24 July 2014
Dr Helen Matthews
Consultant Gastroenterologist
2. Developing people for
health and healthcare
Summary
• What’s new in gastroenterology?
Hepatitis C & Direct Acting Anti-virals
• Gastroenterology and AAU
(Alcohol)
GI Bleeds
Paracetamol Overdose & ALF
Anorexia and re-feeding
5. Developing people for
health and healthcare
Alcohol & AAU
• Alcohol & brief
intervention for hazardous
& harmful drinking
AUDIT-C or FAST
• Wernicke’s
Encephalopathy
Parenteral Thiamine 5
Days
• Delirium Tremens
• Oral lorazepam
• Parenteral
lorazepam/haloperidol/olanz
apine
• Acute Alcohol Withdrawal
Clinical Institute
Withdrawal Assessment
– Alcohol, revised
(CIWA-Ar)
Benzodiazepine (or
carbamazepine, off label
with informed
consent….)
Symptoms triggered
regimen
Alcohol-use disorders overview
NICE 2014
6. Developing people for
health and healthcare
Acute GI Bleeds
• Risk assessment:
Initial Blatchford AND
Rockall Score after
endoscopy
• History
• Haematesis/Malaena?
• PMH
• Co-morbidities
• Medication
7. Developing people for
health and healthcare
Examination
• Resting tachycardia =
Mild/moderate hypovol
• Orthostatic hypotension =
blood loss 15%
• Supine hypotension: >40%
• PR!
Initial Resuscitation
• Blood transfusion with
care
• Platelets if platelets <50
AND actively
bleeding/haemodynamicall
y unstable
• FFP if fibrinogen <1g/Litre
OR PT/INR or APTT >1.5
times normal
• Prothrombin complex
concentrate (Beriplex) if
taking warfarin and
actively bleeding
8. Developing people for
health and healthcare
• Controversial
• Transfuse if Hb <70g/L, aim >70 g/L
Transfuse/aim Hb >90 g/L if unstable
angina, elderly
• Avoid overtransfusion in variceal bleeds
(and others?)
• Hypovolaemic patients with normal Hb may
need blood
Blood Transfusion
9. Developing people for
health and healthcare
Villaneuva et al. NEJM 2013
• 1610 presenting with UGI Bleed screened,
921 randomised
• Restrictive (<70 g/L) versus Liberal (<90 g/L)
• Survival (95 % vs 91%; HR death 0.55 ,95%
CI 0.33-0.92: p=0.02)
• Further Bleeding (10% vs 16%;p=0.01)
• Adverse events (40% vs 48%; p=0.02)
10.
11. Developing people for
health and healthcare
Medical Treatment Prior to Endoscopy
RESUSCITATION
NON-VARICEAL: PPI
?Hold off until after
endoscopy (NICE
2012 versus ROW)
Re-introduce aspirin
ASAP
VARICEAL:
Full septic screen
and prophylactic
antibiotics
Terlipressin 2mg
qds iv
12. Developing people for
health and healthcare
When to call the GI Bleed SpR/Consultant?
• Endoscopy to unstable patients
with severe upper GI bleeding
immediately after resuscitation
• Offer endoscopy within 24
hours of admission to all other
patients with upper GI bleeding
• Interventional radiology to all
patients who rebleed after
endoscopy
• Surgery if IR not available
• Consider early TIPS in varices
NICE Guidelines 2012
13. Developing people for
health and healthcare
Paracetamol/APAP overdose: New Guidance on
Treatment with Intravenous Acetyl Cysteine
• ALL patients with timed
paracetamol level on or
above a single
treatment line receive
acetylcysteine
regardless of risk
factors hepatotoxicity
MHRA Sept 2012
14. Developing people for
health and healthcare
Paracetamol/APAP overdose: New Guidance on
Treatment with Intravenous Acetyl Cysteine
• If in doubt (staggered overdose/timing) GIVE –
do not use nomogram
• Administer initial dose of acetyl cysteine as an
infusion over 60 minutes
• Hypersensitivity is no longer a contraindication
MHRA Sept 2012
15. Developing people for
health and healthcare
Acute Liver Failure:
Transplant Listing Criteria in UK – Superurgent #1
• Ph<7.25 after 24hrs
and fluid resus
• PT>100s or INR >6.5
AND creat>300/anuria
AND Gd3-4 enceph
• Lactate >3.5 after 24
hours on admission or
>3 after resus
• or 2/3 from 2 with clinical
deterioration (raised ICP,
FiO2>50%, ↑inotropes)
NHSBT Liver Advisory Group 2013
1. Paracetamol poisoning (25%)
16. Developing people for
health and healthcare
Subacute/Acute Liver Failure
Transplant Listing Criteria in UK – Superurgent #2
2. Seroneg hepatitis,
hep A/B, drug reaction
(55%)
• PT>100s/INR>6.5 and any
enceph
• Any enceph PLUS 3 of
drug/seroneg; >40yrs;
jaundice to enceph >7days;
bili >300umol; PT>50s or
INR>3.5
3. Acute
Wilson’s/Budd
Chiari and any
enceph
4. HAT d0-21 post LT
5. AST>10000 u/L; INR
>3; Lactate >3 d0-7
6. NHS Live liver
donor, severe liver
failure <4/52
NHSBT Liver Advisory Group 2013
17. Developing people for
health and healthcare
Survival % UK
Diagnosis 1 year 3
years
5 years
Elective LT 88 (92) 82 75
Superurgent LT 78 (88) 74 72
Data from RCS/NHSBT Liver transplant audit, 2012
(1994-2012)
Survival % by Aetiology
Diagnosis 1 year 3
years
5 years 10 years
Cirrhosis 83 76 71 60
Acute Liver
Failure
68 63 61 55
Cancer 78 62 53 40
Data from European Liver Transplant Registry, 2008
19. Developing people for
health and healthcare
Re-Feeding and Underfeeding
• Potentially fatal cardiac and neurological
abnormalities (WHO 1999; Mehanna et al. 2008)
• Early identification of high risk patients
• BMI <16, Rapid Weight Loss, ETOH abuse.
NICE 2006
• PO4, K+, Mg2+,Vitamin, U&E, Glucose
22. Developing people for
health and healthcare
Summary
• Ask about alcohol use: FAST/AUDIT-C
• Don’t over transfuse especially the cirrhotics
(but resuscitate!)
• Only one line for PODs
• Re-feeding versus underfeeding
Editor's Notes
The MARSIPAN group came together after clinical experience indicated that patients with severe anorexia nervosa, often young, had been admitted to medical facilities in a seriously ill state and had subsequently deteriorated and died, at times from identifiable causes such as pneumonia and at others from the effects of starvation or the re-feeding syndrome. Some of the cases led to widespread coverage in the media (BBC News, 2008; Daily Telegraph, 2008), others to serious and untoward incident inquiries. One such inquiry (Scottish Parliament, 2004) concluded that liaison between medical and psychiatric or eating disorders services could be improved. However, messages from individual clinicians suggested that other issues were also important.
Weight gain corner stone of treatment
The pathogenesis of hypophosphatemia begins when stores of phosphate are depleted during episodes of anorexia nervosa and starvation. When nutritional replenishment begins and patients are fed carbohydrates, glucose causes release of insulin, which triggers cellular uptake of phosphate (and potassium and magnesium). Insulin also causes cells to produce a variety of depleted molecules that require phosphate (eg, adenosine triphosphate (ATP) and 2,3-diphosphoglycerate), which further depletes the body’s stores of phosphate [10]. The lack of phosphorylated intermediates causes tissue hypoxia and resultant myocardial dysfunction and respiratory failure.
Vitamin and trace mineral deficiencies are due to starvation [10]. These deficiencies are exacerbated by the onset of anabolic processes that accompany refeeding the patient.
Volume overload begins with an increase in insulin secretion during the early stage of refeeding the patient [9]. This eventually increases renal sodium reabsorption and retention, and then fluid retention.
