This document discusses the peri-operative management of patients with diabetes who require surgery. It notes that 30-50% of patients with diabetes will require surgery in their lifetime. Key considerations for pre-operative evaluation include assessing diabetes control, complications, medications, and associated conditions. The "threatening trio" of silent heart issues, renal dysfunction, and neuropathy are also discussed. Guidelines are provided for continuing oral medications, insulin and glucose management during the peri-operative period. Evidence around tight glycemic control in the ICU is summarized, noting the risk of hypoglycemia. Maintaining blood glucose between 140-180 mg/dl is now recommended for critically ill patients.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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2. Magnitude of the Problem……
30%-50% of patients with diabetes will
require some surgery within their
lifetime.
12% of the general population without
diabetes
7. Pre op evaluation
Type and duration of diabetes
Complications- CAD, CKD, Autonomic neuropathy
Medications
Control of diabetes- HbA1c, Hypos
Associated disorders- Hypertension, Dyslipidemia
9. Preoperative Considerations,
The threatening Trio………….
1. Silent Myocardial Ischemia:
ECG: may not show anomaly
Autonomic neuropathy blunts angina
>5-years of diabetes mellitus: do preoperative TMT.
Empirical Beta-adrenergic blockade preoperatively
10. Preoperative Considerations,
The threatening trio…(contd.)
2. Renal Dysfunction (Elevated Creatinine)
70% reduction in a GFR with a creatinine of
>1.5mg/dl
Intravenous fluid sensitivity is high: propensity
for volume overload.
Increased half-life of insulin and increased risk of
hypoglycemia.
Increase the frequency of glycemic monitoring.
13. Does hyperglycemia have a
detrimental impact?
Chronic Hyperglycemia:
200-250mg/dl related to complications-
4 fold increase in death.
Target: 140-180mg/dl
17. Oral Hypoglycemic Agents the need to
continue…….
Metformin……traditional phobia of lactic acidosis:
some stop 48 hours before any surgery.
Definitely: septic state, hypotension,
Renal or any major organ failure.
No increased risk if hypoglycemia when used alone.
Sulphonylureas/ Meglitinides
Thiazolidinediones…..May be continued.
18. Oral Hypoglycemic Agents
Acarbose: Avoid due to GI side effects
DPP4 inhibitors: Avoid on the day of surgery
because of delayed gastric emptying
19. Anaesthetic Considerations…….
Epidural Anaesthesia:
No significant increase in catecholamines,
counter-regulatory hormones and precursors of
gluconeogenesis.
General Anaesthesia:
Isoflurane- increase in growth hormone and glucose
levels
Enflurane- no significant impact on insulin, cortisol
or glucose levels.
Halothane- mild increase in hyperglycaemia.
20. Peri-operative insulin
and glucose dosing….
The Standard:
When on:- Intermediate acting + Regular insulin
[Mixtard(30/70) or Humusulin(30/70)
or Bovine Mixact(30/70)]
Give 2/3rds of the PM dose (previous night)
Give Half of the AM dose or only ½ NPH dose.
Start on IV D5W at 100ml/hour and titrate
according to the IV glucose algorithm
21. Peri-operative insulin and glucose dosing….(contd).
Glucose-Potassium-Insulin
IV 5%Dextrose/ saline 100-150ml/hour
+ 1.5g KCL to each litre.
+ Regular Insulin: 12 Units/litre
Glucose infusion 3.75-5 gm/hr + Insulin infusion 0.02u/kg/hour
Severe infection: 0.04u/kg/hour
Steroid-Dependent State: 0.04u/kg/hour
CABG or on Vasopressors:0.06u/kg/hour
Blood glucose/ 100= insulin units/ hr infusion
Hourly GRBS- insulin dose adjustment
NO ROOM FOR URINE SUGAR MONITORING
22. Peri-operative insulin
and glucose dosing….(contd).
Changing over to regular dosing:
Overlap the IV infusion for at least two more hours with
the subcutaneous insulin prior to discontinuing the IV
insulin, maybe for longer if the infusion rates are high.
Twice daily Mixtard with top up Actrapid with lunch if the
midmorning sugars are >300mg/dl
Morning dose depends on the midmorning sugar
(So change the dose the next morning)
Night dose depends on the fasting sugar
(So change the dose the same evening)
23. Hyperglycemia in the critically ill-
what is the evidence?
Hyperglycemia –Fasting blood glucose level > 100
mg/dl is common during critical illness.
Illness-induced hyperglycemia was considered a
beneficial, adaptive response
Provides brain and the red blood cells with additional
energy.
However, hyperglycemia in response to critical illness
is also associated with adverse outcome.
24. Intensive Insulin therapy in SICU
Van Den Berge et al, NEJM 2001
Single center study in adult surgical ICU patients (n-1548;
cardiac surgery and high risk or complicated non-cardiac
surgery)
2 Groups
Intensive control arm (80–110 mg/dl)
Conventional treatment arm (180-200 mg/dl; started when bl.
Glu > 215 mg/dl)
Arterial blood glucose measurements- 1 to 4 hrly
Central venous continuous insulin infusion
Dextrose 20% was administered on the first day and thereafter,
enteral nutrition was started.
25. Intensive Insulin therapy in SICU - Results
Intensive insulin therapy
Lowered ICU mortality from 8.0 to 4.6% (↓ 3.4%)
Lowered in-hospital mortality from 10.9 to 7.2% (↓ 3.7%).
Intensive insulin therapy reduced morbidity by preventing organ
failure as evidenced by
reduction of duration of mechanical ventilation
decrease in the incidence of acute kidney failure and of
polyneuropathy
preventing severe infections.
26. Intensive Insulin therapy in MICU
Van Den Berge et al, NEJM 2006
1200 Patients
In-hospital mortality was 40.0% in the control group and
37.3% in the intervention group (not statistically
significant)
Similar organ-protective effects were documented, but not
as strikingly as in the surgical study.
A larger proportion of patients in medical ICU who were
admitted with established organ damage, possibly
reducing the opportunity of prevention by glucose
lowering.
27. VISEP- Intensive insulin therapy and pentastarch
resuscitation in severe sepsis.N Engl J Med 2008
Brunkhorst FM et al
Multicenter trial (n = 537) was designed as a four-arm
study to assess
the difference between two choices of fluid
resuscitation (10% pentastarch vs. modified
Ringer’s lactate)
the efficacy and safety of intensive insulin therapy
in patients with severe sepsis and septic shock
Blood glucose targets
intervention (79–110 mg/dl)
control (180–200 mg/dl) groups.
28. VISEP- Results
The insulin arm of the study was stopped early,
because of increased hypoglycemia (12.1%) in the
intensive insulin therapy group
The fluid resuscitation arm of the study was also
suspended because of increased risk of organ failure
in the 10% pentastarch arm.
The 90-d mortality was 39.7% in the intensive vs.
35.4% in the conventional treatment arm.
29. Impact of tight glucose control by intensive insulin therapy
on ICU mortality and the rate of hypoglycaemia: final
results of the glucontrol study
Devos P et al Intensive Care Med 2007
Multicenter RCT (n = 1101)
Tight glycemic control (80–110 mg/dl) vs. an intermediate
glucose control (140–180 mg/dl)
Impact on survival in a mixed population of critically ill
patients
Stopped early -increased incidence of hypoglycemia
(9.8%).
Hospital mortality did not differ between the intensive
insulin therapy group (19.5%) and the control group
(16.2%).
30. NICE-SUGAR (Normoglycemia in Intensive Care
Evaluation and Survival Using Glucose Algorithm
Regulation) multicenter study
NEJM, March 2009
Multicenter study - 6100 patients
Tight glucose control (81-108 mg/dl) vs. usual care (<180
mg/dl)
Targeting tight glucose control increased 90-d mortality
from 24.9 to 27.5% (↑2.6%)
Excess deaths were attributed to cardiovascular causes
(41.3 vs. 35.8%)
No difference in organ failure or septicemia
Severe hypoglycemia was more common in the tight
control group (6.8%) as compared to usual care (0.5%)
31. Real-Time Continuous Glucose Monitoring
in Critically Ill Patients
DIABETES CARE, VOLUME 33 (3), MARCH 2010
• A total 124 patients receiving mechanical ventilation were
randomly assigned to 2 groups
• Intensive insulin therapy to maintain normoglycemia (80–110
mg/dl)
the real-time CGM group
n = 63
glucose values
given every 5 min
the control group
n = 61
selective arterial
glucose measurements
according to an algorithm
(simultaneously
blinded CGM)
for 72 h
32. In critically ill patients, real-time CGM reduces hypoglycemic events
but does not improve glycemic control
33. Toward Understanding Tight Glycemic Control in the ICU
A Systematic Review and Meta-analysis
CHEST 2010; 137(3):544–551
Study ICU
No of
pts
Insulin dose U/day Mortality %
Control
group
Intrevention
group
Control
group
Intrevention
group
Vanden
Berge 2001
SICU 1548 33 71 10.9 7.2
Vanden
Berge 2006
MICU 1200 10 59 30.1 29.9
Glucontrol
2007
Mixed 1078 10 43 25.9 24.7
VISEP 2008 Mixed 537 5 32 15.3 18.7
De La Rosa Mixed 504 12 52 32.4 36.6
Arabi 2008 Mixed 523 31 71 13.6 16.9
NICE
SUGAR
2009
Mixed 6022 17 50 20.8 22.3
35. There is no evidence to support the use of intensive
insulin therapy in general medical-surgical ICU
patients who are fed according to current guidelines.
Tight glycemic control is associated with a high
incidence of hypoglycemia and an increased risk of
death in patients not receiving parenteral nutrition.
36. Joint statement by AACE and ADA
Beneficial effects on outcomes can be derived
from glucose in the target range
between 140 and 180 mg/dl
in critically ill patients
37. Glucose is not just an innocent bystander during
critical illness because altering its circulating levels
has been shown to affect outcome in both directions.
Lowering blood glucose has the potential to prevent
secondary injury to threatened vital organ systems
and thereby to improve outcome.
The optimum level as well as the optimal mode to
reach that level should be defined.
38. Maintain blood glucose levels as close to normal as
possible
without evoking
unacceptable glucose fluctuations
hypoglycemia
hypokalemia.