KNOW ABOUT THE CANCER - WORLD CANCER DAY SPECIAL ISSUE

Cancer is the uncontrolled growth of abnormal cells in the body. Cancerous cells are also called malignant cells.Cells are the building blocks of living things.
Cancer grows out of normal cells in the body. Normal cells multiply when the body needs them, and die when the body doesn't need them. Cancer appears to occur when the growth of cells in the body is out of control and cells divide too quickly. It can also occur when cells forget how to die.
There are many different kinds of cancers. Cancer can develop in almost any organ or tissue, such as the lung, colon, breast, skin, bones, or nerve tissue.

There are many causes of cancers, including:
Benzene and other chemicals
Drinking excess alcohol
Environmental toxins, such as certain poisonous mushrooms and a type of poison that can grow on peanut plants (aflatoxins)
Excessive sunlight exposure
Genetic problems
Obesity
Radiation
Viruses
However, the cause of many cancers remains unknown.
The most common cause of cancer-related death is lung cancer.
The three most common cancers in men in the World are:
Prostate cancer
Lung cancer
Colon cancer
In women the three most common cancers are:
Breast cancer
Colon cancer
Lung cancer
Some cancers are more common in certain parts of the world. For example, in Japan, there are many cases of stomach cancer, but in the United States, this type of cancer is pretty rare. Differences in diet may play a role.
Some other types of cancers include:
Brain cancer, Cervical cancer, Hodgkin's lymphoma, Kidney cancer, Leukemia, Liver cancer, Non-Hodgkin's lymphoma, Ovarian cancer, Skin cancer, Testicular cancer, Thyroid cancer, Uterine cancer.
Symptoms
Symptoms of cancer depend on the type and location of the cancer. For example, lung cancer can cause coughing, shortness of breath, or chest pain. Colon cancer often causes diarrhea, constipation, and blood in the stool.
Some cancers may not have any symptoms at all. In certain cancers, such as pancreatic cancer, symptoms often do not start until the disease has reached an advanced stage.
The following symptoms can occur with most cancers:
Chills
Fatigue
Fever
Loss of appetite
Malaise
Night sweats
Weight loss
Signs and tests
Like symptoms, the signs of cancer vary based on the type and location of the tumor. Common tests include the following:
Biopsy of the tumor
Blood tests (which look for chemicals such as tumor markers)
Bone marrow biopsy (for lymphoma or leukemia)
Chest x-ray
Complete blood count (CBC)
CT scan
MRI scan
Most cancers are diagnosed by biopsy. Depending on the location of the tumor, the biopsy may be a simple procedure or a serious operation. Most patients with cancer have CT scans to determine the exact location and size of the tumor or tumors.
A cancer diagnosis is difficult to cope with. It is important, however, that you discuss the type, size, and location of the cancer with your doctor when you are diagnosed. You also will want to ask about treatment options, along with their benefits and risks.
It's a good idea to have someone with you at the doctor's office to help you get through the diagnosis. If you have trouble asking questions after hearing about your diagnosis, the person you bring with you can ask them for you.
Treatment
Treatment varies based on the type of cancer and its stage. The stage of a cancer refers to how much it has grown and whether the tumor has spread from its original location.
If the cancer is confined to one location and has not spread, the most common treatment approach is surgery to cure the cancer. This is often the case with skin cancers, as well as cancers of the lung, breast, and colon.
If the tumor has spread to local lymph nodes only, sometimes these can be removed.
If surgery cannot remove all of the cancer, the options for treatment include radiation, chemotherapy, or both. Some cancers require a combination of surgery, radiation, and chemotherapy.
Lymphoma, or cancer of the lymph glands, is rarely treated with surgery. Chemotherapy and radiation therapy are most often used to treat lymphoma.
Although treatment for cancer can be difficult, there are many ways to keep up your strength.
If you have radiation treatment, know that:
Radiation treatment is painless.
Treatment is usually scheduled every weekday.
You should allow 30 minutes for each treatment session, although the treatment itself usually takes only a few minutes.
You should get plenty of rest and eat a well-balanced diet during the course of your radiation therapy.
Skin in the treated area may become sensitive and easily irritated.
Side effects of radiation treatment are usually temporary. They vary depending on the area of the body that is being treated.
If you are going through chemotherapy, you should eat right. Chemotherapy causes your immune system to weaken, so you should avoid people with colds or the flu. You should also get plenty of rest, and don't feel as though you have to accomplish tasks all at once.
It will help you to talk with family, friends, or a support group about your feelings. Work with your health care providers throughout your treatment. Helping yourself can make you feel more in control.
by

AKSHAYA SRIKANTH
Pharm.D Intern

HEART DRUGS DEATHS: A NEGLIGENCE OF PHARMACIST ROLE IN PAKISTAN

Heart Drugs Deaths: A result of negligence of Pharmacist role in Pakistan.

The deaths of heart patients in Pakistan have exposed the defects in the health system of Pakistan; following are the main reasons for defective Health system.

Negligence of Health system by Federal Government and Parliament.

In past General Zia used to provide moral guidelines to Pakistani nation, once he advised Pakistani nation not to use Ghee as that was dangerous for health of people.

While present president Zardari never have spoken any single words about such subjects while he himself is suffering from heart disease while Zia himself was not suffering from Heart Disease. Infact Zardari and Parliament removed the subject of health from the federal subjects, while even United nations have not done such thing although that is not a government but maintain this subject in the form of very efficient system of WHO (*World health organization).

It is obvious from eighteen amendments that present parliamentarians including opposition have made such decisions without thoroughly examining the issue and made blind decisions, therefore Pakistani nation is paying price of their mistakes.

At present there are very strict regulations for import of drugs in USA, CANADA EU countries, but in Pakistan due to eighteen amendment Drugs act 1976 have become totally irrelevant. All drugs which are used in heart disease are imported from China and India and no drug is manufactured in Pakistan, Local Pharma Industry just formulate and convert the imported drugs into finished dosage form, and due to ambiguity created by eighteen amendments by foolish parliamentarians, Health system due is running without any inspection and monitoring system. Moreover Federal Government have not taken any step for manufacturing of Pharmaceuticals in Pakistan, infact only genuine manufacturing facility of Penicillin Plant in Mianwali established in 1960 have also been destroyed and Pakistani nation is forced to import low quality drugs from Garage based Pharmaceutical Industry in China and India.

Negligence of Role of Pharmacist in Pakistan:

Role of Pharmacist is very important in USA,CANDA,EU and in other parts of world, but in Pakistan to grasp the whole budget the doctors have made their monopoly in hospitals and do not understand the importance of Pharmacist in the hospital whose main responsibility is to understand the use of drugs, their interactions and side effects, as kingdom of drugs is now so much broad it is not simply possible for physicians to master this field, therefore it is their responsibility and duty to demand and take the professional help from Pharmacist in discharging their duties.

From this accident it is clear that When you will appoint non pharmacist and will try to make pharmaceuticals by workers without supervision of pharmacist then you will have to face such music always. Violation of Good manufacturing practices and using non professional and non Pharmacist staff results in such type of accidents, therefore running of Pharmaceuticals Industry by non professional and non pharmacist persons should be discouraged at present MOST OF THE PHARMACEUTICALS OWNERS are businessman such as distributors,and shop keepers, no one can expect care and quality from such peoples, Medicines should not be a business for money making, Therefore Pharmacist should be provided facilities and financial support and loans for running and owning the Pharmaceutical Industries, because only they are educated and qualified for this job.

Moreover importing Drugs from India and China garage based pharmaceuticals is not only harmful for the economy but also dangerous for the health and safety of the nation and measures should be taken to improve growth of Local Pharmaceuticals as well as to promote exports of Pharmaceuticals.Only when we will hand over Pharmaceuticals business to Pharmacist then only we can compete with India or China, otherwise we will continue to kill our peoples.

Laws and regulations about Health should be made by health professional and not by political personalities like Raza Rabani,Ishaq Dar or Zardari or Nawaz Shareef.

Pharmacists and other health professionals and physicians should work to augment and improve their roles for service of humanity and not just for money making.

Akshaya Srikanth, 

Pharm.D Intern

India

5th ISCR Annual Conference receives overwhelming response from industry

Dr Prem Kumar Reddy inaugurating the conference

The fifth annual conference of Indian Society for Clinical Research (ISCR) was recently held at Taj Krishna in Hyderabad. The theme for this year's conference was ‘Beyond Efficiency to Excellence’ and was attended by over 400 delegates from India and abroad.

Dr Prem Kumar Reddy, a leading authority on cancer research, inaugurated the conference and delivered the keynote address. This was followed by a welcome address by Dr Krathish Bopanna, President, ISCR. Bindhya Cariappa, Chairperson, Scientific Committee presented an overview of the conference, which was followed by a vote of thanks by Dr Radhika Bobba, Chairperson, Local Organising Committee. 

A panel discussion in progress

In synchrony to ISCR's objective of ensuring that the conference serves as a platform for the best minds in clinical research to share innovative views and best practices in clinical research, this year’s sessions focussed on excellence in line with the conference theme. The two-day conference had two clinical research tracks that touched upon each aspect of clinical development and covered early development, regulatory affairs, medical writing, clinical research technology, ethics, investigator site perspectives, project management, data management, quality assurance, pharmacovigilance, biostatistics and a discussion on the perception of clinical trials in India.  

Delegates attended Akshaya, Mandar Kelkar,
 Dr.Parthasarathi, Anand Harugery

The conference was preceded by four workshops on study management, medical writing, statistics and pharmacovigilance. Unique to this conference was also the young clinical research debate conducted at the end of day one of the conference. The conference was concluded by a valedictory speech by Dr PM Bhargava, scientist and recipient of Padma Bhushan and a vote of thanks to delegates, speakers, sponsors, organisers and volunteers. 

Participants at the conference

Speakers who attended the conference were Dr Rajesh Karan, Novartis; Dr Julius Vaz, Dr Reddy's Laboratories; Dr Shreemanta K Parida, Dept of Biotechnology; Dr Deven Parmar, Wockhardt; Dr Sudhakar Mairpadi, Phillips; Shenaz Vakharia, Theraverity; Dr Shashidhar Rao, Novartis; Dr Sanjay A Pai, Columbia Asia; Dr Roopa, Basrur, Parexel; Dr Graham Bunn, Medidata Solutions; Gunjan Jain, Oracle; Dr SD Rajendran, Sristek; Dr Ajay Parker, SIRO Clinpharm; Carol Isaacson Barash, Genetics, Ethics and Policy Consulting; Dr Gauri Gholap, Optra Systems; Sudip Sinha, CliniRx; Dr Mubarak Naqvi, Sanofi Aventis; Dr Aamir Shaikh, Assansa; Dr Ajoy Roy, Parexel; Dhiren Joshi, Voisin Life Sciences; Vivek Ahuja, Baxter; Dr Manish Kumar Shah, Pfizer; Narasimha Kumar, Parexel; Dr Sneha Limaye, CRF; Dr Milind Antani, Nishith Desai Associates; Gourav Kumar, Apollo Hospitals; Dr Vishwanath Iyer, Novartis; Dr Chitra Lele, Sciformix; Tommy Pedersen, Quintiles; Bindhya Cariappa, ClinTec international; Dr Rupam, KIMS; PV Rao, eminent media person; Dr Suresh Menon, Novartis; Professor Sarma, NALSAR; Dr Nimita Limaye, Siro Clinpharm; Dr Hema Bajaj, Sanofi Aventis; Mark Aubrey, Daiichi Sankyo; Dr Raghunatha Rao, NIMS; Dr Purvish Parikh, Americares and Dr Senthil Rajappa, Indo-American Cancer Hospital. The resounding success of the conference has raised the bar for the sixth annual conference to be held in Mumbai next year.

Source:ExpressPharma

by

Akshaya Srikanth

Pharm.D Intern

FDA Approved Vismodegib - Treatment for Advanced Basal Cell Carcinoma

Erivedge (vismodegib) was approved by the U.S. Food and Drug Administration to treat adult patients with basal cell carcinoma, the most common type of skin cancer. The drug is intended for use in patients with locally advanced basal cell cancer who are not candidates for surgery or radiation and for patients whose cancer has spread to other parts of the body (metastatic).

Erivedge, reviewed under the agency’s priority review program, is the first FDA-approved drug for metastatic basal cell carcinoma. Erivedge was reviewed under the FDA’s priority review program that provides for an expedited six-month review of drugs that may offer major advances in treatment. The drug is being approved ahead of the March 8, 2012 prescription user fee goal date.

Basal cell carcinoma is generally a slow growing and painless form of skin cancer that starts in the top layer of the skin (epidermis). The cancer develops on areas of skin that are regularly exposed to sunlight or other ultraviolet radiation.

Erivedge is a pill taken once a day and works by inhibiting the Hedgehog pathway, a pathway that is active in most basal cell cancers and only a few normal tissues, such as hair follicles.

“Our understanding of molecular pathways involved in cancer, such as the Hedgehog pathway, has enabled the development of targeted drugs for specific diseases,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “This approach is becoming more common and will potentially allow cancer drugs to be developed more quickly. This is important for patients who will have access to more effective therapies with potentially fewer side effects.”

The safety and effectiveness of Erivedge was evaluated in a single, multi-center clinical study in 96 patients with locally advanced or metastatic basal cell carcinoma. The clinical study’s primary endpoint was objective response rate (ORR) or the percentage of patients who experienced complete and partial shrinkage or disappearance of the cancerous lesions after treatment. Of the patients with metastatic disease receiving Erivedge, 30 percent experienced a partial response and 43 percent of patients with locally advanced disease experienced a complete or partial response.

The most common side effects observed in patients treated with Erivedge were muscle spasms, hair loss, weight loss, nausea, diarrhea, fatigue, distorted sense of taste, decreased appetite, constipation, vomiting, and loss of taste function in the tongue.

Erivedge is being approved with a BOXED WARNING alerting patients and health care professionals of the potential risk of death or severe birth effects to a fetus (unborn baby). Pregnancy status must be verified prior to the start of Erivedge treatment. Male and female patients should be warned about these risks and the need for birth control.

Erivedge is marketed by South San Francisco based-Genentech, a member of the Roche Group.

Source:FDA

by

Akshaya Srikanth

Pharm.D Intern

India

BLOOD SUGAR TESTING: Why? When? & What to do?

Guess what?  If you asked me what my blood sugar is right now, I have no idea.  Neither do you!

• Did you know that unless your blood sugar is over 200mg/dL, you most likely will have none of the traditional diabetes symptoms such as excessive thirst, urination, fatigue, hunger, or wounds that will not heal?
• If you’ve run blood sugar over 200mg/dL for a period of time, you probably won’t even have symptoms when your sugar exceeds that 200mg/dL point.
• If you have been prescribed medication for diabetes that is aimed at reducing your blood sugar and you begin to feel shaky, dizzy, nauseated, can’t speak clearly, can’t think, feel wiped out….you may assume that you are hypoglycemic.   Are you?  Without testing, you really have no idea…your once high readings may have returned to normal range…and your body may assume you are hypoglycemic when you are far from it!   If you grab some juice or glucose tabs, you will push that normal sugar right back into the very high range.
• Or maybe those symptoms really are hypoglycemia and if you don’t treat it, you will lose consciousness, fall down the stairs, drop your child, run off the road.
• Your Hemoglobin A1C might be 6.3 and you think to yourself:  “Wow, my blood sugar is now normal…why should I spend the money and take the time to test?”  Do you realize that hemoglobin A1C is your average blood sugar 24 hours/day, for about 3 months back in time?  An average is the average of highs and lows.  It is possible to have a 6.3 hemoglobin A1C because you are averaging normal from blood sugar readings that are in the high 200’s and in the low 50’s!
• You may be following your meal plan, exercising, are not stressed, haven’t been sick and think maybe you don’t need that medication.  Without monitoring, how can your physician make an educated decision on your medication or doses?

The When

Testing your blood sugar is a quick, not too painful, fairly accurate way to determine where your blood sugar stands at different times of the day.  Many people don’t know when they should test.   People with type 1 diabetes usually test before each meal, at bedtime, and anytime they feel low.  People with type 2 diabetes have a much different test schedule.

I can’t tell you the number of patients I’ve seen who only test first thing in the morning.  They initially come to my office with months of wake up (fasting) readings.  I scan them, see some high readings, and ask…What do you think caused your fasting reading to be so high on this morning or that one?

Invariably, the patient will “confess” one of the following scenarios:

• The night before, they went out to dinner late and ate pasta, garlic bread, and zeppoles. .
• The night before, they over-snacked watching a late night football game.
• They had a bagel for breakfast and a candy bar in the afternoon the day before.
• They had a snack right before bed 

Well, here is an eye-opener.  When a person with type 2 diabetes has a high fasting blood sugar, it is not because of anything that happened dietarily the day or night before!!!!  Why?  Carbohydrate is the nutrient that converts into blood sugar and carbs have a lifespan of about 5 hours.  When more than 5 hours pass after you eat carbs, your brain sends a signal to the pancreas to release a hormone called glucagon and this hormone signals the liver to release glycogen (sugar stores) into the blood.  So…anytime you check your blood sugar and more than 5 hours has passed since you last ate, you are looking at your liver’s self feeding mechanism!

If you only test your blood sugar in the morning before you eat, you are only seeing what your liver is up to.  That reading tells you nothing about how your body is reacting to the food you ate the previous day/night.

So, how can you find out how you are handling food (specifically carbohydrates)?  You should consider testing your blood sugar 2 hours after the START of a meal.  So, if you are having dinner at 6 PM and want to assess how high your blood sugar rose from dinner, test at close to 8PM.  If you wait until bedtime at 11PM, you missed it….because you are at the 5 hour mark.  After you eat, your sugar rises for about 2 hours, then comes back to normal over the next 2 hours, then hangs tight for the last hour of the 5 hour blood sugar curve.

If I have type 2 diabetes, and I want to know how my sugar is doing at the 2 times of the day it is likely to be highest…I would check first thing in the morning before I eat (checks the liver) and 2 hours after the start of my largest meal (checks the food).

What’s Normal?

I suggest that you ask your MD or health care provider for what your target blood sugar should be.  The following are the blood sugar ranges I typically use with my patients with type 2 diabetes whether they are following diet/exercise or diet/exercise/oral meds:

Fasting:  blood sugar less than 120mg/dL  (80-120mg/dL)

2 hours after the start of a meal:  blood sugar less than 140mg/dL.  If you happen to miss the 2 hour after time and check at 3 hours it should be under 130mg/dL.  If you don’t check until 4 -5 hours after the start of a meal it should be under 120mg/dL.  You can see that the highpoint is at the 2 hour mark.

Those with type 2 diabetes taking insulin will usually test premeal and at bedtime.  Your MD will tell you your individual targets if you use insulin to control your diabetes.

What to Do with It?

I find it is helpful to write my numbers down.  I know that the meter can keep hundreds of readings in memory…and I know they are time stamped (if you bother to set the meter’s time) but for me….I like to see patterns.  Even if you only use a sheet of paper…you can head it like this and mark or circle your readings that are out of zone.  Then, try to come up with a reason.

Chart for those in the USA using mg/dl 

Fasting	After Breakfast	After Lunch	After Dinner	Reason
110	2 hrs = 126
107		2 hrs = 157		had a bagel
140			2 hrs 122	didn’t sleep well
152	3 hrs = 120			poor sleep
139			2 hrs 109	poor sleep

Chart for the rest of the world in mmol/L

Fasting	After Breakfast	After Lunch	After Dinner	Reason
6.1	2 hrs = 7
6.0		2 hrs = 8.7		had a bagel
7.8			2 hrs 6.8	didn’t sleep well
8.4	3 hrs = 6.6			poor sleep
7.7			2 hrs 6.0	poor sleep

By highlighting any numbers that are out of range and trying to come up with a reason for the reading, I can see that my sleep difficulties are really affecting my blood sugar and may need to address this with my MD if the situation does not improve.   Why would my fasting reading be elevated?

• Poor sleep
• Pain
• Infection or Illness
• Not eating a night snack (liver is “on” longer)
• No exercise previous evening (muscles “consume” blood sugar for hours after exercise ends)
• Forgot to take my Metformin at bedtime
• Right before menstrual period
• Stress out

Why would my post meal readings be elevated?

• Forgot my medication today
• Pain
• Illness or infection
• Overeating carbs at the meal I’m checking
• No exercise earlier in the day
• Right before menstrual period
• Taking steroid based medication (prednisone/cortisone)
• High stress day

What about low blood sugar?

Blood sugar under 70mg/dL, when taking diabetes medication (orals or insulin) is considered to be hypoglycemia and needs to be treated as directed by your physician.  The standard treatment is a quick source of carb like 3-4 glucose tabs, ½ cup juice, ½ can regular soda (6 ounces), 8 ounces nonfat milk,, etc.  After waiting 10 minutes, retest your blood sugar and make sure it is over 80.  If it remains under 80 after the treatment, repeat and retest in 15 minutes ascertaining that does, indeed, rise over 80.  Report repeated hypoglycemia (not an isolated event) to your physician as you may require a medication or dosage change.

AKSHAYA SRIKANTH, Pharm.D*

INSULIN INDUCED LIPOHYPERTROPHY

Lipohypertrophy and lipoatrophy of injection sites was a major problem with the old impure insulins. The problem improved somewhat with the advent of the mono-component bovine and porcine insulins and the current pure human insulins, such that lipoatrophy in particular is now very rare.

However it now manifests more subtly, with thickening of the skin  rather than the formation of lumps and pitting. Even diabetologists have been known to miss it, when not looking for it carefully. The complication has occurred with the new genetically engineered modified human insulins, with and without continuous subcutaneous insulin infusions.The question is whether there will ever be any form of insulin therapy that will be without complications.

Lipohypertrophy occurs because patients inject the same site day after day. It frequently occurs on both sides of the umbilicus or in the mid-thigh areas as these are convenient places to inject, and where the patient’s hands reach most naturally. Eventually the area becomes hyposensitive. Once the patient feels pain when injecting elsewhere, but not in the lipohypertrophic area, he or she tends to continue injecting in the same site even if aware of the need to rotate sites. 

Some classification systems neglect subtle lipohypertrophy that is not visible but only palpable, and also add lipoatrophy as the most severe form. Grouping lipohypertrophy and lipoatrophy together is inappropriate: separate mechanisms have been suggested as a cause – lipoatrophy may result from a local immune reaction against impurities of the insulin preparations, while lipohypertrophy may result from the local trophic action of insulin. Rare lipohyper- trophy syndromes associated with diabetes exist and have a poor prognosis; the term has been inappropriately used to describe the local occurrence of lipohypertrophy due to injected insulins.

DISCUSSION

Lipohypertrophy has occurred with continuous insulin delivery systems, i.e. subcutaneous indwelling catheters and insulin pump therapy. Subcutaneous indwelling catheters are placed for a period of 4 - 5 days. Patients are instructed to avoid areas of lipohypertrophy, but as has been noted above the condition is not necessarily recognised by patients and they may place catheters in areas where early lipohypertrophy is already present. In the past, lipohypertrophy and lipoatrophy caused obvious changes to the skin, and the effects were cosmetically disturbing for patients. With more subtle  presentation, there is less incentive for the patients to try to avoid lipohypertrophy. However, injecting in lipohypertrophic areas affects the rate of absorption of the insulin, contributing to erratic blood glucose control.

It has been recommended that in order to diagnose the condition sites should be palpated and not just visually examined. In order to feel subtle skin thickening the hand should be stroked firmly over the injection sites in a sweeping motion rather than using traditional techniques of light and deep palpation.

CONCLUSION
Lipohypertrophy is difficult to recognise. Extensive education is required, firstly of doctors so that they can learn to recognise the problem and be encouraged to examine closely, by palpation, for presence of the disorder. Secondly, patients need to be educated that they can avoid the problem, and to be reeducated where the problem has already occurred.

by
Akshaya Srikanth,
Pharm.D Intern
Hyderabad, India

MADE EASY 5 MINUTE - ECG INTERPRETATION MODULE II

A heart rhythm that originates in the sinoatrial node and is normally conducted is called a Normal Sinus Rhythm. The characteristics of a normal sinus rhythm are a regular rate between 60-100 beats per minute, a narrow complex, preceded by a P-wave where all the complexes look the same.

ANALYZE A RHYTHM 

Rhythm Analysis: 

Step 1: Calculate rate

Step 2: Determine regularity

Step 3: Assess the P wave

Step 4: Determine PR interval

Step 5: Determine QRS duration

STEP 1: CALCULATE RATE 

Option 1

Count the # of R waves in a 6 second rhythm strip, then multiply by 10

Remember: All rhythm strips in the modules are 6 second in length.

Interpretation?" 9x10 = 90 bpm

Option 2

Find a R wave that lands on a blod line.

Count the # of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes -150, 3 boxes -100, 4 boxes - 75, etc 

STEP 2: DETERMINE REGULARITY

Look at the R-R distances (using a caliper or marking on a pen or paper)

Regular (are they equidistant apart)?, Occasionally irregular?, Regularly irregular? Irregularly irregular?

Interpretation? Regular

STEP 3: ASSESS THE P WAVES

Are there P waves?

Do the P waves all look alike?

Do the P waves occur at a regular rate?

Is there one P wave before each QRS?

Interpretation? Normal P waves with 1 P wave for every QRS

STEP 4: DETERMINE PR INTERVAL

NORMAL  0.12 - 0.20 SECONDS.(3-5 BOXES)

Interpretation? 0.12 Seconds

STEP 5: QRS DURATION

Normal: 0.04- 0.12 seconds. (1-3 boxes)

Interpretation? 0.08 Seconds

RHYTHM SUMMARY

RATE : 90-95 bpm

REGULARITY : regular

P WAVES : normal

PR interval : 0.12 s

QRS duration : 0.08 s

Interpretation? NORMAL SINUS RHYTHM

Prepared and Presented by

Akshaya Srikanth, Dr.S.Chandra Babu*

Pharm.D Internee, *Asst.Prof of Medicine

RIMS, Kadapa, India

Flesh- Eating Bug Kills In Hours

Flesh-eating disease is the medical equivalent of being struck by lightning: it’s extremely rare and very tragic.

And the fact that it moves at breakneck speed, capable of killing a healthy person in as little as 12 hours, makes it an especially frightening and intriguing disease.

“You don’t have the luxury of waiting around a few days to find out what’s going on,” says Dr. Michael Gardam, an infectious disease specialist at University Health Network in Toronto. “You’ve got to jump on it right away.”

The tricky thing about this bacterial infection is that typical symptoms include skin infection and flu-like aches and pains, so some patients and even doctors may not recognize what they’re dealing with until it’s too late.

The disease recently sparked headlines when a Mississauga woman, Debbie Sebesta, died from it last Wednesday. Three days earlier, the otherwise healthy woman was complaining of a bruise and pain in her leg. Within hours, flu-like symptoms such as chills and vomiting had set in and were worsening by the minute.

After being rushed to hospital, Sebesta underwent surgery to remove large part of her leg, which was infected with necrotizing fasciitis, often called flesh-eating disease because it kills muscle and skin as it spreads through the tissue.

Cases such as Sebesta’s are “the tip of the iceberg,” says Dr. Neil Rau, an infectious diseases specialist with a private practice in Oakville, who uses the analogy of being struck by lightning to highlight their rarity.

A few years ago, one of his patients cut her index finger while peeling an apple and became infected. Days later, the infection spread up her arm, to the armpit and across the chest. She was operated on, but later succumbed to the disease.

Such tragedies are rare, says Rau, noting that even in severe cases of the disease, most people don’t die. Such was the case in the winter of 1994 when Lucien Bouchard, then-leader of the Bloc Québécois, was forced to have his leg amputated because of the illness.

“For every terrible case we hear about, there are millions of people who have no symptoms or only mild symptoms,” says Rau.

According to Health Canada, there are between 90 and 200 cases of necrotizing fasciitis each year, about 20 to 30 per cent of which are fatal.

Infection is caused by different strains of bacteria, including group A streptococcus (GAS), a bacterium often found in the throat and on the skin of healthy people. Most people who carry GAS have no symptoms of illness and most infections are relatively mild illnesses, such as strep throat.

Infection often develops when bacteria enters the body, usually through a minor cut or scrape. In rare cases, that infection will spread and release harmful toxins.

Among the telltale signs that a person may have the disease is a small cut that may not look so bad but is causing immense pain, a skin infection that is spreading and flu-like symptoms, such as vomiting, diarrhea and chills.

One of the cardinal features of flesh-eating disease, says Gardam is that “the pain is more than you’d expect from what you’re looking at.”

Eight limbed boy celebrating after surgery to remove parasitic twin

STORY: These incredible pictures show the remarkable work of surgeons who removed a parasitic twin from a boy dubbed, 'The Eight-Limbed Boy'.

Deepak Paswaan was taunted and called a 'devil' and 'freak' as he was born with a parasitic twin jutting from his stomach.

Born in Bihar, India, Deepak spent his young life carrying around the under-developed legs and arms of what would have been his twin in a normal pregnancy.

But last summer, top doctors at the Fortis Hospital Bangalore agreed to operate on Deepak for free, as his parents, Indu and Veeresh, couldn't afford the whopping £50,000 it would have cost.

A team of six surgeons first cut away the extra limbs and then spent the final two hours sealing off the blood vessels Deepak shared with his twin.

The brave lad spent two weeks in hospital before being sent home. Today, the only reminder is a six-inch scar running from his rib cage to his stomach from where the twin was removed. 

Had he gone without surgery, Deepak's life would have been at risk due to the increased strain on his organs and frequent infections. The parasite even had its own intestines, which had to be taken away from Deepak's liver.

Speaking about the surgery, Deepak's mum, Indu, said she was incredibly nervous about the procedure:

'There was a major artery connecting Deepak to the twin, and if that had not been clipped properly, it would have put Deepak's life in danger. Me and his dad waited at the hospital while Deepak spent four hours in surgery. We sat hoping and praying that he would be okay.

'Once we found out he'd made it through, we were so relieved. All of the fear left us and suddenly all we could see was a brighter future for Deepak. He sometimes tells us that his father cut off the twin and threw it away in the fields, other than that, he hardly ever talks about it. He's too busy running around with his friends - he could never do that before as the twin weighed him down and he'd quickly get out of breath.'

Indu also explained that Deepak battled years of abuse about his condition, with some people suggesting he was possessed by the devil:

'People used to throw things at Deepak and I would hear all the whispers from neighbours, saying he was possessed by the devil. People told me he was a monster who would eat us.'

Deepak is completely healthy after the operation, and the only reminder is the scar across his tummy.

The little boy can now do everything he struggled with before his operation, saying:

'I can run faster than my two elder brothers - before I could never keep up. I really like my new body. It's much more fun. I am very happy.'

Lead surgeon at Fortis Hospital Bangalore, Dr Ramcharan Thiagrajan, said: 'This is a very rare phenomenon and only a small proportion of babies with parasitic twins live. We are very happy with the results.'

CASE DESCRIPTION:

A case of a seven-year-old Indian boy has caught the attention of the medical fraternity across the world for being a rare case in which his conjoined twin was attached to his abdomen. While imagining the actual figure of the boy with total eight limbs is hard to do, that's what the boy from Bihar had to face for years. 

The boy had no option but to bear the stigma of seeing scared eyes of people around him as he was called a devil by many. But a ray of hope was seen in the form of surgeons in Bangalore, who attempted a four hours long operation to remove the extra limbs. The boy has got a fresh lease of life with new body which he's certainly enjoying showing others who used to tease him earlier.

"This is a very rare phenomenon - only a small proportion of babies with parasitic twins live", said lead surgeon Dr. Ramcharan Thiagarajan, who performed the complicated operation for free.

Though the poor family tried their best to save the boy from emotional trauma, he had to go through it from the time of birth.

Now, the seven-year-old is enjoying the life of a normal boy and the credit goes to the leading surgeons from Bangalore's Fortis Hospital.

by

Akshaya Srikanth

Pharm.D Intern

Hyderabad, India