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Tuesday, June 30, 2015

Importance of Debridement and Total Contact Cast in Trophic Ulcer Healing

Posted by Prahallad Panda on 7:35 PM Comments

An ulcer refusing to heal may be due to various diseases. Among all, diabetes, leprosy and cancer are most important. Those due to diabetes and leprosy are called Trophic Ulcers; Trophe=Nutrition. There is impaired nutrition to the place due to lack or less blood supply; neuropathy i.e. damage to the nerve fibre.

Deutsch: Geschwür am diabetischen Fuß
Deutsch: Geschwür am diabetischen Fuß (Photo credit: Wikipedia)
Lack of pain sensation, mostly in the foot, makes it vulnerable to repeated trauma; pain makes the person cautious, to use foot carefully and draws attention.
Apart from the specific disease oriented treatment, offloading of foot after debridement plays a major role in healing the ulcer.
Offloading can be achieved in various ways, among the available methods, non-removable ones are more helpful; Total Contact Cast (TCC) or plaster boot.
After through debridement of the infected and dead tissue, excision of the callous and hypertrophied skin, either TCC or plaster boot is to be applied for 21 days. After this period, the ulcer can be inspected for healing and if required, can be kept offloaded for a further period of 21 days.
Debridement of the wound helps healing by migration of platelets and thereby the growth factor; Offloading helps by saving from repetitive trauma and pressure to the part.

Thursday, April 2, 2015

Formation and Accumulation of Ketone Bodies In Diabetic Ketoacidosis

Posted by Prahallad Panda on 8:51 PM Comments

Finding Ketone bodies in blood and urine are hallmark of Diabetic Ketoacidosis along with clinical features.

These are three in number, namely, acetoacetate (AcAc), 3-beta-hydroxybutyrate (3HB) and the third,least abundant, acetone.

Ketones are always present in the blood in some amount and their levels increase during fasting and prolonged exercise.

Diabetes is the most common pathological cause leading to elevated blood ketones. In diabetic ketoacidosis (DKA), high levels of ketones are produced in response to low insulin levels and high levels of counter-regulatory hormones.
Acyl CoA is produced from break down of fatty acid, when cannot enter the Citric Acid Cycle (Cycle is down) due to lack of insulin sensitivity, get converted & accumulate in the form of ketone bodies. 
In acute DKA, the ketone body ratio (3HB:AcAc) rises from normal (1:1) to as high as 10:1. In response to insulin therapy, 3HB levels commonly decrease long before AcAc levels.

The frequently employed nitroprusside test only detects AcAc in blood and urine. This test is inconvenient, does not assess the best indicator of ketone body levels (3HB), provides only a semiquantitative assessment of ketone levels and is associated with false-positive results.

Recently, inexpensive quantitative tests of 3HB levels have become available for use with small blood samples.
These tests offer new options for monitoring and treating diabetes and other states characterized by the abnormal metabolism of ketone bodies.


Sunday, March 22, 2015

A Novel Host Immune Protein for Differentiating between Acute Bacterial and Viral Infection

Posted by Prahallad Panda on 11:04 AM Comments

Can we doctors definitely say in the acute phase, whether an infectious disease is due to bacteria, virus or mixed? Is there any blood test to know it?
Answer will be no to a larger extent. Diagnosis, largely depends on the epidemiology; most of upper respiratory infections are due to viral infection. Such types of assumptions and uncertainties lead to misuse of antibiotics, antibiotic resistance and adverse effect due to antibiotic use; nontheless, the financial burden on the family.
Several bio-markers like CRP (C-Reactive Protein), procalcitonin and Interleukin-6 are used to support the diagnosis of bacterial infection. But, take the case of CRP, it is increased in cases of bacterial infection and non-infectious inflammatory diseases as well.
Recently, in a research article published in PLOS One, the researchers claim to have successfully tested for a novel Host Immune Protein that is mostly elevated in viral infection and least in bacterial infection.
In the PLOS One study, the ImmunoXpert immune signature was developed and independently validated on a cohort of 1002 patients with acute infections and yielded highly accurate results, with sensitivity and specificity greater than 90%. The best performing host-protein was TNF-related apoptosis-inducing ligand (TRAIL) to diagnose viral infection.

MeMed, Ltd., announced publication of the results of this large multicenter prospective clinical study that validates the ability of its ImmunoXpertTM in-vitro diagnostic blood test, enrolling over 1000 patients between 2009 and 2013.
Reportedly, three host proteins are tested in ImmunoXpert kit; CRP, IP 10 and TRAIL; from swing of results, the most probable cause of infection i.e. bacterial or viral can be distinguished. TRAIL (member of the tumor necrosis factor family implicated in programmed cell death), IP-10 (IFN-gamma-inducible protein 10) small cytokine implicated in multiple cellular processes including chemotaxis and cell growth inhibition, and CRP (acute phase protein with diverse roles in tissue injury, infection and other inflammation processes).
This test will perhaps be a boon to mankind and handy to the doctors for near accurate diagnosis. 


Friday, February 20, 2015

A Little about Swine Flu

Posted by Prahallad Panda on 10:56 AM Comments


Sunday, December 21, 2014

Why Cardiac Troponin Test need to be Repeated Several Times in a case of Suspected Acute Coronary Syndrome (ACS)

Posted by Prahallad Panda on 7:08 PM Comments

Cardiac Troponin (cTn) I or T need to be repeated at least once after 12 hours of onset of the symptoms, if patient is seen within 12 hours and the initial result is negative to exclude the diagnosis of Myocardial Infarction. Highly sensitive cTn may be repeated 2-3 hourly for two to three times for the same purpose.
Normal Values 1
Cardiac troponin levels are normally so low they cannot be detected with most blood tests. Troponins are found only in skeletal muscles and heart muscles; smooth muscle cells do not contain troponins.
Test results are usually considered normal if the results are:
  • Troponin I : less than 10 µg/L
  • Troponin T : 0–0.1 µg/L
Normal troponin levels after 12 hours of chest pain mean a heart attack is unlikely.
What abnormal results mean:
An increase in the troponin level, even a slight one, usually means there has been some damage to the heart. Significantly high levels of troponin are a sign that a heart attack has occurred.
Most patients who have had a heart attack have increased troponin levels within 6 hours. After 12 hours almost everyone who has had a heart attack will have raised levels.
Troponin levels may remain high for 1 to 2 weeks after a heart attack.
Increased troponin levels may also be due to:
  • Abnormally fast heart beat
  • High blood pressure in lung arteries (pulmonary hypertension)
  • Blockage of a lung artery by a blood clot, fat, or tumor cells (pulmonary embolus)
  • Congestive heart failure
  • Coronary artery spasm
  • Inflammation of the heart muscle usually due to a virus (myocarditis)
  • Strenuous exercise (for example, due to marathons or triathlons)
  • Trauma that injures the heart such as a car accident
  • Weakening of the heart muscle (cardiomyopathy)
Increased troponin levels may also result from certain medical procedures such as:
  • Cardiac angioplasty/stenting
  • Heart defibrillation or electrical cardioversion (purposeful shocking of the heart by medical personnel)
  • Open heart surgery
  • Radiofrequency ablation of the heart
The Changing Scenario:
Previously, clinicians often had to wait an average of 6 hours with the lower-sensitivity, lower-precision cTn assays to see a conclusive increase in plasma cTn levels after the first troponin measurement, but today's high-sensitivity cTn tests that are separated by a mere 2 to 3 hours, can be highly informative.
Given the urgent need for early diagnosis of ACS and appropriate emergency intervention, as well as the ease of performing this relatively inexpensive assay, clinicians do not need to wait 6 to 8 hours before ordering a second troponin test to rule in ACS.
It is recommend to collect a second specimen for cTn testing within 2 to 3 hours from the collection of the blood sample at presentation to help confirm the diagnosis of MI.
Why dynamics of Troponin is Important:
The most common cause of cardiac injury is myocardial ischemia, ie, acute myocardial infarction. To be detectable, Troponin T takes 2 to 4 hours after the onset of myocardial necrosis, attends peak after about 12 hours and can remain elevated for up to 14 days.
In patients with MI, there is a lag before troponin elevations can be detected.Thus, the markers should be serially monitored upon suspicion for acute coronary syndrome (ACS). The initial recommendations were to check the markers every 6 hours until the expected peak was reached. However, with the more sensitive assays now available, very low concentrations of elevated cardiac markers can be detected, and evidence has demonstrated that checking troponins 3-4 hours after the initial draw can help in early diagnosis of ACS.
The safest rule of thumb is that a single negative test result for troponin does not exclude AMI in a patient with current or very recent symptoms, nor does it exclude clinically significant coronary artery disease.
Let us go here to recapitulate the physiological Role of Troponin in cardiac muscle contraction to appreciate it

Importance of the Dynamics of Troponin:
The dynamics of troponin levels (rise and/or fall over time) help distinguish AMI from non-AMI conditions, thus serial troponin testing is the standard approach recommended for assessing patients with suspected acute coronary syndrome (ACS).
The safest rule of thumb is that a single negative test result for troponin does not exclude AMI in a patient with current or very recent symptoms, nor does it exclude clinically significant coronary artery disease.
About acute myocardial infarction (AMI)
  1. AMI is part of a group of conditions collectively known as acute coronary syndrome (ACS), which includes both ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI), and unstable angina.
  2. These conditions are associated with common symptoms but have different underlying pathologies; STEMI is usually associated with a relatively large amount of damage (Transmural) to the myocardium (heart muscle) caused by a major blockage in the coronary artery, and can be detected with ST-elevation on an ECG trace. By comparison, NSTEMI is associated with relatively less damage to myocardium (Sub-endocardial) caused by partial blockage of the coronary artery or blockage of a smaller artery, and does not produce ST-elevation on ECG.
  3. Acute coronary syndromes arise from an obstruction in the coronary arteries, usually caused by atherosclerosis and build-up of plaque which ruptures. When blood flow to the heart is reduced or blocked for a significant length of time (around 30-60 minutes) damage to cardiomyocytes (heart muscle cells) occurs, a pathological change which distinguishes an AMI from unstable angina.
  4. Patients with ACS generally present with chest pain, a symptom which is responsible for around 700,000 emergency department attendances per year in England and Wales and 253,765 emergency admissions per year.
  5. During 2011/12, the Myocardial Ischaemia National Audit Project (MINAP) reported 79,433 admissions with AMI recorded in England and Wales, 32,439 (41%) of which were categorised as STEMI, and 46,994 (59%) were categorised as NSTEMI.
  6. The incidence of acute myocardial infarction increases with age, with the average age of first STEMI being 65 years, and of first NSTEMI 70 years. The incidence is also greater amongst men, with men being twice as likely to have an AMI as women.

Why Troponin test is preferred to Creatine Kinase MB

The skeletal and cardiac muscle troponin T and troponin I are immunologically distinct entities. Separate sets of genes code for these proteins. Thus, the cardiac troponin assays, which rely on antigen antibody interaction, are specific for cardiac troponins and can be used to differentiate between the skeletal and cardiac troponins.
Cardiac troponin levels do not rise in the presence of skeletal damage without cardiac myocyte damage. However, this is not the case for creatine kinase MB, which, being present to some extent in skeletal muscle and several other tissues such as the intestines, tongue, diaphragm, uterus, and prostate, may be elevated upon injury to these tissues, potentially resulting in false-positive results. Because of this, troponin testing is superior to creatine kinase MB testing.
Status of Electrocardiography (ECG) as a single mode of diagnosis of AMI:
Electrocardiography (ECG) was one of the earliest diagnostic modalities introduced to evaluate ischemic injury to the heart. Despite its usefulness, ECG continues to be nonsensitive in diagnosing ischemic cardiac events, as ECG findings are normal in many patients with ischemic injury.
The introduction of various markers of cardiac injury, such as creatinine kinase MB, troponins, and myoglobins, has revolutionized the diagnosis of myocardial injury. The cardiac troponins, by virtue of being the most sensitive and specific, have become the preferred biomarker for evaluation of patients with suspected MI.

Determining infarct size:
Peak troponin values can provide an estimate of the infarct size and the severity of myocardial damage. These values are more sensitive in the setting of transmural infarction (ST-segment–elevation MI [STEMI]) than in subendocardial infarctions (NSTEMI). This correlation holds true for both troponin T and troponin I (peak or values at 72-96 hours). Higher values generally correlate with a larger infarct
Significance of degree of troponin elevation
The degree of troponin elevation correlates well with both the 30-day mortality and long-term mortality. Various clinical trials have evaluated the degree of elevation of both troponin I and troponin T and found that higher elevations at presentation and peak are associated with worse long-term outcomes. The absolute values have been used to guide treatment decisions and to identify patients who are at an increased risk of death.
Prognostic value of the timing of elevation
Patients who present with elevated troponin levels at baseline tend to have worse outcomes than those in whom troponin levels are elevated at 8 hours. Outcomes are best in patients in whom troponin levels never elevate.
In both STEMI and NSTEMI, elevated levels of troponin T and troponin I at presentation are associated with a worse prognosis in terms of both short-term and long-term mortality. 
How often to perform troponin testing and the need for serial testing

In patients with MI, there is a lag before troponin elevations can be detected.Thus, the markers should be serially monitored upon suspicion for acute coronary syndrome (ACS). The initial recommendations were to check the markers every 6 hours until the expected peak was reached. However, with the more sensitive assays now available, very low concentrations of elevated cardiac markers can be detected, and evidence has demonstrated that checking troponins 3-4 hours after the initial draw can help in early diagnosis of ACS.

Jaffe AS: 2001-A biomarker odyssey. Clin Chim Acta 1999;284:197-211


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