Murugan's CARDIOLOGY IN DAY TO TODAY PRACTICE

·         Once a patient is diagnosed to have CAD, (coronary artery disease ) Patient has be treated

 as having CAD for life time. Statins and antiplatelets to be continued  life long for all. ACEI &         

 beta blocker are  also beneficial for  majority of patients.

·        There is no cure for CAD.  Whatever the treatment we do, like PTCA with Stenting or CABG will only reduce the severity of disease.

·        Hence best strategy to tackle CAD is its  prevention.

·       Prevention of CAD should start from child hood, focusing on diet, exercise, maintaining body weight, Stress reduction, etc.

·        Normal ECG, Normal ECHO and Negative TMT will not rule out CAD.  Meticulous history taking is essential in diagnosing CAD.

·        All T inversions that we see commonly in the ECGs  need not represent CAD. Many a times it is due to non coronary causes or normal variants. Morphology of the T wave (symmetrical and

     arrow head ‘T’)  and clinical scenario are important in decision making.  Investigations like   

     Troponin, Echo and TMT also guide us.

·        Troponins will be elevated in the blood 6-12 hrs after acute coronary syndrome.  Hence Troponin, taken before 12 hrs will not rule out CAD.

·        In patients with Acute MI. Primary PTCA is the treatment of choice, provided it is feasible with in 1 ½ hrs of first medical contact.  If not feasible, he has to be thrombolysed. Though thrombolysis can be done upto 6 hrs of pain onset, if it is done within one hour,  (golden hour) the salvage of myocardium and the outcome will be better.  So time is myocardium.

   

·        CT  Coronary angiogram is an evolving tool for diagnosing CAD.  However for assessing the severity  of stenosis of Coronary arteries, Catheter based coronary angiogram is superior to  CT angiogram.  Hence if CAD is strongly suspected, it is better to go for catheter based coronary angiogram.

·        In patients with CAD, after non cardiac surgery, Antiplatelet agents that were stopped, should be restarted at the earliest. Example after 6 hrs of surgery. Delay in or forgetting to restart  antiplatelet  agents is one of the  common and preventable cause for post op MI.

·        In patients with CCF, during inter current  illness liker Fever, Diarrhea,Vomiting – where

      there is chance for dehydration and hypotension.  -  DIURETICS, ACEI and  ARBS should

      be  stopped with close monitoring of volume status and BP and they are to be  restarted

      gradually.  This will prevent the development of ARF.

·        NSAID intake is one of the common cause for worsening of CCF and pulmonary oedema in patients with CCF.  Hence in patients with CCF- It is better to avoid NSAID including coxibs.  Most of the pain can be effectively managed with Paracetamol, Tramadol, muscle relaxants and physiotherapy.

·        One of the common cause for hospitalization in patient`s with CAD & CCF is non compliance and discontinuation of medication.  It`s our responsibility to educate and  convince the      patient  about uninterrupted continuation of medications.

·        As per the concept in 1990^s, beta blockers were contra indicated in CCF.  Currently beta blockers namely – Carvidilol, Bisoprolol and Metoprolol are the main stay of therapy in CCF.  

 

·        In the treatment of SHT the concept  in 1990^s was to start with single drug, go to maximum dose and then add another drug and so on.  Current concept is to start with lower dose of one or two drugs dependent on the levels of BP, then add another drug instead of increasing the dose of the first drug.

·        According to current guidelines beta blockers are not the first line antihypertensives.  ACEI,

      ARBS, CCB and diuretics are the first line drugs. 

Palaniappan's   ENDOSCOPIC INETERVENTION   GASTROENTEROLOGY PRESENT SCENARIO

Indeed 21^st century looks bright and exciting in the field of Gastrointestinal Endoscopy.

 Interventional  endoscopy is evolving into its own subspeciality.

Advances in endoscopy techniques and devices have led to a variety of new exciting applications for endoscopy and minimally invasive endoscopic surgical procedures

ENDOSCOPIC ULTRASOUND   [ EUS ]

Eus  is the most accurate imaging modality for staging GI tumors  Retroperitoneal  and Mediastinal masses. Re orientation of Ultrasound transducer on the echoendoscope allows for fine needle aspiration of these masses and cysts trans luminally   as opd procedure all  under monitored anaesthesia with increased diagnostic accuracy. Its less invasive less costly eliminating need for surgery.EUS thus has significantly helped to differentiate benign from malignant lesions and is also the procedure of choice when tissue acquisition fails.EUS thus leads to more effective and efficient medical and surgical management

ENTERAL STENTING 

Self expandable metal  stents  for palliation of malignant luminal   [Esophageal  Gastro Duodenal  Colonic ]  or biliary  obstruction.Its the modality of choice for Tracheo Esophageal Fistula

ENDOSCOPIC HEMOSTASIS

New endoscopic accessories and coagulation devices are available to address complex bleed of GI mucosal or vascular origin,post polypectomy bleed,or mucosal  gap defects that are spontaneous perforation or secondary to endoscopic  resection or therapy.Bleeding mucosal AV Malformations or Radiation Proctitis can be addressed with Argon Plasma Coagulation modality which was available only for surgical use

Bleeding varices controlled by Band ligation devices Glue therapy Metal stenting thus avoiding a potentially life threatening scenario

ENDOSCOPIC MUCOSAL RESECTION  [EMR]

GI tract is home to some of the deadly human diseases.Exacerbating the problems is the difficult of accessing it for diagnosis or intervention and the concomitant discomfort to patients besides expenses.Diagnosing and treating these maladies was challenging for many years but technological innovation has continually improved our ability in helping our patients

In the recent few years EMR is a familiar technique in our part of the world though in vogue for more than 15yrs in Japan .EMR is for superficial GI neoplasms precancerous lesions which have no node spread.Thus organ is preserved and as well curative therapy achieved in par to Surgical therapy.

To study these early lesions we have High Resolution endoscopy, Magnification endoscopy ,Dye based mucosal endoscopy called chromoendoscopy.These modalities delineate normal from abnormal mucosa guide in biopsy sampling to avoid sampling errorsand  sometimes to avoid bx if its s/o benign lesion and in advanced way to resect them too. Endoscopic Sub mucosal Dissection[ESD] is  advancement of EMR technique for one piece resection of superficial mucosal  lesions which is a labourious and highly complex procedure routinely done in eastern part of the world now being introduced in other parts of the world

STANDARD ENDOSCOPIC PROCEDURES

 Gastroscopes      for  Esophagus Stomach and Duodenum screening and therapy

Duodenoscope   for side viewing scopy of Ampulla in D2  and ERCP towards   Biliary / Pancreatic endotherapy.This includes Bile duct                                                                                                                                                                                                                                                stone clearance    stricture  dilation    leak management post surgery or trauma .Pancreatic stone stricture  leak management

Colonoscope   for complete screening of colon upto Terminal Ileum as diagnostic and therapeutic aspects

Enteroscope [Single and Double Balloon] for screening small bowel in c/o occult GI bleed unexplained diarrhea small bowel tumors Inflammatory bowel disease

SpyGlass scope for direct viewing of lumen of biliary and pancreatic lumen and also in therapy

Wireless Capsule Endoscope is a miniature pill sizes camera swallowed which screens small bowel where bi directional scopy is normal in c/o GI bleed or chronic diarrhea                                                                  24Hr Ph study  for Esophageal Reflux disease    Manometry study for Achalsia Cardia / GERD and other motility disorders of Esophagus are routine prerequisites prior to Surgery for these issues

THIRD SPACE ENDOSCOPY   ENDOSCOPIC ONE HANDED SURGERY

This is the final frontier in Endoscopy in vogue only few years since.We all know GI lining mucosa is  layered like mucosa submucosa muscularis propria and serosa.Lesion in submucosa can be accessed with endoscope, tumors can be acessed by a mucosal rent made endoscopically submuosal space is accessed and tumor  removed and mucosal rent issealed with  clips with no perforation or surgical need as muscularis layers are not breached at all.                                                                                                               Thus Per Oral Endoscopic Motomy[POEM] is done for Achalasia Cardia   PerOral Endoscopic PyloroMyotomy for Gastroparesis  Per Rectal Endoscopic Myotomy PREM for Hirschprungs Disease are all recent advancements in the field of Endoscopy

LIMITATIONS OF ENDOSCOPY

Adverse events related to sedation besides bleed perforation and infection.Currently advancements in devices enable to seal perforation with clips or loops endoscopically thus precluding surgery.This is applicable to luminal bleed complications

                   Nagarajan's     Basics in Nephrology

What are the anatomical compartments in the kidney ?

      Vascular

      Glomerular

      Tubular

      Interstitium

      Collecting system – intra renal and  extra renal

What are the physiological process involved in Urine formation?

       Glomerular filtration

      Tubular reabsorbtion

      Tubular secretion

What are the functions of Kidney and effect s of its nonfunctioning ?

       Excretory function                Uremia

      Fluid balance                          Fluid overload

      Electrolyte balance                Hyperkalemia

      Blood pressure                       Hypertension

      Acid base balance                  Metabolic acidosis

      Endocrine function                Anemia, Bone disease

How to use the terminologies Acute or Chronic and   Kidney  Failure or Kidney Disease ?

Any Kidney disease with evidence of disease process more than three month is denoted as “Chronic kidney Disease”

The Term Kidney Failure no longer used for denoting all kidney damages. It is restricted  to the  dialysis requiring  patients only.  

  The term Acute renal Failure and Chronic Renal Failure should be used only in dialysis requiring patients.

The term Chronic kidney disease or Acute Kidney Injury  is used with appropriate stage for the  diagnosis

of all patients with kidney disease.

          For Example

                  Chronic Glomerulo Nephritis  / Chronic Kidney disease Stage 4

                  Chronic Interstitial Nephritis /  Chronic Kidney disease stage 2

                   Acute Kidney Injury / Acute Tubular Necrosis

What are the importance of staging Chronic kidney disease?

       Facilitate defining Epidemiology of CKD

      Provide common language for patients & practitioners

      Framework for evaluation & management of CKD

What are the stages of Chronic Kidney Disease ?

                Chronic kidney  disease staging done based on the evidence of Kidney Damage  and Estimated Glomerular Filtration Rate( e GFR)

              

Stage	Description	eGFR (ml/mt/1.73 m2)	Remarks
1	Kidney damage with normal or elevated GFR	> 90	Evidences for kidney damage is must for diagnosis
2	Kidney damage with mildly decreased GFR	60 to 89	Evidences for kidney damage is must for diagnosis
3 A	Moderately decreased GFR	45 to 59	No evidences of Kidney damage needed
3 B	Moderate to severely decreased GFR	30 to 44	No evidences of Kidney damage needed
4	Severely decreased GFR	15 to 29	No evidences of Kidney damage needed
5	Kidney failure	Less than 15	Dialysis requiring stage

What are the evidences required to diagnose  Kidney  damage or Kidney Disease?

           Kidney damage defined by structural or functional abnormalities of the Kidney with or             without decreased GFR, manifest either by

                Markers of kidney damage -

                abnormalities of composition of blood  -

                                   Increased  Blood Urea and Serum Creatinine Levels

                urine abnormalities – Proteinuria, Hematuia, Casts etc

               Abnormalities in  Imaging tests(X Ray, USG Abdomen, CT ,MRI etc)

               Pathological abnormalities  - Abnormalities in Kidney Biopsy

What are the stages of Acute Kidney injury ?

     

Stage	Serum Creatinine	Urine Output
1	1.5–1.9 times increase from baseline OR > 0.3 mg/dl increase	< 0.5 ml/kg/h for 6–12 hours
2	2.0–2.9 times baseline	0.5 ml/kg/h for > 12 hours
3	>3.0 times increase from baseline OR Increase in serum creatinine to > 4.0 mg/ OR Initiation of renal replacement therapy OR  In patients < 18 years, decrease in eGFR to <35 ml/min per 1.73 per square metre body surface	< 0.3 ml/kg/h for > 24 hours OR Anuria for  > 12 hours(Obstruction ruled out)

     

How to Assess Renal Function ?

Glomerular filtration rate

                       Represents excretory function of the Kidney

1.      Endogenous creatinine clearence

     

           GFR is often estimated using serum creatinine concentrations [Cr]. Creatinine (Cr) is a metabolite of creatine (intermediate in muscle energy metabolism).  Cr is freely filtered at the glomerulus with no tubular reabsorption and minimal secretion (10%). The  rate of production determined by muscle mass. Normaly Cr excreted = Cr filtered (at steady state).

     

             Rrequires blood and 24 hour urine samples; measure plasma [Cr], 24 hour urine volume

and urine Creatinine[Cr]

        GFR = urine [Cr] x urine volume/plasma [Cr] x duration of urine collection in minutes

(Increasing Cr secretion can overestimate true GFR, particularly in azotemic patients

 Incomplete urine collection can underestimate true GFR; over-collection of urine overt'stimates it )                

      

2.      Estimated Glomerular Filtration( e GFR)

                   eGFR is reported in millilitres per minute which is written as

mL/min/1.73m2. (the “1.73m 2” indicates a result expressed relative to body

surface area).

Estimated Creatinine Clearence (Cockcroft - Gault Formula)

CrCl (mg/dl) ~ (140 - age)(body mass) / (plasma [Cr] x 72)

(multiply above result by 0.85 for women,  normal range is >90 ml/min)

MDRD equation : (Online Calculator)

    

                     186 x (Creat / 88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if black)

CKD EPI Formula (Online Calculator)

         CKD-EPI equation expressed as a single equation:

GFR = 141 × min (S_cr /κ, 1)^α × max(S_cr /κ, 1)^-1.209 × 0.993^Age × 1.018 [if female] × 1.159 [if black]
where:
S_cr is serum creatinine in mg/dL,
κ is 0.7 for females and 0.9 for males,
α is -0.329 for females and -0.411 for males,
min indicates the minimum of S_cr /κ or 1, and
max indicates the maximum of S_cr /κ or 1.

When Not to Use Creatinine-based Estimating Equations ?

Individuals with unstable creatinine concentrations

            Creatinine-based estimates of kidney function are only useful when renal function is stable; serum creatinine values obtained while kidney function is changing will not provide accurate estimates of kidney function.

Persons with extremes in muscle mass and diet.

               This includes, but is not limited to, individuals who are amputees, paraplegics, bodybuilders, or obese; patients who have a muscle-wasting disease or a neuromuscular disorder; and those suffering from malnutrition

What are the essential elements to be defined in a patient detected to have kidney disease in the management aspect?

            Acute or Chronic

            Primary or secondary

            Renal function impaired or not

            Which compartment  involved in the disease process

            Renal Replacement therapy (Dialysis or Transplantation ) required or not

            What is the probable pathology of the disease