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1: Ulster Med J. 2007 Sep;76(3):150-3. Cited Articles, Free in PMC, LinkOut

Prospective survey of serial troponin T requesting in an acute teaching hospital.

Loughrey BV, Spedding RL, Herity NA, Murphy JC, Walker E, Graham WR, McDonnell M.

Department of Clinical Biochemistry, Belfast HSC Trust, Lisburn Road, Belfast BT9 7AD, United Kingdom. brona.loughrey1@belfasttrust.hscni.net

BACKGROUND: Requests for troponin T, a biomarker for myocardial infarction, may be sent in a variety of clinical situations. In most cases, a single sample 12 hours or more after symptom onset should be sufficient for diagnosis. We chose to investigate how troponin T testing is used in our hospital with emphasis on those who had serial rather than single troponin measurements during their hospital stay. METHODS: Prospective survey of 50 patients with serial troponin T requests out of a total of 321 patients who had troponin T levels measured during the same time period. RESULTS: The time of symptom onset could be clearly identified in 40/50 patients. In 22 of these the first troponin was taken prior to 12 hours after symptom onset. For the 18 patients whose first troponin was taken after 12 hours, the second result remained in the same category (normal or high) as the first in all cases. This was not the case for 3/10 patients whose first troponin was sent within 12 hours and was normal. Early troponin results rarely affected immediate patient management and did not inform decisions about fibrinolytic therapy. CONCLUSIONS: Serial troponin testing was most commonly due to a sample being sent within 12 hours of symptom onset or to unnecessary repetition of an appropriately timed sample. Patient management was rarely enhanced by early troponin testing.

PMID: 17853642 [PubMed - indexed for MEDLINE]

Related Links

• Cardiac troponin T as a marker for myocardial ischemia in patients seen at the emergency department for acute chest pain. [Am Heart J. 1999]
• Serum markers in the emergency department diagnosis of acute myocardial infarction. [Emerg Med Clin North Am. 2001]
• Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. [N Engl J Med. 1997]
• Effective resource management using a clinical and laboratory algorithm for chest pain triage. [Clin Lab Manage Rev. 1996]
• A systematic review of troponin T and I for diagnosing acute myocardial infarction. [J Fam Pract. 2000]
• » See all Related Articles...

sBMJ | How to write a case report

sBMJ | How to write a case report: "How to write a case report Rahij Anwar and colleagues give advice on the practical details of writing case reports Research has become an integral part of medical careers. A case report is a way of communicating information to the medical world about a rare or unreported feature, condition, complication, or intervention by publishing it in a medical journal. When to start Be on the look out for a case report from the start of your basic surgical or medical training. This will introduce you to the research world, and if your report is published it will be an asset to your CV. Any kind of research entails a lot of hard work and persistence. Your thought processes should be geared towards research in your postgraduate career, and you should use every opportunity you get for writing a report. So if you come across something unusual, discuss it with a consultant, particularly one who is keen on research. Many consultants have huge amounts of material in the top drawers of their desks, waiting to be published. All they want is an enthusiastic medic who will help share their load in writing and getting it published. They are usually helpful if you ask them about this. How to start A senior doctor's help is a must from the beginning. He or she may know from their experience what cases are suitable for pub"

Stress ulcer prophylaxis Where to give, Where not to Give

UpToDate®: Stress ulcer prophylaxis in the intensive care unit: "Definite risk factors for the development of stress ulcers include mechanical ventilation for more than 48 hours and coagulopathy. In addition, possible risk factors include shock, sepsis, hepatic and renal failure, multiple trauma, burns (>35 percent total body surface area), organ transplantation, head and/or spinal trauma, and a prior history of upper GI bleeding or peptic ulcer disease"

UpToDate®: Prevention of venous thromboembolic disease

UpToDate®: Prevention of venous thromboembolic disease: "we recommend the following treatment programs for hospitalized medical patients:
* Graduated compression stockings should be considered for low risk patients [18,103]
* Heparin or warfarin is recommended for patients following myocardial infarction who have no other significant risk factors for venous thromboembolism [18,104]
* In acutely ill patients hospitalized with heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors (eg, active cancer, previous VTE, sepsis, acute neurologic disease, acute inflammatory disease), either low dose heparin or LMW heparin is recommended [18,79,80,85,105-107].
* On admission to a critical care unit, all patients should be assessed for their VTE risk; most should receive thromboprophylaxis.
* For patients with ischemic stroke and lower limb paralysis, low dose heparin or LMW heparin is recommended [18,47,106,108]. (See 'Medical complications of stroke', section on VTE prophylaxis).
* Intermittent pneumatic compression may be used for high risk patients who are at high risk for bleeding, although this recommendation is not based upon clinical trial data [109]"

Smoking Cessation Treatments - BMJ

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Treatment of menopausal symptoms with hormone therapy

UpToDate®: Treatment of menopausal symptoms with hormone therapy: "A low-estrogen oral contraceptive (20 mcg of ethinyl estradiol) remains an appropriate treatment for perimenopausal women who seek relief of menopausal symptoms, and who also desire contraception, and in some instances need bleeding control (in cases of dysfunctional uterine bleeding). Most of these women are between the ages of 40 and 50 years and are still candidates for oral contraception. For them, an oral contraceptive pill containing 20 mcg of ethinyl estradiol provides symptomatic relief while providing better bleeding control than conventional estrogen-progestin therapy because the oral contraceptive contains higher doses of both estrogen and progestin (which suppresses the hypothalamic-pituitary-ovarian axis). In our practice, when women taking a low-dose oral contraceptive during menopause reach age 50 or 51 years, we discuss stopping the pill altogether, or changing to an estrogen replacement regimen if necessary for symptoms. If estrogen is then given, the same recommendations for use would apply (for management of symptoms but not for disease prevention). Because women at this age are apt to have hot flushes when estrogen is stopped abruptly, we recommend tapering the oral contraceptive by one pill per week as described for estrogen therapy."

Management Of Metastatic Breast Cancer

UpToDate® image: "Decision algorithm for patients with metastatic breast cancer algorithm Selection of systemic modality: endocrine therapy (ET) versus chemotherapy. DFI: disease-free interval; ER: estrogen receptor; PR: progesterone receptor."

Prednisolone Vs Prednisone

UpToDate®: Glucocorticoid withdrawal: "The systemic bioavailability of prednisone is equivalent to that of prednisolone (0.77 to 0.80) [4]. Prednisone itself is biologically inactive, but it is rapidly converted to the active form prednisolone. However, patients with severe liver disease may have difficulty converting prednisone to prednisolone; in such patients, it is possible that one might not get the same effect from prednisone as from prednisolone. In addition, certain drug interactions can affect the metabolism and bioavailability of prednisone. As an example, barbiturates, phenytoin, or rifampin, attenuate the biological effects of glucocorticoids"

Lifestyle Modifications for Hypertension - JNC 7

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Promising new CD4-targeted anti-HIV drugs

It is imperative to continue efforts to identify novel effective therapies that can assist in containing the spread of HIV. Recently acquired knowledge about the HIV entry process points to new strategies to block viral entry. For most HIV strains, the successful infection of their target cells is mainly dependent on the presence of the CD4 surface molecule, which serves as the primary virus receptor. The attachment of the viral envelope to this cellular CD4 receptor can be considered as an ideal target with multiple windows of opportunity for therapeutic intervention. Therefore, drugs that interfere with the CD4 receptor, and thus inhibit viral entry, may be promising agents for the treatment of AIDS. The CD4-targeted HIV entry inhibitors cyclotriazadisulfonamides represent a novel class of small molecule antiviral agents with a unique mode of action. The lead compound, CADA, specifically interacts with the cellular CD4 receptor and is active against a wide variety of HIV strains at submicromolar levels when evaluated in different cell-types such as T cells, monocytes and dendritic cells. Moreover, a strict correlation has been demonstrated between anti-HIV activity and CD4 interaction of about 20 different CADA analogues. In addition, CADA acted synergistically in combination with all other FDA-approved anti-HIV drugs as well as with compounds that target the main HIV co-receptors. In this article, the characteristics of cyclotriazadisulfonamide compounds are presented and the possible application of CADA as a microbicide is also discussed.

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Sir Robert Hutchinson

"From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us!"

A Quote Of Sir Robert Hutchinson

Clinical Cases and Images

We all know that there is a big difference between what we read in the books and what we see in our clinical practice every day. Somehow, the patients are different from their disease description in the textbooks. As one experienced physician put it succinctly: "his CHF did not read the book." How to bridge this gap between theory and practice? By creating a case-based curriculum of clinical medicine. See what the real medicine looks like.

This curriculum was started by physicians at the Cleveland Clinic and the Case Western Reserve University (St. Vincent/St. Luke) Internal Medicine Residency Program for the purpose of medical education. Please read the website disclaimer.

President's address - K.M.C.

President's address and interaction with the students of Kurnool Medical College on the occasion of its golden jubilee, Kurnool

Kurnool , India | Posted on February 2nd, 2007

Removing the pain is a great Mission

"Medical professionals are in God's mission"

I am indeed delighted to participate in the Golden Jubilee Celebrations of Kurnool Medical College and interact with the students and faculty members. I congratulate the Kurnool Medical College community both present and past who have built a robust educational framework for medical education during the last five decades. My greetings to the principal, faculty members, doctors, nurses, para-medical personnel, support staff, medical students and distinguished guests.

Dear Graduating students, when I see you all, in front of me, a scene of our country appears which links the new doctors and their role in the national mission. What is that scene? In our country, 700 million people live in 600,000 villages equivalent to 200,000 panchayats. We have 2020 Vision Document prepared by TIFAC, which mentions about the typical disease pattern which will be faced by the country in 2020. It is expected that HIV/TB combination, water borne diseases, cardiac diseases will be the predominant diseases and we have to find solutions for diagnosing and treatment. Also there are challenges for researchers for discovering molecule leading to drugs for various diseases such as diabetics, cancer, allergic diseases, inflammatory diseases, and certain type of new pattern of diseases in the tribal sector such as sickle cell disease. Many of you may take up practising healthcare in various fields and some of you may opt for research and development. The opportunities for you in the country, will be challenging equally both in the urban and rural areas. With the development of electronic connectivity and knowledge connectivity, and the spreading of health care centres and quality education we should be able to provide quality health care to our rural citizens. I am sure many of you will find working in rural areas to be really challenging.

For example, tele-medicine is a new area, you may find being used in large number of places for diagnosis and advice. Another area which is knocking at our doors is preventive healthcare. Some of you may participate in the research, development and use of vaccines against HIV, malaria and even against the cardiac diseases. There are several other avenues such as application of stem cell therapy for many ailments like treatment of heart failure and diabetics. Students should be aware of such developments taking place in the country and elsewhere. I have selected the topic for discussion "Removing the pain is a great Mission."

Tradition of Research and Vision

Recently, I met Dr. Charles Cummings, of the Johns Hopkins University Board and his team. I asked him, a question which was in my mind, "Dr Charles, What made Johns Hopkins a world class medical research institution in addition to its cherishing societal missions?" His answer was, "it is due to a great tradition, and it started with a number of visionaries simultaneously with value system, focused missions and the nature of working together. The most important aspect is the research, research base and the quantity of clinical data added everyday. This tradition continues even now". Indeed it is a great message from Dr. Charles. I am sure, every medical institution in the country should imbibe this culture that comes out of research tradition, leading to the results of the research reaching the people in the form of medi-care, medicines or vaccines. I recall, in India one of the leading institutions in Hyderabad L.V. Prasad Eye Institute has set a tradition of providing quality eye care particularly with social commitment of 1:1. 1:1 implies one free eye care service for every paid eye care service provided by the Institute. Also, they have a tradition of excellent research in Ophthalmology and they are spreading the mission to various parts of the country particularly their research in stem cell which has led to the restoration of eye sight to 300 patients with burn affected eyes.

Health status of India

India has made considerable progress in its health status since its Independence and particularly during the last fifteen years. At the time of Independence, the life expectancy of an Indian was less than thirty years. Between 1991-2006, the life expectancy of Indians has gone up from 58 to 64.35 years, infant mortality has come down from 87 to 60 deaths per 1000 live births and population growth rate has decreased from 1.9% to 1.4%. Still infant mortality is very high. We have to bring infant mortality to less than 1%.

I would like to briefly talk to you on some of the diseases and actions proposed and future need. Our experiences will definitely be shared with the third world developing nations in order to provide healthcare for all.

Drug for faster cure of tuberculosis

The entire country has been brought under the Revised National Tuberculosis Control Programme (RNTCP). This will ensure that maximum number of Tuberculosis cases are detected every year and brought under direct surveillance. The treating agency must ensure that at least 80% success in fully curing the disease is achieved within the year. If this regime is followed continuously for over ten years our tuberculosis load will come down to less than ten per one lakh of population. It is essential to work faster on the development and clearance of new drugs which are in the pipeline. Educational institutions should also participate in this mission.


India has also made significant contributions in developing drugs that are critically required for India. One of the achievements comes from a laboratory of the Council of Scientific and Industrial Research (CSIR). CSIR lab has developed a new therapeutic molecule for Tuberculosis. This molecule has shown the potential to cure TB in around 2 months, as against the standard treatment of 6 to 8 months. This breakthrough is very important. After completing the pre-clinical studies, the molecule transformed into a drug called Sudo-terb is undergoing clinical trials in humans. This development has been done as a public-private partnership involving the Lupin, the three CSIR Laboratories, namely, Central Drug Research Institute, Indian Institute of Chemical Technology and National Chemical Laboratory, and the University of Hyderabad. It is hoped that the drug will be in the market soon after the clinical trials. In addition to the above, there is also a need to develop a more effective vaccine against tuberculosis. The combined action of surveillance, detection and disciplined treatment have to work together to ensure faster cure of existing cases. Prevention of future cases has to be achieved through R & D efforts of developing new breed of vaccine and medicines. The collaborative action is needed between healthcare personnel, academicians, doctors, researchers and the pharmaceutical companies both in the private and public sectors to accomplish this mission.

Malaria

Incidence of Malaria has reduced from 22 lakh to 18 lakh in the period 1998-2006. However, the death cases has increased from 644 to 943. I understand that the conventional medicine used for treatment of Malaria namely Chloroquin has become resistant to Falciparum which causes cerebral Malaria. Our scientific community has developed and produced a drug named Arteether from Artemisinin which has been found to be an effective cure for cerebral Malaria. I understand that this drug is being exported to over forty countries. Also, Ranbaxy has acquired a malarial drug molecule and they are progressing towards clinical trials. The fully developed drug will be available in the market soon. This will be another important milestone in the treatment of Malaria.

Over the years, I find that in spite of our efforts there is no rapid reduction in the occurrence of Malaria cases in the country. While taking up new projects, it is essential to have multi-faceted inter-sectoral collaboration between various partners so that the impact assessment of the project on new type of diseases can be foreseen and suitable preventive action taken to contain the disease. In addition to this, we have to improve the surveillance, develop rapid diagnostic kit and use the conventional prevention methods of spraying to control the vector. International Centre for Genetic Engineering and Bio-technology in collaboration with Bharat Bio-tech has developed a vaccine for Malaria which will go for toxicity trials on animals. There is a need to speed up such projects so that they will benefit the entire community who are affected by Malaria in different parts of the world. KMC can participate in such missions. Now, I would like to present HIV /AIDS control.

HIV/AIDS Control

Today in our country, all age groups put together have an incidence of 5.7 million HIV cases. 163 out of 611 districts in the country have a high proportion of HIV cases. The scientific community had a very important mission of determining the genetic nature of HIV that will lead to its cure. The genetic nature when studied had some surprises. The retro virus is RNA based and not DNA based. Most retro viruses have only three genes, whereas the HIV virus had nine genes, with 9200 base pairs. With this understanding of the genetic nature, a number of drugs have come in at least to control HIV in as it is where it is condition. This intervention extends the life of HIV affected persons. The typical drug which has been developed and produced abroad is AZT, based on DNA synthesis. It halts the spread of the disease. Another medicine found is INDINAVIR with equally good results. A foreign University has tried a combination of AZT-INDINAVIR and 3TC, for some patients, which gave unique results fully suppressing the HIV AID virus. Of course research is continuing. I am sharing this with the young students, to convey that there is a possibility of controlling HIV and extending the life of patients. However, the cost of the medicine was so far prohibitive. Indian companies have already brought down the cost of first line treatment to an AIDS patient from 12,000 US dollars to 300 US dollars per year. Similarly, the cost of second line treatment has also been brought down through the development of medicines such as Viraday a substitute for Atripla from 12,000 US dollars a month to 110 US dollars a month. Medical community assembled here should make use of these medicines so that further cost effective methods can be evolved.

Development of Anti HIV Vaccine

Apart from the HIV control protocol, the most important mission for the country today has to be the prevention of the spread of HIV further. There is no other way other than developing and leading to production an effective anti-HIV vaccine.

Phase one clinical trials of an imported Adeno-Associated Virus based HIV vaccine was initiated at the National AIDS Research Institute, Pune in early 2005. Thirty volunteers that were enrolled in the study and given HIV vaccine will complete follow up in January 2007. The vaccine has been tolerated well by volunteers and safety is good. Immunogenicity studies were carried out during the follow up. Results will be decoded and analyzed after follow up of the last volunteer is completed. In the event of the successful completion of Phase-I trials, technology transfer to an Indian company will take place. Another Phase-I vaccine trial was initiated last year at the Tuberculosis Research Centre for the Modified Vaccinia Ankara (MVA) based vaccine developed from the Indian HIV-1 sub type C virus genes. This vaccine has been developed by Indian Scientists in collaboration with a US company under the ICMR-NACO-LAVI programme. These two anti-HIV vaccines have to be completed with a time bound mission mode, as it is very important for India's HIV control programme. It is also essential to take up a third fully indigenous anti-HIV programme as a collaborative work between educational institutions like KMC, research laboratories and traditional medicine practitioners.

Management of Cardiac Diseases

Multi-dimensional solutions are available for management of the diseases based on my discussion with experts. The solutions include medicinal treatment using Statins, which lowers the cholesterol in the blood by reducing the production of cholesterol by the liver. Statins block the enzyme in the liver responsible for making excess cholesterol. However one has to be careful about the side effects and take adequate precautions while treating the patients. The second is through angiography and angioplasty using stents. I understand that very soon we may have bio-degradable stents. The next generation stents may be nano-stents. If the heart blockage is severe, valve defect and death of cells in the heart due to less blood supply etc. surgical intervention will be necessary or it may lead to treatment using stem cells.

Non-invasive treatment for Coronary Artery Disease

Today, I find that cardio vascular treatment moving towards a totally non-invasive treatment using EXTERNAL COUNTER PULSATION (ECP), a truly non-operative, non-pharmaceutical, safe and effective treatment which is being used in many countries. In India also a few centres have come up. This is a ripe area for research of the faculty members and students of KMC, Kurnool.

Conclusion

Human disorders can be classified into three broad categories. They are genetic disorders, disorders due to cellular function deficiency and disorders arising out of certain pathogens. I recommend intensive research for developing and producing cost effective treatment regime for the above categories of disorder through


(a) Gene therapy and gene chip research


(b) Stem cell research and


(c) Combination vaccine and pathogen specific antibiotics



This could lead to cost effective and safe treatment for the needy and improve the quality of life of mankind on this planet. KMC can be a partner in some of these research areas.

Recently, there was a meeting of cured patients, their doctors and a few social workers. One important point emerged during the interaction was that the relationship between the patient and doctor extends to patients' family. This in turn, transmits effective messages from one family to another family on advice to prevent diseases, necessity of periodic checks, the dietary habits and the need for life style changes including exercise for good health. Actually, I believe this good contact between the doctor and patients is very valuable. I request every doctor of KMC to play the role of a teacher in advising every family on disease prevention and methods to lead a healthy life. This message should also be given to all the students graduating from KMC so that they will find time to put this noble action into practise during the medical career.

Giving quality health care through continuous acquisition of knowledge, upgrading diagnosis and treatment, providing care and counselling particularly to the unreached should become the life time mission of each one of you graduating from KMC. Thus you will contribute effectively to the mission of developed India 2020.


My greetings to all the members of KMC Kurnool during their Golden Jubilee Celebrations and my best wishes to the students and faculty members of this college in their mission of developing quality healthcare professionals for nation building.

May God bless you.



Five Point Oath for Medical Professionals

1. We the medical professionals realize that we are in God's mission.

2. We will always give part of our time for treating patients who cannot afford.

3. We will treat at least 20 rural patients in a year at minimum cost by going to rural areas.

4. We will encourage the development of quality indigenous equipments and consumables by making use of them and assisting in enhancing the quality and reliability of the products.

5. We will follow the motto "Let my brain remove the pain of the suffering humanity and bring smiles".

Five Point Oath for Medical Professionals

1. We the medical professionals realize that we are in God's mission.

2. We will always give part of our time for treating patients who cannot afford.

3. We will treat at least 20 rural patients in a year at minimum cost by going to rural areas.

4. We will encourage the development of quality indigenous equipments and consumables by making use of them and assisting in enhancing the quality and reliability of the products.

5. We will follow the motto "Let my brain remove the pain of the suffering humanity and bring smiles".

-- Sri A.P.J. Abdul Kalam, President Of India.



Health Care: Technology Vision 2020 (Detailed Report)
Code No : TIFAC:V:08:III:DR

Title : Health Care: Technology Vision 2020 (Detailed Report)

Summary : In the field of eye care immediate attention is to be given for adequate availability of indigenously produced Vitamin-A. Indigenous production of better quality Intraocular lens (IOLs). ; To tackle the problems of Cancer, it is essential to develop state level transfusion services network. Action should be taken to set up one Cobalt-60 unit per million population and Plasma phersis facilities at specialised centres.; Investment in R&D for availability of newer anti-epileptic drugs at lower costs and for generating indigenous technology for electromyelography, needs priority attention. ; Indigenous technological strengths for production of low cost rapid diagnostic kits are required to tackle cardiovascular disorders. ; Indigenous production of consumables for dialysis and transplants is an important area identified for tackling renal diseases.; Replacing iodised salt with double fortified salt, and provision of prophylaxis for all eligible children, are emphasized in the area of Maternal & Child Health. ; For managing diabetes, indigenous production of low-cost self monitoring kits and inexpensive human/newer types of insulin, are required.; Monoclonal diagnostic aids for detecting TB, wider application of biological vector control for malaria, reliable barrier methods to minimise risks of accidental transmission of AIDS etc., are to be given priority for controlling infectious diseases. "It is forecast that TB, AIDS, Vector-borne and diarrhoeal diseases are likely to be major ones in the future."; For controlling genetic disorders it is envisaged to resort to primary prevention of neural tube defects by folic acid supplementation to all child bearing women.; Well organised trauma & burn care services at district levels, indigenous production of high-quality, low-weight prosthetic & orthotic devices, are very important for to prevent damage from injuries and accidents.

Table Of Contents : Scenario topics : The Ophthalmology Scenario, Scenario of Cancer In India, Scenario: Neurological, Neuro-Surgical, Psychiatric disorder, and addictions, Scenario for Cardiovascular Disorders, Scenario: Renal Diseases and Hypertension, Scenario: Maternal & Child Health, Scenario: Diabetes, Scenario:Infections Diseases, Scenario: Genetic Disorders, Scenario: Gastro-Intestinal disorders, Scenario: Accidents and Injuries, Scenario: Acquired Immuno Deficiency Syndrome.

Price : Rs3000/-

Category : Technology Vision 2020 Reports

Online Executive Summary of the report will be available soon

For Ordering, please fill the order form or contact Shri A.K Ahuja, Manager (P&CS)
Technology Information, Forecasting & Assessment Council (TIFAC), 'A' Wing, Vishwakarma Bhawan, Shaheed Jeet Singh Marg, New Delhi-110016.(India), Ph: +91-(0)11-26511374, 26592615, 26592614, Fax no.: +91-(0)11-26961158, Email: publication@tifac.org.in