The cut off level for NT-pro BNP proposed by the authors(1) should take into account the fact that blood levels of this parameter may be
lower in subjects with body mass index equal to or exceeding 30 kg/metre
squared despite left ventricular end diastolic pressures which exceed
those of counterparts with lower body mass indices(2). Lower cut-off
levels might then have to be devised in obese subjects....
The cut off level for NT-pro BNP proposed by the authors(1) should take into account the fact that blood levels of this parameter may be
lower in subjects with body mass index equal to or exceeding 30 kg/metre
squared despite left ventricular end diastolic pressures which exceed
those of counterparts with lower body mass indices(2). Lower cut-off
levels might then have to be devised in obese subjects. Polymorphism of
the type B human natriuuretic peptide receptor gene(3) might well,
theoretically, be another confounding factor in the evaluation of NT-
pro BNP levels, given the fact that blood levels of this parameter
depend, in part, on regulation of gene expression(4).
References
(1) Turley AJ., Roberts AP., Davies A et al
NT-pro BNP and the diagnosis of left ventricular systolic dysfunction
within two acute NHS trust catchment areas: the initial Teeside experience
Postgrad Med J 2007:83:206-8
(2) Taylor JA., Christenson RH., Rao KJorge M., Gottlieb SS
B-Type natriuretic peptide and N-terminal pro B-type natriuretic peptides
are depressed in obesity despite higher left ventricular end-diastolic
pressures
Am Heart J 2006:152:1071-6
(3) Rahmutula D., Nakayama T., Soma M.,et al
Systematic screening of type B human natriuretic peptide receptor gene
polymorphisms and association with essential hypertension
Journal of Human Hypertension 2001:15:471-4
(4) Onuoha GN., Nicholls DP., Patterson A., Beringer T
Neuropeptide srcretion during exercise
Neuropeptides 1998:32:319-25
In the above study acute coronary syndrome(ACS) was defined as the
presence of ischaemic cardiac symptoms (presumably, chest pain)(1), and it
was not made clear whether or not this was to the exclusion of a pain-free
presentation(2) characterised, instead, by, for example, sudden onset left
ventricular failure or "collapse"(3). In the "worst case scenario"
exclusion of ST segment elevation (STEMI) patient...
In the above study acute coronary syndrome(ACS) was defined as the
presence of ischaemic cardiac symptoms (presumably, chest pain)(1), and it
was not made clear whether or not this was to the exclusion of a pain-free
presentation(2) characterised, instead, by, for example, sudden onset left
ventricular failure or "collapse"(3). In the "worst case scenario"
exclusion of ST segment elevation (STEMI) patients presenting without chest
pain could distort the prevalence of raised cardiac troponin T levels in
patients without ACS.
Also of concern was the fact that, among the
electrocardiographic stigmata of ACS listed by the authors, no mention was
made of left bundle branch block (LBBB) even though, in a recent study,
there was enzymatic validation of MI in as many as 80.7% of patients with
new LBBB(4).
All audits eveluating cardiac troponin levels in acute
coronary syndromes should take cognisance of atypical clinical as well as
atypical ECG stigmata of this syndrome otherwise there might be a
distorted evaluation of the prevalence of false positive troponin levels.
References
(1) Wong P., Murray S., Ramsewak A., etal
Raised cardiac troponin T levels in patients without acute coronary
syndrome
Postgrad Med J 2007:83:200-205
(2) Canto JG., Lawrance RA., Sapsford RJ et al
Prevalence, clinical charcteristics, and mortality among patients with
myocardial infarction presenting without chest pain
JAMA 2000:283:3223-9
(3) Bayer AG., Chandra JS., Farag RR., Pathy MSJ
Changing presentation of myocardial infarction with increasing age
J Am Geriatrics Soc 1986:34:263-6
(4) Wong C-K., French JK., Aylward PEG et al
Patients with prolonged ischemic chest pain and presumed new left bundle
branch block have heterogenous outcomes depending on the presence of ST
segement changes
J Am Coll Cardiol 2005:46:29-38
Cuba represents an important alternative example where modest
infrastructure investments combined with a well-developed public health
strategy have generated health status measures comparable with those of
industrialized countries (1). However the economic crisis which began in
1991 after the withdrawal of the Soviet Union wreaked havoc on many
aspects of Cuban society. Although the impact on health in...
Cuba represents an important alternative example where modest
infrastructure investments combined with a well-developed public health
strategy have generated health status measures comparable with those of
industrialized countries (1). However the economic crisis which began in
1991 after the withdrawal of the Soviet Union wreaked havoc on many
aspects of Cuban society. Although the impact on health indices was
relatively modest and now are recovering, the Cuban’s health care system
is still suffering the consequences of a very long period of severe
shortage. Perhaps less evident is the crisis’ impact on
professional performance where a number of causes are involved and
include limited resources, lack of technical discipline and
particularly, poor mechanisms of evaluation/compensation. Taking into
account this situation the health system in Cuba is working, at the same
time with the recapitalization of their technology, in new mechanisms to
achieve the performance of their enormous work force and health’s
infrastructure.
The first experience on performance’s management began in 1999 at the
University Hospital in Cienfuegos, an institution located on the central
and south region of Cuba. After a redefinition of the hospital’s vision
and mission a task force was created to define a set of core performance
indicators for each group from professionals to simple workers. As result
of a comprehensive and participative consultation process a new standards were
generated which are improving year by year and include: work quantity,
quality and results; knowledge; communication skill; human relationship;
behavioural attitude towards postgraduate studies; personal image;
creativity, attendance, and working hours efficiency; fulfilments of the
established regulations and level of patients satisfaction. Individual
performance assessment results of each employee were analysed in private
meetings with the participation of the evaluated worker and his/her
supervisor. The final marks in those individual interviews included a
positive agreement between two different points of view: on one side,
previous self evaluations of workers and, on the other side, the
evaluator’s criteria. This open procedure, face to face, helpfully solved
the distress frequently reported in other types of performance assessment
(2).
Cienfuegos´s hospital is now a top-ranking Cuban hospital
although its main strength is not the technology. Undoubtedly the
management of poor performance, such as has been described by Mayberry (3),
has played a crucial role. The
next step is using this evidence to introduce the pay for performance in
order to achieve an adequate balance between process and results and
between results and tangible incentives, a new policy that Cuba needs to
implement.
References:
1.Cooper R, Kenelly J, Ordúñez P. Health in Cuba. Int J of Epi 2006;
35:817–824.
2.Alvarez FC, Ordúñez PO, Espinosa AD. Introducción de la evaluación
del desempeño individual en un hospital cubano. Metodología y resultados.
Rev Calidad Asistencial.. 2006; 21(2): 102-110.
3.Mayberry JF. The management of poor performance. Postgrad. Med. J.
2007; 83:105-108.
Isolated systolic hypertension and ageing is common in Cuba too and we wish to share our more recent results.
Cienfuegos is the demonstration area for the Action Plan for the Multifactorial Reduction of Noncommunicable Diseases in Cuba. As a part of this project, a baseline was taken to obtain up-to-date information on the prevalence and control levels of hypertension (HBP). There are 76,803 inhab...
Isolated systolic hypertension and ageing is common in Cuba too and we wish to share our more recent results.
Cienfuegos is the demonstration area for the Action Plan for the Multifactorial Reduction of Noncommunicable Diseases in Cuba. As a part of this project, a baseline was taken to obtain up-to-date information on the prevalence and control levels of hypertension (HBP). There are 76,803 inhabitants between the ages of 25 and 74. This study was cross-sectional, based on a population sample of 1,475 people, selected randomly. The sample population was then separated by gender and age (25-44, 45-64, 65-74 years). The rate of participation in the clinical examination was 80%.
Cuba has a universal health system that provides high-quality services at no cost to most of the population, which has proven to be highly effective in hypertension control. (1-2)
HBP prevalence in the study population was 21.4% (Confidence Interval 95% 17,5-25,3). In this study, 39.9% (CI 95% 33,1-46,6) of individuals were found to have controlled HBP. In the 65-74 age group, which has the highest prevalence of HBP (56.6%), also has a greater
proportion of individuals who seek treatment. A considerable proportion of people with HBP between 65 and 74 years, in the categories of examined HBP, had confirmed isolated systolic hypertension (ISH) presence: HBP present
but subject is unaware = 76,4% of ISH (CI95% 59,4-93,5), HBP condition known but subject does not receive treatment = 40,5% (CI 25,9-55,0) and, HBP treated, hypertension controlled 60,7% (CI 48,0-73,5). However, this group’s relative risk was moderately high due to uncontrolled HBP, (> 65 years) but only 3% of individuals with HBP that did not know of their condition and 9% of those who were receiving treatment were uncontrolled.
Hence, the principal challenge for the group > 65 years, is dealing with a higher prevalence of HBP and confronting a greater risk of short-term cardiovascular complications. It is also necessary to identify an effective therapeutic regimen for reaching the goal of controlling hypertension, despite the persistent controversy concerning the ease with
which one can achieve a SBP level lower than 140 mmHg.(3)
There is another element which was not quantified in this study but contributes, in other scenarios, to the high frequency of uncontrolled hypertension. This element could explain, in a context such as the one found in Cuba, that with broad coverage and access, approximately half of
individuals with treated but uncontrolled hypertension showed mild cases of hypertension and the rates of control in the elderly were lower. It has to with the so-called therapeutic inertia.(4)
References
1. Cooper RS, Ordúñez P, Iraola-Ferrer M, Bernal JL, Espinosa A.
Cardiovascular disease and associated risk factors in Cuba: Prospects for
prevention and control. Am J Public Health 2006;96:94-101.
2. Orduñez P, Munoz JLB, Pedraza D, Silva LC, Espinoza-Brito A,
Cooper RS. Success in control of hypertension in a low-resource setting:
the Cuban experience. J Hypertens 2006;24:845-849.
3. Pinto E. Blood pressure and ageing. Postgraduate Medical Journal
2007;83:109-114; doi:10.1136/pgmj.2006.048371.
4. Okonofua EC; Simpson KN; Jesri A; Rehman SU; Durkalski VL; Egan
BM. Therapeutic Inertia Is an Impediment to Achieving the Healthy People
2010 Blood Pressure Control Goals. Hypertension 2006;47:345.
Although adult respiratory distress syndrome (ARDS) is a complication common to both ketotic and non-ketotic diabetic decompensation (1), being arguably attributable to the development of adverse osmotic gradients which generate pulmonary oedema (2), the fact that ARDS is much commoner in diabetic ketoacidosis (DKA) than in hyperosmolar non-ketotic (HONK) diabetic decompensation (3)(4)(5) suggests that th...
Although adult respiratory distress syndrome (ARDS) is a complication common to both ketotic and non-ketotic diabetic decompensation (1), being arguably attributable to the development of adverse osmotic gradients which generate pulmonary oedema (2), the fact that ARDS is much commoner in diabetic ketoacidosis (DKA) than in hyperosmolar non-ketotic (HONK) diabetic decompensation (3)(4)(5) suggests that the discrepancy in prevalence might be attributable to risk factors unique to DKA.
Support for the view that acidosis may be an important risk factor comes from the documentation that the association of tachypnoea and metabolic acidosis can give rise to pulmonary oedema in the animal model of ARDS (6). In humans it has been suggested that the microangiopathy, and, hence, increased capillary permability, documented in the skeletal muscle of diabetic patients might have, as its corollary, an increase in capillary permeability in the presence of ketoacidosis (7). Accordingly, metabolic acidosis and its corollary, ketoacidosis, might be the additional risk factor rendering patients with DKA more liable than their counterparts with HONK to ARDS.
References (1) Kearney T and Dang C. Diabetic and endocrine emergencies. Postgraduate Medical Journal 2007:83:79-86
(2) Kitabachi AE and Wall BM. Diabetic ketoacidosis.
Medical Clinics of North America 1995:79:9-37
(3) Lorber D. Nonketotic hypertonicity in diabetes mellitus. Medical Clinics of North America 1995:79:39-52
(4)Carroll P and Matz R. Adult respiratory distress syndrome complicating severely uncontrolled diabetes mellitus:report of nine cases and a review of the literature
Diabetes care 1982:5:574-80
(5) Marshall SM and Alberti KGMM. Hyperosmolar non-ketotic diabetic coma. The Diabetes Annual 1988;4:235-247
(6) Sinha R., Tinka MA., Hizou R et al. Metabolic acidosis and lung mechanics in dogs. American review of Respiratory diseases 1972:106-881
(7) Brun-Buisson CJL., Bonnet F., Bergeret S., Lemaire F., Rapin M. Recurrent high-permeability pulmonary edema associated with diabetic ketoacidosis. Critical Care Medicine 1985:13:55-56
In the discussion on the medical management of benign prostatic
hyperplasia [1], it was an omission not to make mention of the role of the ingestion of cranberry juice in reducing the recurrence rate of urinary tract infection and/or bacteriuria. The reported antibacterial properties of cranberry juice are attributable to its ability to inhibit bacterial adherence [2], and this has translated into a 12%-2...
In the discussion on the medical management of benign prostatic
hyperplasia [1], it was an omission not to make mention of the role of the ingestion of cranberry juice in reducing the recurrence rate of urinary tract infection and/or bacteriuria. The reported antibacterial properties of cranberry juice are attributable to its ability to inhibit bacterial adherence [2], and this has translated into a 12%-20% reduction in recurrence rate of urinary tract infection(UTI)[3],[4] and a 42% reduction in bacteriuria [3] in adult women. There is no reason to assume that these
results can not be extrapolated to men with benign prostatic hyperplasia, and the benefit might well be that there would be one less indication for transurethral resection of the prostate [5].
References
(1) Connolly SS., Fitzpatrick JM. Medical management of benign prostatic hyperplasia. Postgraduate Medical Journal. 2007:83:73-78
(2) Schmidt DR., Sobota AE. An examination of the anti-adherence activity of cranberry juice on urinary and nonurinary bacterial isolates. Microbios 1988:55:173-81
(3) Raz R., Chazan B., Dan M. Cranberry juice and urinary tract infection. Clinical Infectious Diseases 2004:38:1413-9
(4) Kontiokari T., Sundqvist K., Nuutinen M.,et al.
Randomised trial of cranberry-lingonberry juice and lactobacillus GG drink for the prevention of urinary tract infections in women.British Medical Journal 2001:322:1-5
(5) Thorpe A., Neal D. Benign prostatic hyperplasia
Lancet 2003:361:1359-67
I am an SHO in the 'old' system. I believe the MMC has certain advantages but I have some serious concerns as well.
The maintenance of a personal portfolio and more time and attention from the educational supervisors sounds quite good.
The concerns are:
1. The training period for acquiring the generic skills varies from person to person. The move from time- based to competency-based training resulting in the curtailing of SHO training raises serious concerns.
2. Considering a particular speciality, for example medicine, six months gives more time to enjoy the specialty, learn the basics, acquire specific
skills and finally decide which specialty to pursue for further training.
3. With the old SHOs undergoing a transition now, the competition is unfair because SHOs with one year's experience are competing with those with 2.5-3 years' experience at the ST2 level.
4. F2 trainees have protected teaching times which range from half a day up to a full day which will compromise the quality of the patient care. Doctors should have protected teaching times, but ward work and
patient care should not be compromised at any cost because that is the difference between a medical student and a PRHO or an SHO.
5. The role of membership exams is still not very clear.
Coeliac disease gluten-sensitive enteropathy remains under-diagnosed and can have serious complications. [1] Gluten sensitivity has various manifestations such as enteropathy, dermatopathy and neuropathy. Furthermore, due to the disease overlap about 8% of patients with coeliac
disease develop neurological manifestations. [2] The most common manifestations are ataxia and peripheral neuropathy; and rapidly...
Coeliac disease gluten-sensitive enteropathy remains under-diagnosed and can have serious complications. [1] Gluten sensitivity has various manifestations such as enteropathy, dermatopathy and neuropathy. Furthermore, due to the disease overlap about 8% of patients with coeliac
disease develop neurological manifestations. [2] The most common manifestations are ataxia and peripheral neuropathy; and rapidly progressive neuropathy can be fatal in some cases. [3]
The mechanism for gluten neuropathy is likely to be immunological and through a low grade vasculitis. [3] Neurological features can be the presentation as well as complications of coeliac disese and can be successfully treated with a gluten free diet. [4]
Competing interest: None
References:
1. Goddard CJR, Gillett HR. Complications of celiac disease: are all patients are at risk? Postgrad Med J 2006; 82: 705-712
2. Holmes GKT. Neurological and psychiatric complications in celiac disease. In: Gobbi G, Anderman F, Naccarto S, eds. Epilepsy and other neurological disorders in celiac disease. London: john Libbey, 1997.
3. Hadjivassiliou M, Grunewald RA, Kandler RH, et al. Neuropathy associated with gluten sensitivity. J Nerol Neurosurg Psychiatry 2006;77:1262-66.
4. Hadjivassiliou M, Davies-Jones GAB, Sanders DS, et al. Dietary treatment of gluten ataxia. J Neurol Neurosurg and Psychiatry 2003;74:1221-6
The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to
take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimat...
The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to
take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimatization by increasing the ventilation but it does not mask the symptoms. Only dexamethasone masks the symptoms of AMS and symptoms can recur if people take dexamethasone for severe AMS then stop it when the symptoms improve and ascend up again. Hence people can take dexamethasone themselves for severe AMS only when they are descending. [2,3]
Diamox is a very useful medication in altitude illness. It has been used not only in prevention and treatment of Acute Mountain Sickness (125 mg twice a day for mild AMS and 250 mg twice a day for severe AMS) but
also as adjuvant treatment (to what is mentioned in the article) in High Altitude Pulmonary Edema (HAPE) and High Altitude Cerebral Edema (HACE). The use of diamox as adjuvant makes sense because the sole problem in these pathological processes is hypoxia and diamox improves oxygenation by causing hyperventilation.
When people get HAPE or HACE, they should descend immediately. It must be emphasized here that they must descend with a friend (or porters to carry them down to avoid exertion). We had few cases of both Nepali porters and foreign trekkers in the Everest region where HAPE patients were advised to go down alone by their team mates. However, they were not able to walk and were found by others in bad condition lying helpless on the way after several hours and had to be carried to the clinic (at
Pheriche).
The author has not mentioned the usefulness of Sildenafil(Viagra) and Salmeterol in the treatment and prevention of HAPE. [4] Sildenafil helps by
decreasing the pulmonary artery pressure and Salmeterol helps in reabsorption of the oedema fluid.
References:
1. Clarke C. Acute mountain sickness: medical problems associated with acute and subacute exposure to hypobaric hypoxia. Postgraduate Medical Journal 2006;82:748-753
2. Levine B, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med 1989;321:1707-13. [Abstract]
3. Ferrazzini Z, Maggiorini M, Kriemler S, Bartsch P, Oelz O. Successful treatment of acute mountain sickness with dexamethasone. BMJ 1987; 294:1380-83.
4. West JB. The Physiologic Basis of High-Altitude Illness. Ann Intern Med. 2004;141:789-800.
It was interesting to go through the informative article on mountain sickness by C Clarke. [1] There are some points we wish to make.
The author mentions that the preventive dose of acetazolamide for Acute Mountain Sickness(AMS) is 125mg but does not mention its role in the treatment of AMS. Acetazolamide is used widely in the Himalayas at a dose of 250 mg twice daily until the symptoms resolv...
It was interesting to go through the informative article on mountain sickness by C Clarke. [1] There are some points we wish to make.
The author mentions that the preventive dose of acetazolamide for Acute Mountain Sickness(AMS) is 125mg but does not mention its role in the treatment of AMS. Acetazolamide is used widely in the Himalayas at a dose of 250 mg twice daily until the symptoms resolve. A placebo controlled trail showed the drug decreased the severity of
symptoms by 74 percent within 24 hours. [2]
From my experience as a research doctor in the Everest region this autumn (October - November 2006) the side effects of acetazolamide, although quite annoying, were not that serious to anyone and they showed good compliance. This is in contrast to the author’s experience of the side effects of acetazolamide.
The author mentions that High Altitude Pulmonary Oedema(HAPE) is usually followed by AMS, but around as many as 50% HAPE patients do not have symptoms of AMS. [3] In addition, my experience in the Himalayas has shown a large number of patients who were diagnosed to have HAPE did not have the preceding symptoms of AMS.
Regarding the correlation between the age and AMS, studies show that age is reported to have no effect for individuals less than 60 years old, but has been reported to be protective for older individuals which is not
mentioned in the discussion of old and young. [4,5,6,7]
We were surprised that the author did not mention sleep disorders at high altitude which is very common. The problems are with initiating sleep and numerous awakenings due to apnoenic episodes and having vivid dreams. For these problems acetazolamide 125 mg or some even suggest as low as 62.5 mg just before bed time improves the quality of
sleep.
Laxmi Vilas Ghimire, MBBS
Research doctor
HAPE prevention Trial, Everest region.
Tribhuvan University Teaching Hospital
Kathmandu, Nepal
Matiram Pun
Junior Intern
Institude Of Medicine
Kathmandu, Nepal
References:
1. Clarke C. Acute mountain sickness: medical problems associated
with acute and subacute exposure to hypobaric hypoxia. Postgraduate
Medical Journal 2006;82:748-753;
2. Hackett P H. Roach R C. High–Altitude Illness. N Engl J Med,
2001;345: 107-114
3. Hultgren HN, Honigman B, Theis K, Nicholas D. High-altitude
pulmonary edema at a ski resort. West J Med 1996;164:222-7.
4. Bartsch P., and Roach R. (2001). Acute mountain sickness and high-
altitude cerebral edema. In High Altitude: An Exploration of Human
Adaptation. T. Hornbein and R.
Schoene, eds. Marcel Dekker, New York; pp. 731–775.
5.Hackett P.H., Rennie D., and Levine H.D.. The incidence,
importance, and prophylaxis of acute mountain sickness. Lancet, 1976;
2:1149–1155
6.Honigman B., Theis M.K., Koziol-McLain J., Roach R., Yip R.,
Houston C., Moore L.G., and Pearce P. Acute mountain sickness in a
general tourist population at
moderate altitudes. Ann. Intern. Med. 1993; 118:587–592.
7. Serrano-Duenas M.. Acute mountain sickness: the clinical
characteristics of a cohort of 615 patients.Med.Clin. 2000;115:441–445.
Dear editor
The cut off level for NT-pro BNP proposed by the authors(1) should take into account the fact that blood levels of this parameter may be lower in subjects with body mass index equal to or exceeding 30 kg/metre squared despite left ventricular end diastolic pressures which exceed those of counterparts with lower body mass indices(2). Lower cut-off levels might then have to be devised in obese subjects....
Dear editor
In the above study acute coronary syndrome(ACS) was defined as the presence of ischaemic cardiac symptoms (presumably, chest pain)(1), and it was not made clear whether or not this was to the exclusion of a pain-free presentation(2) characterised, instead, by, for example, sudden onset left ventricular failure or "collapse"(3). In the "worst case scenario" exclusion of ST segment elevation (STEMI) patient...
Dear Editor
Cuba represents an important alternative example where modest infrastructure investments combined with a well-developed public health strategy have generated health status measures comparable with those of industrialized countries (1). However the economic crisis which began in 1991 after the withdrawal of the Soviet Union wreaked havoc on many aspects of Cuban society. Although the impact on health in...
Dear Editor,
Isolated systolic hypertension and ageing is common in Cuba too and we wish to share our more recent results.
Cienfuegos is the demonstration area for the Action Plan for the Multifactorial Reduction of Noncommunicable Diseases in Cuba. As a part of this project, a baseline was taken to obtain up-to-date information on the prevalence and control levels of hypertension (HBP). There are 76,803 inhab...
Dear Editor,
Although adult respiratory distress syndrome (ARDS) is a complication common to both ketotic and non-ketotic diabetic decompensation (1), being arguably attributable to the development of adverse osmotic gradients which generate pulmonary oedema (2), the fact that ARDS is much commoner in diabetic ketoacidosis (DKA) than in hyperosmolar non-ketotic (HONK) diabetic decompensation (3)(4)(5) suggests that th...
Dear Editor,
In the discussion on the medical management of benign prostatic hyperplasia [1], it was an omission not to make mention of the role of the ingestion of cranberry juice in reducing the recurrence rate of urinary tract infection and/or bacteriuria. The reported antibacterial properties of cranberry juice are attributable to its ability to inhibit bacterial adherence [2], and this has translated into a 12%-2...
Dear Editor,
I am an SHO in the 'old' system. I believe the MMC has certain advantages but I have some serious concerns as well.
The maintenance of a personal portfolio and more time and attention from the educational supervisors sounds quite good. The concerns are:
1. The training period for acquiring the generic skills varies from person to person. The move from time- based to competency-bas...
Dear Editor,
Coeliac disease gluten-sensitive enteropathy remains under-diagnosed and can have serious complications. [1] Gluten sensitivity has various manifestations such as enteropathy, dermatopathy and neuropathy. Furthermore, due to the disease overlap about 8% of patients with coeliac disease develop neurological manifestations. [2] The most common manifestations are ataxia and peripheral neuropathy; and rapidly...
Dear Editor,
The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimat...
Dear Editor
It was interesting to go through the informative article on mountain sickness by C Clarke. [1] There are some points we wish to make.
The author mentions that the preventive dose of acetazolamide for Acute Mountain Sickness(AMS) is 125mg but does not mention its role in the treatment of AMS. Acetazolamide is used widely in the Himalayas at a dose of 250 mg twice daily until the symptoms resolv...
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