Things I like about Jamaica

Once you heard somebody saying “Jamaica”, a beautiful island with white sandy beaches and the relaxing reggae music will come into your mind. Yes, it has many beautiful beaches and resorts and I love that. However, I can enjoy those in my homeland Myanmar (aka Burma) too.

So, what are the things really impressive to me? It would be nothing important for other people but directly affect my job or profession, which is the fact that there are –

NO Rabies

NO Malaria, and

NO Snake Bites.

When I was a house surgeon (internship after med school) back home, I came across with several cases of malaria and snake bites. These cases are really stressful and need prompt management including intensive care as they have dreadful complications and high mortality rate. And, I also had to concern with the vaccination of the rabies for every dog bite cases, even though I never saw a case of rabies.

Once I reached Jamaica, I put aside my knowledge about the management of cerebral malaria, differentiation and management of neurotoxic and hemorrhagic snake bites, management of thalassemia and so on. Instead, I focused on the sickle cell disease, obesity and other metabolic diseases. I see my very first case of sickle cell disease here, which is a JFK (just for knowledge) or GTK (good to know) topic in our med school. And I swear to god that I have never seen and manage a gunshot case until I reach Jamaica.

Before I forget to mention, I notice that there is also a relatively low prevalence of tuberculosis which really ease me a lot as you all know how difficult to control and deal with the TB patients. Patient compliance on long treatment regime and follow-up, social support, and the threat of MDR-TB, HIV vs TB are all the challenges. I remembered the days of my ward rounds with a face-mask on TB ward in my home-town hospital. I just made a shallow breathing during the ward round, and felt like I am choking until the round is finished. I am not exaggerating, the mask that I wore was not N-95 and even if it said N-95, you cannot trust and rely on all those equipments, right?

You can have a very unlucky day with your condom burst.

You can have a needle-prick from a HIV positive patient and PEP (post-exposure prophylaxis) failed.

This is our damn LIFE. We live in the world of uncertainty and are risking our lives everyday.

In the end, it’s not going to matter how many breaths you took, but how many moments took your breath away
-shing xiong

Fork in the mouth !

No, it is not about Fork to Mouth Disease (FTMD) (i.e. fat / overweight people living in denial and believing that their weight gain is from an over-active pituitary or thyroid gland – urban dictionary). It is literally a fork stuck in the mouth.

One evening, in fact, it is my very first week as a junior resident in casualty, my senior colleague came into the SMO’s office, where the SMO and I were having a conversation, reporting that he was just seeing a case with a fork in the mouth. Instantly, we all considered she is stabbed. We went there right away and saw a young lady about in her 30s, sitting in bed comfortably with the fork coming out from her mouth.

She mumbled that she was just eating and nobody stabbed her. We said “Ok, let’s have a look”. She could open her mouth normally, meaning her temporomandibular (TM) joint is normal, and we found out the fork just trapped between the floor of the tongue without any penetration. I regret that I didn’t take any picture of it. I really wish you guys to see. Anyway, don’t worry, I just drew a sketch by “FreshPaint” which I like most among windows 8 apps.

Image

Sorry for the eye pain with the bad drawing 😉

We tried to pull out with normal force but it didn’t work and she was in pain. I never know tongue muscle is that strong gripping the fork as if that is its own. Also, the lower teeth seemed to be a kind of barrier to come out easily. The SMO asked us to ascertain that the fork is not penetrating at all by putting finger between the tongue and the fork. And then, he asked the nurse to prepare a gauze soaked with adrenaline explaining us just in case it bled or hematoma formed. Then, he asked the lady to relax and just pulled out with a brisk force like we pull out the chest tube. Everything was perfect then.

So, how could that happen? The SMO admitted that he has never seen such a case in his life with the experience of over 35 years of medical practice. Is it something wrong with hypoglossal nerve? When I googled it, I just found a few possible differential diagnoses that can cause tongue spasm or involuntary contraction of the tongue muscle.

The first one is Meige’s syndrome. (Don’t confuse with Meigs syndrome which is a triad of ovarian tumor, ascites and pleural effusion) That one is also know as Brueghel’s syndrome and oral facial dystonia. It mainly affects TM joint and eye muscles (blepharospasm)Another possible differential should be Tourette syndrome.

Share your knowledge in the comment session below please.

Compilation of Drugs involved in specific conditions (2)

Enzyme Inducers  (NO GAS in CaR)
  • NNRTIs – Nevirapine *
  • Omeprazole – Induces P-450 1A2 **
  • Griseofulvin, Glucocorticoids
  • Alcohol (chronic)
  • Sulphonyureas/ St John’s Wort
  • Carbamazepine,  Pheytoin, barbiturates, Primidone
  • Rifampicin, Quinine
*    NNRTIs either induce or inhibit depending on the concomitantly administered drug
**  competitive inhibitor of the enzymes CYP2C19 and CYP2C9
Enzyme Inhibitors  (DOG RAISE)
  • Diltiazem, Verapamil
  • Omeprazole, Cimetidine,
  • Gemfibrozil, Grapefruit juice
  • Ritonavir (PI in HAART)
  • Amiodarone/ Allopurinol/ Acute alcohol intake, metahnol(acute), Disulfiram;
  • Isoniazid, Imidazoles (ketoconazole, fluconazole)
  • Sulphonamides, Sodium valproate, SSRIs (fluoxetine, sertraline)
  • Erthyromycin, Ciprofloxacin, quinupristin, metronidazole, quinidine
  • * Drugs that cause displacement of warfarin from protein
NSAID, OHA, metronidazole, salicylates, Co-trimoxazole
Drugs which are known to cause impaired glucose tolerance include:

  • Thiazides, furosemide (less common)
  • Steroids
  • Tacrolimus, Ciclosporin
  • Interferon-alpha
  • Nicotinic acid
  • Atypical Antipsychotics e.g. Olanzapine
  • Beta-blockers cause a slight impairment of glucose tolerance.
They should also be used with caution in diabetics as they can interfere with the metabolic and autonomic responses to hypoglycaemia
Drug-induced thrombocytopenia (probable immune mediated)

  • quinine
  • abciximab
  • NSAIDS
  • diuretics: furosemide
  • antibiotics: penicillins, sulphonamides, rifampicin
  • anticonvulsants: carbamazepine, valproate
  • heparin
Drug causes of gingival hyperplasia

  • phenytoin
  • ciclosporin
  • calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include

acute myeloid leukaemia (myelomonocytic and monocytic types)
Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed.
There is however considerable overlap, with some drugs causing a range of changes to the liver
The following drugs tend to cause a hepatocellular picture:

  • Paracetamol (Acetaminophen)
  • Diclofenac
  • Sodium Valproate, Phenytoin
  • MAOIs
  • Halothane
  • Anti-Tuberculosis: isoniazid, rifampicin, pyrazinamide
  • Statins
  • Alcohol
  • Ecstasy/ amphetamine
  • Amiodarone
  • Methotrexate
  • Methyldopa
The following drugs tend to cause cholestasis (+/- hepatitis):
  • Oral Contraceptive pill
  • Antibiotics: ciprofloxacin, flucloxacillin, co-amoxiclav, erythromycin*, nitrofurantoin
  • anabolic Steroids, testosterones
  • Phenothiazines: chlorpromazine, prochlorperazine
  • Sulphonylureas
  • Fibrates
  • rare reported causes: nifedipine
*risk may be reduced with erythromycin stearate
Drugs affected by acetylator status

  • isoniazid
  • procainamide
  • hydralazine
  • dapsone
  • sulfasalazine

Compilation of Drugs involved in specific conditions (1)

1. Drugs that may increase the risk of neurotoxicity by Lithium:

  • Diuretics (esp. thiazides),
  • ACEI/ ARBs
  • Diltiazem or verapamil

2. Drugs that can be cleared with haemodialysis – mnemonic: BLAST

  • arbiturate
  • ithium
  • lcohol (inc methanol, ethylene glycol)
  • alicylates
  • heophyllines (charcoal haemoperfusion is preferable)
 Drugs which cannot be cleared with haemodialysis include
  • tricyclics
  • benzodiazepines
  • dextropropoxyphene (Co-proxamol) – opioid analgesic
  • digoxin
  • beta-blockers
3. Drugs apparently safe in breast feeding:

  • antibiotics: penicillins, cephalosporins, trimethoprim
  • endocrine: glucocorticoids (avoid high doses), levothyroxine*
  • epilepsy: sodium valproate, carbamazepine
  • asthma: salbutamol, theophyllines
  • psychiatric drugs: tricyclic antidepressants, antipsychotics**
  • hypertension: beta-blockers, hydralazine, methyldopa
  • anticoagulants: warfarin, heparin
  • digoxin
Drugs that should be avoided in breast feeding:

  • antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • psychiatric drugs: lithium, benzodiazepines
  • aspirin
  • carbimazole
  • sulphonylureas
  • cytotoxic drugs
  • amiodarone

*the BNF advises that the amount is too small to affect neonatal hypothyroidism screening
**clozapine should be avoided

 
4. Drug causing oculogyric crisis :

  1. phenothiazines
  2. haloperidol
  3. metoclopramide
  4. postencephalitic Parkinson’s disease

5. Acute intermittent Porphyria (AIP)

a. Drugs which may precipitate attack

  • barbiturates
  • benzodiazepines
  • halothane
  • alcohol
  • oral contraceptive pill
  • sulphonamides
b. Drugs considered safe to use

  • paracetamol
  • aspirin
  • codeine
  • morphine
  • chlorpromazine
  • beta-blockers
  • penicillin
  • metformin
Unsafe/ High risk/ To avoid :
  • Arsine
  • Chloramphenicol
  • Chloroquine, Primaquine, Pamaquine, Pentaquine
  • Ciprofloxacin
  • Probenecid
  • Dapsone
  • Dimercaprol
  • Doxorubicin
  • Furazolidone
  • Glibenclamide
  • Glucosulfone
  • Isobutyl Nitrite
  • Menadiol (Vit K3, K4)
  • Mesalazine (5-ASA), O-ASA
  • Metamizole
  • Methylene Blue
  • Nalidixic acid
  • Nitrofurantoin
  • Naphtalene
  • Urate Oxidase
  • Phenacetin
  • phenazopyridine
  • Phenylhydrazine
  • Sulfamethoxazole, Sulfasalazine, Sulfapyridine
Low-risk drugs which can probably be given in NORMAL THERAPEUTIC DOSES to G-6-PD-deficient subjects without nonspherocytic hemolytic anemia
  • Acetaminophen (paracetamol, Tylenol, Tralgon, hydroxyacetanilide)
  • Acetophenetidin (phenacetin)
  • Aminopyrine (Pyramidon, amidopyrine)
  • Antazoline (Antistine)
  • Antipyrine
  • Ascorbic acid (vitamin C)
  • Benzhexol (Artane)
  • Chloramphenicol [high risk for Mediterranean and Asian variants]
  • Chlorguanidine (Proguanil, Paludrine)
  • Chloroquine
  • Colchicine
  • Diphenhydramine (Benadryl)
  • Isoniazid
  • L-Dopa
  • Menadione sodium bisulfite (Hykinone)
  • Menapthone
  • p-Aminobenzoic acid
  • Phenylbutazone
  • Phenytoin
  • Probenecid (Benemid)
  • Procain amide hydrochlonde (Pronestyl)
  • Pyrimethamine (Daraprim)
  • Quinidine
  • Quinine
  • Streptomycin
  • Sulfacytine
  • Sulfadiazine
  • Sulfaguanidine
  • Sulfamerazine
  • Sulfamethoxypyridazine (Kynex)
  • Sulfisoxazole (Gantrisin)
  • Trimethoprim
  • Tripelennamine (pyribenzamine)
  • Vitamin K

Medical Apps for Android

Here, I would like to mention the medical apps that I am using on my android tablet (nexus 7). All of them are available on google playstore for free.

1. Medscape – my favorite reference app; you can have offline access except pictures and videos if you downloaded the data; it is all about:

  1. MEDICAL NEWS FROM MEDSCAPE NEWS
  2. CLINICAL REFERENCE FROM MEDSCAPE REFERENCE – Drugs; Diseases, Conditions & Procedures; Medical Calculators
  3. CONTINUING MEDICAL EDUCATION FROM MEDSCAPE EDUCATION

2. Epocrates – my second-line reference; I like the calculators in it too

3. Calculate by QxMD – Calculate, calculate, calculate everything !

4. NICE Guidance – no need to explain; the name implies; just the UI making me disappointed

5. Prognosis : Your Diagnosis – great case scenarios for clinical practice, judgement and decision; discussion part is really awesome

  • Prognosis : STD
  • Prognosis : Respiratory
  • Prognosis : Diabetes
  • Prognosis : Cardiology
  • Prognosis : Questions

6. Quick LabRef – Quick Clinical Laboratory Values Reference

7. MPR – Monthly Prescribing Reference (MPR) provides concise prescription and OTC drug information, side effects and interactions

8. Ophthalmology – intended for medical students but I found really helpful and informative

9. Heart Sounds & Murmurs – sounds too low to hear with normal speakers in normal surrounding; better study with your headphones (noise cancelled) in a quiet environment

I know there are paid apps out there that are really nice and useful . But, for me the above FREE apps are more than enough.

Nevertheless, if you know any good app for android, please give me a link and the information under the comments below.

Thank you.

Basic clinical guideline for your diabetic patient

Today, let me share a post of my senior doctor, Dr. Khin Swe Myint about an advice and the basic guideline on treating diabetic patients because I see this helpful for junior doctors, GPs and clinicians in their daily practice. Of course, you adjust with your local guidelines and NICE guidelines as culture, eating habit/ dietary pattern, treatment facility etc. may vary.
Here is what she said :

If you are treating any patient with type 2 diabetes, please make sure you go though all check lists, not only to help their glycaemic control but also screen for any micro and macro vascular complication, as well addressing their cardiovascular risk and deal with this.

My advices are:

A. Check list
1. All patients with diabetes must have HbA1c check at least every 6 months bare minimal. Medication adjustment should be based on HbA1c. Not one of “fasting or random glucose” (which is not helpful at all). I am sure it is cheaper than some of specialist consultation fees.

2. Put all patients on statin (either simvastatin 40mg Od or atovastatin 10mg) unless contraindicated or women of child being age who have plan for pregnancy

3. Check their BP– keep target at least <140/90. If evidence of chronic kidney disease keep lower <130/80.

4. Look at their fundi for any retinopathy at least once a year.

5. Once a year, check their feet for any peripheral neuropathy (10 g monofilament and vibration sense will be enough to pick up any early sign) and circulation.

6. Counseling for stop smoking (nicely don’t tell them off)

7. Weight control and regular excercise

8. Labs – U&E, LFT, Lipid profile, urine Albumin creatinine ratio – once a year minimal

9. Please support your patients with some education. This is not only dietary advice but also important of monitoring and watch out for the complication.

B. glyceamic control
1. If you are starting someone with anti diabetes agent, start with Metformin 500mg Od for a week and gradually titrated up to 1g BD if patients can tolerate. Try to avoid if creatinine >150µmol/l and any acute metabolic state (liver failure, uncontrolled heart failure, acute renal failure). Otherwise, it is the safest drug.

2. Next step is to add on Sulphonylurea (e.g., gliclazide- maximal dose is 160mg BD)

3. Then you can add your fancy DDP-4 inhibitor or gliptins if you wish

4. Please learn from your colleagues who had experience in starting people on insulin as inevitably all patients with type 2 will need insulin, the only question is how soon. One easy way to start is adding basal insulin like insulatard e.g., 12 to 16 units at bedtime and titrated with fasting glucose reading.

C. BP control
1. you can start ACE-i. If you do, start small dose, check U&E a week later to make sure it suits and then make sure you titrated up to maximum. This is also applied for patients with microalbumiuria

2. Secondly, add thiazide diuretics which is cheap. It will be a good combination with ACEI. Most Myanmar patients will have high salt intake and therefore, they will response better to diurectics. (Bendroflumethiazide 2.5mg is pretty good start)

3. Then add calcium blocker if BP still not controlled. Do not ever use short acting nifedipine. All CCB are pretty much good. Nifedipine M/R, Amlodipine etc. Do warn patients about potential headache and ankle swelling.

4. For any resistant hypertension patients, check whether they are taking too much liquorice, that can increase BP very high and also hypokalemia. Of course all preserved foods to avoid if possible.

5. Then you add more drugs like alpha blocker (doxazosin etc)

6. Beta blocker may be useful in younger people. If you are using betablocker, I would advice to use Bisoprolol or nevibolol. NOT atenolol. Be ware of Bronchial asthma

D. Know when to refer to specialists
1. If you cannot start insulin by yourselves and patient glycemic control remain poor.

2. In case of acute metabolic complication such as Hyper osmolar nonketotic diabetes state with very high glucose

3. When proliferative retinopathy, new vessels and suspected maculopathy (or sudden reduction in visual acuity)- I will encourage you to invest an ophthalmoscope

4. CKD 3/ 4- they need further assessment including checking for renal bone disease, iron deficiency anaemia etc.

5. Any suspected Charcot joints.

6. Or anything you are not very comfortable looking after.

Enjoys reading. Any question, please let me know.

Pharmacology for Urology

When I was in Urology as a SHO (senior house officer), I have learned my cases and the medications that are used particularly in those urological conditions. So, I made a note for quick review and recall which could be helpful for other junior doctors like me.

First, the two most commonly used drugs in BPH are 5-alpha reductase inhibitors and the alpha blockers. 5-alpha reductase inhibitors have prostate volume reduction effect or apototic effect but the latter have not. However, it takes about 6 months to show the effect of 5-alpha reductase inhibitors and so alpha 1 blockers are used as first line symptomatic agents.

5-alpha reductase inhibitors

Dutasteride and Finasteride – inhibits the conversion of testosterone to dihydrotestosterone; used in combination with alpha-blockers in many cases

Dutasteride (Avodart)dual 5-alpha reductase inhibitor

– 0.5 mg po od

Finasteride (Proscar -5mg and Propecia-1mg) (type 2) 5-alpha reductase inhibitor

– 5mg po od; (1mg od is used in male pattern baldness MPB)

SE –
impotence (1.1% to 18.5%), abnormal ejaculation (7.2%), decreased ejaculatory volume (0.9% to 2.8%), abnormal sexual function (2.5%), gynecomastia (2.2%), erectile dysfunction (1.3%), ejaculation disorder (1.2%) testicular pain and depression. * ?increased risk of high-grade prostate cancer.

pregnancy category X – Mom ! don’t touch the pill, beware of blood transfusion

Alpha Blockers

Selective alpha-1 blockers – Doxazosin, Tamsulosin, Terazosin etc. – inhibits the binding of norepinephrine to the alpha-1 receptors on the membrane of vascular smooth muscle cells

Doxzosin mesylate ( Cardura, Carduran)

Dose: 1mg >>2mg>>4mg>> 8mg (max dose)/day.

Tamsulosin (Flomax, Flomaxtra, Contiflo XL and Urimax) 0.4mg >> 0.8mg od

Two major ADRs (Adverse Drug Reactions) :

  • Immunologic: contains sulfa moiety causing typical reactions to sulfa drugs.
  • Ophthalmologic: ” floppy iris syndrome” during cataract surgery.

Others : Retrograde ejaculation, dizziness and fainting due to BP drop.

N.B. Although prostate specific, it does not have the prostate apoptotic effects of other prostate drugs such as the 5 alpha-reductase inhibitors such as dutasteride and finasteride.

Trial

CombAT (Combination of Avodart and Tamsulosin) trial in 2008,- approved by the FDA on June 14, 2010

provides greater symptom benefits compared to monotherapy with either agent alone for treatment of benign prostatic hyperplasia.

Anticholinergics

Oxybutynin and Tolteredine

Oxybutynin – competitively antagonizes the M1, M2, and M3; also has direct spasmolytic effects on bladder smooth muscle as a calcium antagonist and local anesthetic in very high dose

– used in Overactive bladder/ urinary incontinence; possible treatment of hyperhidrosis

N.B. There was no difference in transdermal oxybutynin and extended-release oral tolterodine.

Contraindications

Untreated angle closure glaucoma and in patients with untreated narrow anterior chamber angles;  partial or complete bowel obstruction, hiatal hernia, GERD, paralytic ileus, intestinal atony of the elderly or debilitated patient, megacolon, toxic megacolon complicating ulcerative colitis, severe colitis and myasthenia gravis. It is also contraindicated in patients with obstructive uropathy and in patients with unstable cardiovascular status in acute hemorrhage.

Tolterodine (DetrolDetrusitol) – acts on M2 and M3

Hormone therapy

Cyproterone acetate CPA (Androcur or Cyprostat) – synthetic steroidal antiandrogen and also has progestogen and antigonadotrophic properties

Uses

1) in OC pills (2mg of CPA +35 or 50mg ehtinyestradiol),

2) hypersexuality, hirsutism, male-female transsexuals (25mg po.bd, up to 100mg/day)

3) metastatic Prostate CA (300mg/day), monitor LFTs, often co-administered with a GnRH agonist and a 5-alpha-reductase inhibitor

SE:  liver toxicity (dose dependent), adrenal suppression (so, monitor cortisol level and U&Es), often co-administered with a GnRH agonist and a 5-alpha-reductase inhibitor

Flutamide – oral, non-steroidal antiandrogen drug, has been largely replaced by Bicalutamide (Casodex, Cosudex, Calutide, Kalumid) –

Uses

1) stage D2 metastatic prostate cancer in combination with a LHRH analogue or as a monotherapy.

2) hirsutism, trials in Ovarian CA , also used in combination with castration

3) andogen receptor positive ER-/PR- metastatic breast cancer

Dose – 50mg po od (recommended same time each day)

Leuprolein or Leuprolide acetate -pituitary GnRH analogue

Pregnancy Category X

Uses: Hormone responsive cancers (Prostate CA, breast CA),

Use in Gynecology – precocious puberty, gender incongruency,  menorrhagia, endometriosis, adenomyosis, Uterine fibroids, in IVF(in vitro fertilization) – control of ovarian hyperstimulation,

Severe cases of CAH (congenital adrenal hyperplasia)

also, possible treatment for Paraphilia and Alzheimer’s dz

SE: s/s of hypo-estrogenism such as headache, hot flushes and osteoporosis

increased risk of heart problems by ~30% (when used for advanced CA Prostate)

Urinary Alkalinizing Agents

Potassium citrate (Cytra-K, Urocit K)

Urinary citrate <150 mg/day: 60 mEq/day PO (20 mEq with each meal) OR

Urinary citrate >150 mg/day: 30 mEq/day PO (10 mEq with each meal)

Maintenance –

  • Titrate dose to achieve urinary citrate 320-640 mg/day & urinary pH 6.0-7.0 (maximum dose 100 mEq/day)

Local Analgesic

Phenazopyridine – Azo dye; 100mg-200mg po tid (no more than 2 days)

used in severe dysuria;  post-procedures

Bleeding control

tranexamic acid (Cyklokapron, Lysteda) – Inhibits fibrinolysis through inhibition of plasminogen activator substances; also exhibits antiplasmin activity

used in conjunction with bladder irrigation in hematuria cases

Alright, I think you should be ready to go to urology unit by now. Good Luck!

N.B. I have also used Doxorubicin (Adriamycin) in many cases with TCC bladder; it is an Anthracycline that intercalates between DNA base pairs, impairs topoisomerase II function and inhibits replication & transcription

Add other drugs and noteworthy facts in the comments below please.