Chronic Liver Disease – the Role of Glutathione

Glutathione is the body’s master antioxidant and protects the body from various diseases. It performs multiple functions to prevent the body from developing diseases and also helps to detoxify chemicals and drugs.

On the other hand, its reducing level increases the risks of toxicity and diseases. GSH along with the other cellular antioxidants, work synergistically to neutralize and scavenge oxygen and other free radical species. Thereby it prevents or diminishes “oxidative stress”.

Progression of liver diseases is contributed by deficiency of GSH and increase of free radical species. Therefore, glutathione has an important role to play in the cases of alcoholic liver disease, viral hepatitis, and particularly hepatitis C.

Various studies were conducted related to the role of antioxidants, particularly L-glutathione, in chronic liver diseases. There were reports on the levels of glutathione present in liver, blood and lymphocyte of patients with chronic hepatitis C. Few of these patients were infected by HIV too.

The liver is the major source of GSH levels in blood. It was found that GSH content in patients with hepatitis C was significantly reduced. This was interconnected with the severity of their liver disease and the ability of the hepatitis C virus to multiply. The GSH levels were found to be further more lowly in the cases of those who were HIV positive, compared to those with only hepatitis C. Patients addicted to drugs were the one’s to have the lowest GSH levels.

Studies suggested that increased levels of glutathione helps to improve the response to interferon treatment in the cases with hepatitis. It was confirmed that oxidative stress occurred in patients with chronic hepatitis and the studies also showed that the levels of free radicals was correlated with the activity of the hepatitis.

In another study conducted in Italy, improved glutathione levels with high intravenous doses in patients with fatty livers, secondary to alcoholic hepatitis or viral hepatitis (B or C), were marked to show improvement in liver tests, which lasted for several months, after the GSH treatment.

It was found that there was a presence of free radicals due to oxidation of lipids in patients with alcoholic liver disease. Therefore it was concluded that oxidant stress contributes to the deterioration of the liver disease.

Studies made it clear that:

* Oxygen and other toxic free radicals, resulting from oxidative stress, occurred in chronic liver disease, which contribute to liver damage in various common types of chronic hepatitis.
* Levels of antioxidants in blood and liver, mostly those of L-glutathione, are found to be lower in these patients compared to others.
* Thirdly, higher levels of L-glutathione have shown to improve liver cell damage as reflected by standard liver tests. In chronic hepatitis C, increase of glutathione not only impairs Virus C replication but also renders interferon anti-viral therapy to be more effective.

The studies suggested that the futures of therapy of chronic hepatitis C are likely to include measures to decrease oxidative stress and injury, and the use of multi drug combinations, including inhibitors of hepatitis C virus.

MaxGXL has been proven to raise glutathione levels by approximately 250-400% in humans as proven by tests in lymphocytes. MaxGXL provides the proper nutrients needed to promote the body’s own ability to manufacture and absorb glutathione.

What You Should Know About The Different Liver Cirrhosis Lab Values

Liver cirrhosis lab values are used to diagnose what stage a person’s liver disease is in. Here are some of the blood tests and lab values that your doctor will go over with you:

– Albumin Normal values for an adult are 3.4-5.4 g/dL. People with chronic liver disease accompanied by cirrhosis usually have levels < 3 g/dL.

– Ammonia Normal ammonia values for an adult are 15-45 ug/dL. When the liver and portal blood flow is impaired, ammonia levels rise.

– Immunoglobulins A variety of immunoglobulins will increase with chronic liver disease. The rise of different immunoglobulins suggest specific liver diseases. Here are the normal adult values:

1. IgA — 140-400 mg/dL (elevated levels detect alcoholic liver disease, cirrhosis, hepatitis, laennec’s cirrhosis, hepatobiliary carcinoma)

2. IgD — 0-8 mg/dL (elevated levels detect chronic infections and liver diseases)

3. IgG — 700-1500 mg/dL (elevated levels detect autoimmune hepatitis, hepatitis, hepatitis c, laennec’s cirrhosis)

4. IgM — 35-375 mg/dL (elevated levels detect biliary cirrhosis, hepatitis, viral infections)

– Platelets Normal adult values are 150,000-450,000/mm3

– Bilirubin The bilirubin values vary for men and women. The normal values for adult men are 0.3-1.1 mg/dL, and for adult women the values are 0.1-0.4 mg/dL. Bilirubin measures how well your liver is excreting bile. But note that there are certain drugs can elevate bilirubin levels.

These are just some of the liver cirrhosis lab values that your doctor will go over with you, and there may be more that he or she will include. If you are listed for a transplant, you are given a Model for End-Stage Liver Disease (MELD) score. The lab values used in the MELD calculation include:

– Bilirubin, which, again, measures your liver’s ability to excrete bile.

– INR, which measures your liver’s ability to make blood clotting factors.

– Creatine, which measures kidney function. Kidneys that aren’t functioning properly are often associated with severe liver disease.

The MELD score can go up and down depending on your lab values. For instance, you can have a high score, then receive treatment and your score will then go down. Now, if you’re not at the stage yet where you need a transplant, then consider some treatments and techniques that can help reverse the effects of liver cirrhosis. There are many things you can do that are safe, inexpensive and effective that will give your liver a break and give you back your energy and vitality.

The complete liver cirrhosis solution combines supplements, a healthy diet and stress-reducing techniques, ending your suffering from nausea, discomfort and worry. You can not only prolong your life, but you can also prolong your quality of life.

Kidney Stones Treatment at Home: Pass Kidney Stones Painlessly

A kidney stones treatment plan will help you pass your kidney stones quicker, and with less pain. Answering these questions will help you to understand if you have them: did you see some blood in your urine? Do you experience pain on your abdomen, side, or groin? If the answers to these questions are yes, then you might be suffering from these stones. It is important to see a doctor right away in order to know your exact condition and the condition of your kidneys and the stones inside them. Stones in the kidney are also known as renal calculi and this is a very hard mineral and a crystalline material that can be formed inside your kidney or within your urinary tract. According to studies, there is one individual that might suffer from renal stones for every twenty individuals. There are diet plans created for people like you who are suffering from them. This article assumes that you are a sufferer, the fact that you are reading this article right now and that you are looking for a the perfect treatment that you can also use at home for your kidney problems.Discover a painless experience using an at home kidney stones treatmentActually there are at-home kidney stones treatment plans for painless passing of the stones that you will discover as you continue reading this article. Normal renal calculi are about 5mm to 10mm in size and they can usually pass through the kidneys in their own, because there are only one to two of ten that need some medical attention. Renal calculi need one to three weeks right before they pass, right after using a treatment. The following is an at-home treatment plan that you can perform in order to help your kidney to pass the stones.Kidney stones treatment you can use at home• The very first fundamental thing that you need to understand is the need for plenty of water. This can keep your urine very clear if you will drink 8 to 10 glasses of water every day. Water cannot only help you eliminate stones already inside your urinary tract or kidney, but it can also help in eliminating other toxins in the body. This is important in any treatment plan.• You can also get a nettle leaf. This leaf is known for the promotion of urine. It is important to drink at least 2 to 3 cups of nettle leaf per day as part of your treatment plan. The nettle leaf can work by constantly keeping the water flow in the bladder and in the kidney, it can also aid in washing away bacteria. You can prepare a nettle leaf tea by mixing 1 to 3 tablespoon of dried nettle leaf in a cup of hot water.

• By taking vitamins such as vitamin A and B6 as a supplement, you can definitely prevent the formation of any renal calculi. This is effective if you will take these vitamins for a couple of months, and it will help you from forming additional stones in the future. Supplements are a very important part of your treatment process.• You can also eat more pomegranates. The seed of the pomegranates is proven effective in treating renal calculi. These seeds can be grounded into a very fine paste and a tablespoon of this paste together with horse gram soup can dissolve renal calculi as fast as possible. In order for you to prepare this cup of soup, you need at least two tablespoons of this horse gram.An at-home kidney stones treatment can be very effective if used properlyThese home remedies for a kidney stones treatment are proven effective by many kidney stones sufferers. But in the event that these homemade remedies does not help you pass the kidney stones, then you need to call your doctor for a specific medical kidney stones treatment. If you are feeling severe pain, it means that the stones are already blocking your urinary tract and there could be an infection. The doctor might suggest a surgical treatment or a medical treatment for use with an at-home kidney stones treatment.

Emetophobia Stories of Success

Emetophobia Stories of Success

Emetophobia is basically an illogical fear about vomiting. Those who are emetophobic will be always having the worry that they may vomit in front of others or they will be vomited by someone. They get afraid when they see someone vomiting or just the vomit. Knowing that someone is vomiting is a horrifying news for them.

Emetophobia starts during childhood of the affected person. Out of his own suffering due to vomiting or the traumatic scene of someone suffering due to vomiting he might have made some wrong interpretations about vomiting. Those interpretations which are actually the outcome of his ignorance and irrational way of thinking at that age get registered in his subconscious mind. It may get triggered even after he attains adulthood. The manifestation of the subconscious mind varies from person to person and accordingly it will be continuous, due to a stimulus or due to a particular incident after many years.

The life of emetophobic people are affected due to the problem. They take less food and never opt for outside food. Out of the fear for vomiting he may keep away from social gatherings and places of work and avoid long travels. Women who have emetophobia will try to delay or even avoid pregnancy and when they become pregnant they find it too miserable.

In order to get rid of emetophobia, you must get rid of vomiting. When you are assured that you will vomit no more you will be able to come out of the fear of vomiting. Vomiting can be successfully cured by way of natural remedies. They are very safe also and offer quick relief from vomiting.

There are various methods of home remedies to get relief from vomiting.

Drink ginger tea or suck shaved ginger so that all digestive disorders will be rectified.

Pour a few drops of peppermint oil on an ice cube and suck the cube. It will soothe your stomach.

You can get relief from vomiting by sucking 2 or 3 cloves.

Dip tamarind in a cup of water, smash it and filter. When you drink that water, you will get relief from nausea.

Emetophobia Recovery System will cure your vomiting as well as relieve you from the fear of vomiting. Thus Emetophobia Recovery System can successfully solve all your problems and you need not go for home remedies also.

Stopping Food Poisoning Before It Happens

Food poisoning what to do is not to get poisoned in the first place by understanding what can harm you. Part of my goal here today is share with you some of these culprits that some people don’t know about, as well as share with you a few tips on how to heal from poisoning.
Mercury is the first kind of poisoning I want to talk about. If we have to much of this metal in our system it can lead to a unhealthy nervous system as well as heart, brain and lung damage.

Young children our the most vulnerable to the damage of this kind of metal. 50% of mercury poisoning comes from fish. Pollution enters oceans/rivers which the fish absorb. We consume this poison after we eat the fish that comes into contact with Mercury.
symptoms include headaches, dizziness, tremors, a fuzzy head, headaches and there really is never a safe level in humans.

We can help reduce poising by consuming smaller younger fish such as salmon, sardines. The fish with the most mercury are bigger, older fish such as, swordfish, tile fish, sushi, tuna.

Next is Bisphenol A also called BP A. What BP A does is cause plastic to become hard and is a ingredient in metal cans. The diseases of cancer and diabetes have been linked to heavy exposure.

To avoid this poison limit consumption of can foods when possible, don’t microwave anything in plastic, and plastic with the 7 Pc sign, including hard plastics try to avoid.  Also try to avoid buying meat that is packaged in plastic if you can and vinyl shower curtains are not the greatest choice for this.  Something like polyester could be better.

Another point the chemical pesticide that a lot of farmers put in vegetables and fruits are not healthy. Attention disorders, autism and obesity have been linked to a lot of exposure.  As you can guess organic products such as meat, vegetables have less pesticides. Potatoes can soak in lots of this chemical so it could be a top choice for organic and apples if you eat a lot. I also have secret spray that can eliminate pesticides click on the link below this article to get the recipe.

Lastly Teflon that coats pans so food doesn’t stick is not healthy as well.  If you use Teflon pans, avoid metal spatulas on them.  If you have a Teflon pan that is scratched throw it out.

To get the complete guide on food poisoning click on <a rel=”nofollow” onclick=”javascript:ga(‘send’, ‘pageview’, ‘/outgoing/article_exit_link/3686890’);” href=”http://www.increasemyhealth.org/articles/food-poisoning-what-to-do”>Food Poisoning What To Do </a>

Causes of Gastric Ulcer

Gastric ulcer is basically due to the imbalanced secretion of stomach enzymes and acids as well as the components released in the mucosal lining of the stomach. This then will get inflamed that may be aggravated by aspirin and NSAIDs or Non-Steroidal Anti-Inflammatory Drugs. NSAIDs are commonly taken to combat the symptoms of other ailments such as back pain and kidney pain. Interestingly enough, stress and a number of emotional problems are not labeled as risk factors to gastric ulcer. Yet there are studies that may show otherwise. They point out that stress may be a contributing factor to the aggravation of the ailment.

Ulcers are a painful introduction to one’s life and will require huge changes in lifestyle to reduce the pain and alleviate the condition. Of course, this is only of any worth, if the patient knows that they have an ulcer, if he/she is unaware as to how to recognize the symptoms of a gastric ulcer then the condition will only get a lot worse. Abdominal pain is usually the most common symptom that an ulcer may be present. The pain can last a long time, sometimes up to several hours, or it could only appear as a stabbing pain and disappear as quickly as it arrived.

Gastric Ulcers are caused when there is an imbalance between the amount of stomach acid the body is secreting and an enzyme called Pepsin and the natural defenses of the stomach lining (known as mucosal). There is a spiral shaped bacteria living in the acid environment of the stomach (Heliobacter Pylori Bacterium) which can also cause gastric ulcers. On the other hand, physical stress and insufficiencies can facilitate the development of gastric ulcer.

Gastric ulcer occurs due to excessive secretion of hydrochloric acid and pepsin, which eventually damage the protective tissue that surrounds the stomach. The presence of bacteria called Helicobacter pylori also contributes to developing gastric ulcer. Furthermore, the ulcer is aggravated by the misuse of certain anti-inflammatory medicines, such as aspirin or ibuprofen. In the past, it was thought that emotional distress was also a cause of gastric ulcer. However, this theory has been contradicted by recent medical research results.

Gastric ulcer is not caused by spicy food, stress, or alcohol, it is caused by bacteria called Helobacter pylori, but billions of people are carrying this bacteria, because it is transmitted through food, drink, or contact with someone infected. So, many of us have these bacteria, and if you combine it with spicy food and stress you have gastric ulcer! Recent studies have also shown that anti-inflammatory medication (ibuprofen and aspirin) seriously contribute to the gastric ulcer’s evolution.

Gastric ulcer usually occurs in the region of the posterior stomach wall, in the proximity of the pyloric orifice. In the initial stage of the disease, the ulcer appears as a circular lesion with a diameter of 1-2 cm. In the absence of proper medical treatment, the ulcer can expand, causing a wide hole in the stomach wall. This complication is referred to as perforated ulcer and it is considered to be a medical emergency. Along with internal bleeding, perforated ulcer accounts for thousands of annual deaths in the United States.

Peptic Ulcer, causes, symptoms and Unani Treatment

A peptic ulcer is the result of hyperacidity, which is caused by an increase in the hydrochloric acid in the stomach. This strong acid, secreted by the cells lining the stomach, erodes the inner lining of the stomach. Dietetic indiscretion such as overeating, taking of heavy meals or highly spiced foods, coffee, alcohol, and smoking are the main factors contributing to this condition.

Causes: There are several reasons of peptic ulcers. The major causes include excess intake of alcohol, smoking, unhealthy and stressful life style. Excess consumption of junk food, untimely food eating habit also led to peptic ulcer. Acidity and food poisoning may also lead to peptic ulcers. Other causes for peptic ulcer include cancer, side effects of certain medicines, etc. Other causes are the ingestion of certain drugs, food poisoning, certain infections, gout, emotional disturbances, stress, and nervous tension

Home Remedies for Peptic Ulcer

Given below are the simplest and the most effective home remedies for the treatment of peptic ulcers.

Fruits:

Among various other fruits, banana is considered as one of an effective fruit for treating peptic ulcer. Banana helps in lowering the acidic substance inside the body. Take 2-3 bananas mixed in a glass of milk for 4-5 times a day.

Similarly, wood apple ( bael ) is also very useful. Take few bael leaves and keep it into water overnight. Drain the mixture and take this 2-3 times a day.

Fenugreek (methi) seeds:

Take 2-3 tablespoon of fenugreek (methi) seeds and boil it in a glass ofwater. Add little amount of soil to it. Allow the mixture to boil till it become half of its constituent. Take this mixture 2-3 times a day, until the ulcer is not cured completely.

Milk:

Milk is really good for patient with peptic ulcer. Patient should take 2-3 glasses of water everyday. Warm milk containing drops of castor oil is also very good for treating peptic ulcer.

Vegetables:

Among vegetables cabbage is very useful for treating peptic ulcer. Cut cabbage into small pieces, allow the vegetable to boil in water till the constituent become half. Drain the mixture and take this 2-3 time a day. One can also add little amount of black pepper powder to it.

Drumsticks:

Drumstick leaves are also an effective home remedy for the treatment of peptic ulcer. Take 15-20 leaves of drumstick and make its paste. Mix this paste in fresh curd. Take this 2-3 times a day. This is one of the important home remedies for peptic ulcers.

Lemon:

Lemon extract or juice is also very effective in treating peptic ulcer. Prepare fresh lemon juice, add little amount of salt to it. This drink helps in digestion and hence helps in treating peptic ulcers. This is one of the best home remedies for peptic ulcers.

Others: An infusion of the leaves of wood apple is another effective remedy for this disease. Fifteen grams of leaves should be soaked overnight in 250 ml of water. In the morning this water should be strained and taken as a drink. The pain and discomfort will be relieved when this treatment is continued for a few weeks. bael leaves are rich in tannins which reduce inflammation and help in the healing of ulcers. The bad fruit taken in the form of a beverage also has great healing properties on account of it mucilage content. This substance forms a coating on the stomach mucosa and thus helps in the healing of ulcers.

The juices of raw vegetables, particularly carrot and cabbage, are beneficial in the treatment of peptic ulcers. Carrot juice may be taken either alone or in combination with spinach, or beet and cucumber. The formula proportions in case of the first combination are 300ml of carrot juice and 200 ml of spinach juice; and in case of the second combination, 300 ml of carrot juice and 100 ml each of beet and cucumber juice to make 500 ml of juice.

Diets for Peptic ulcer patient: The diet of the patient suffering from a peptic ulcer should be so planned as to provide adequate nutrition, while affording rest to the disturbed organs, maintaining continuous neutralisation of the gastric acid, inhibiting the production of acid, and reducing mechanical and chemical irritation. Milk, cream, butter, fruits, fresh raw and boiled vegetables, natural foods, and natural vitamin supplements constitute the best diet. Healthy food habit, balanced diet rich in food and vegetables are very important for keeping our body system healthy. Patient suffering from peptic ulcer should take diet rich in green leafy vegetable, fruits, milk, cheese, etc.

Unani Treatment: In Unani system of medicine plants, animals as well as mineral origin drugs are being used clinically for the treatment of this disease without any side effect. These are time tested, centuries old, safe for use and cost effective. However, there is a need to maintain their purity, quality and safety by subjecting to scientific validation. Unani physicians recommended the following steps for the treatment of peptic ulcer.

1. Use of easily digestable food

2. Avoid of corrosive drugs

3. Use of astringent drugs for binding effect of ulcers

4. Qurs Tabasheer, Qurs Mulaiyn,

5. Samagh arbi in case of oesophageal ulcer

6. Desiccant and cictrizent drugs are effective after complete clearing of slough from ulcers.

7. Jawarish Zanjabeel

Some of single drus as follows;

Khulanjan (Alpinia galangal wild), Khatmi (Althaea rosea linn), Alwa (Aloe barbadensis mill), Gaozban (Anchusa strignosa), Adrak (Zingiber officinale), Kalonji (Nigella sativa Linn), Asgand (Withania somnifera), Kutki (Picorhiza kurroa), Kela (Musa paradisiacal), Heel kalan (Amomum subulatum), Heel khurd (Elettaria cardamomum), Jaiphal (Myristica fragrans), Neem (Azadirachta indica) etc

Gastritis Is More Than Indigestion

It is the inflammation of the stomach getting the defense system on roll. It would mean that the stomach is injured and the white blood cells move on the walls of the stomach for help. The inflammation can be caused due to an infection caused by bacterium which can lead to stomach ulcers. Any other injury can also cause such problems.

Some of the other reasons for having gastritis other than bacterial infection is due to smoking, alcohol abuse, excess caffeine, irregular eating habits, greasy foods and spicy food are all causes of gastritis. Avoid using drugs which can be more harmful than beneficial.

Some of the methods to prevent gastritis is to eat regularly and have the right kind of food. There should be a complete stoppage of smoking as well as limiting yourself on the consumption of caffeine and alcohol. Avoid taking medications which can be harmful and could create more problems with the current condition. Avoid having foods which would take time to digest.

Some of the signs and symptoms which you would face during this condition is abdominal discomfort, continuous pain which occurs between the navel and lower ribs, there are increasing chances of nausea and which may occur with the addition of vomiting. The lack of good appetite does not help in such case and just happens to make things worse for you. Belching, bloating or the fullness of your stomach shows you the signs of gastritis.

You can take good care of yourself without the interference of the doctor. If you practice some of the basic requirements for better health there won’t be any need for the doctor. Have regular eating habits, have a healthy diet, try to exercise regularly and avoid stress in you life.

The Diversity of Lupus Symptoms

Lupus is a complex autoimmune disease that generates a wide variety of symptoms. The symptoms produced by lupus may range from mild to severe and generally occur in flares, unpredictably aggravating or ameliorating over time. Some of the common symptoms of lupus are: pronounced fatigue, pain and swelling of the joints, skin rashes and fever. At skin level, lupus often causes the occurrence of the “butterfly rash”, which appears across the nose and cheeks. Although the butterfly rash is the most common rash characteristic to lupus, the disease can cause many other different types of rashes located in various regions of the body: face and ears, scalp, neck, arms, shoulders, hands, chest and back.

The autoimmune disease can also produce symptoms such as chest pain, increased sensitivity to sunlight, alopecia (hair loss), anemia or leucopenia (decrease in the number of red blood cells, respectively white blood cells), and paleness or cyanosis of the fingers and toes (due to poor oxygenation of the body extremities). Patients with lupus often suffer from headaches, vertigo (dizziness), decreased vision, poor concentration, psychological conditions (depression) and sometimes even seizures and faints. The progression of the disease is unpredictable and symptoms may come and go unexpectedly. Over time, patients with lupus may experience different sets of symptoms, occurring in flares and varying in intensity and duration.

When lupus affects the lymphatic system of the body, the most common symptoms of lupus are swelling and pain of the lymph nodes throughout the body. Most cases of lupus either affect the lymphatic system, the musculoskeletal system or the skin. When lupus affects the musculoskeletal system, the most common symptoms are muscular pain, fatigue, swelling and stiffness of the joints. When confined to the skin, lupus commonly generates rashes, inflammation and irritation of the skin.

Lupus often causes kidney affections such as nephritis (inflammation of the kidneys), interfering in the process of excretion and determining the accumulation of toxins inside the body. Lupus patients who also suffer from kidney impairments usually require strong medication treatments in order to prevent the occurrence of serious complications.

In many cases, lupus affects the circulatory system of the body, causing inflammation of the blood vessels (vasculitis), anemia or leucopenia (decrease in red and white blood cells). Lupus may also lead to the occurrence of thrombocytopenia, a decrease in the number of platelets in the blood, condition that interferes in the process of blood coagulation, increasing the risk of bleeding.

When lupus affects the central nervous system, the most common symptoms are dizziness, headaches, temporary memory loss (amnesia), decreased vision, or neuropsychological problems (depression, unpredictable behavioral changes). Some of these previously mentioned symptoms aren’t solely caused by lupus; often they occur as a result of emotional stress and prolonged lupus medication. The majority of these symptoms can be reversed by interrupting the treatment or reducing the dose of medication.

At pulmonary level, patients with lupus may suffer from pleuritis (inflammation of the interior lining of the chest), condition that causes pronounced discomfort and pain, especially when taking deep breaths. Patients with lupus are also very susceptible of developing pneumonia. At coronary level, patients with lupus may suffer from coronary vasculitis (inflammation of the arteries that deliver blood to the heart), myocarditis and endocarditis (inflammation of the heart itself) and pericarditis (inflammation of the heart protective membrane). If discovered in time, the implications of lupus at coronary level can be efficiently reversed with medical treatment.

So if you want to find more about Lupus or more details about symptoms of lupus please follow this link http://www.lupus-guide.com

Lower Extremity Ulcers of the Legs, Ankles, and Feet

An ulcer is a sore on the skin or a mucous membrane often associated with the disintegration of tissue and the formation of pus. Ulcers can result in the complete loss of the epidermis, the dermis, and in more advanced cases subcutaneous fat. Ulcers that appear in the skin are distinguished by inflamed tissue with an area of reddened skin. Skin ulcers are most often associated with diabetes, but have numerous other causes including exposure to heat or cold, irritation, and problems with blood circulation.

Lower extremity ulcers and amputations are an increasing problem among individuals with diabetes. Data from the 1983-90 National Hospital Discharge Surveys (NHDS) indicate that 6% of hospitalizations listing diabetes on the discharge record also listed a lower extremity ulcer condition. In hospitalizations that listed diabetes, chronic ulcers were present in 2.7% of the patients. The average length of stay for diabetes discharges with ulcer conditions was 59% longer than for diabetes discharges without ulcers. Recent data suggest that foot ulcers precede approximately 85% of nontraumatic lower extremity amputations (LEAs) in individuals with diabetes.

More than half of lower limb amputations in the United States occur in people with diagnosed diabetes. NHDS data also indicate that there were  about 54,000 diabetic individuals who underwent  nontraumatic LEAs in 1990. Lower extremity amputations are more common in individuals with diabetes than without diabetes.

Several studies have demonstrated the beneficial effect of patient education on reducing LEAs. A randomized trial showed that patient self-care was helpful in preventing serious foot lesions. Several amputation prevention programs have reported striking pre- and post-intervention differences in amputation frequency after instituting comprehensive, multidisciplinary foot care programs. Part of the hospital care and self care program should be the administration of a topical growth factor gel to the wound.

What are the types and symptoms of ulcers? Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin. The three most common types of leg and foot ulcers are:

  1. Venous stasis ulcers
  2. Arterial (ischemic ulcers)
  3. Neurotrophic (diabetic ulcers)

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look as defined below:

1. Venous stasis ulcers

Venous ulcers are located below the knee and are primarily found on the inner part of the leg, just above the ankle. The base of a venous ulcer is usually red and may also be covered with yellow fibrous tissue, or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discolored and swollen. It may even feel warm or hot. With edema (swelling) the skin may appear shiny and tight. The skin of the lower leg may also have brown or purple discoloration known as “stasis skin changes.”

Venous stasis ulcers are common in patients who have a history of leg swelling, long standing varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80 to 90% of all leg ulcers.

2. Arterial (ischemic)

Arterial ulcers are usually located on the feet and often occur on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes. Arterial ulcers also commonly occur in the nail bed if the toenail cuts into the skin or if the patient has had recent aggressive toe nail trimming or an ingrown toenail removed.

The base of an arterial or ischemic ulcer usually does not bleed. It has a yellow, brown, gray, or blackened color. The borders and surrounding skin usually appear as though they have been punched out. If irritation or infection are present, there may or may not be swelling and redness around the ulcer base. There may also be redness on the entire foot when the leg is dangled; this redness often turns to a pale white/yellow color when the leg is elevated.

Arterial ulcers are usually very painful, especially at night. The patient may instinctively dangle their foot over the side of the bed to relieve the pain. Patients usually have prior knowledge of poor circulation in their legs and may have an accompanying disorder.

3. Neurotrophic (diabetic)

Neurotrophic ulcers are usually located at increased pressure points on the bottom of the feet. However, neurotrophic ulcers related to trauma can occur anywhere on the foot. These types of ulcers occur primarily in people with diabetes although anyone who has impaired sensation of the feet can be affected.

The base of the ulcer is variable, depending on the patient’s circulation and may appear pink/red or brown/black. The borders of the ulcer are punched out and the surrounding skin is typically calloused.

Neuropathy and peripheral artery disease are often co-morbid in people who have diabetes. Nerve damage (neuropathy) in the feet often results in a loss of foot sensation and changes in the sweat-producing glands. Thus, a person may not feel the development of foot calluses or cracks, increasing the risk of injury or infection. Symptoms of neuropathy include tingling, numbness, and burning or pain.

What causes leg ulcers? Leg ulcers may be caused by:

  1. Poor circulation, often caused by arteriosclerosis
  2. Diabetes
  3. Venous insufficiency (a failure of the valves in the veins of the leg that causes congestion and slowing of blood circulation in the veins)
  4. Other disorders of clotting and circulation that may or may not be related to atherosclerosis
  5. Renal (kidney) failure
  6. Hypertension (treated or untreated)
  7. Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
  8. Inflammatory diseases including vasculitis, lupus, scleroderma or other rheumatological conditions
  9. Other medical conditions such as high cholesterol, heart disease, high blood pressure, sickle cell anemia, bowel disorders
  10. History of smoking (either current or past)
  11. Pressure caused by lying in one position for too long
  12. Genetics (they may be hereditary)
  13. A malignancy (tumor or cancerous mass)
  14. Infections
  15. Certain medications

How are leg ulcers diagnosed and treated?

First, the patient’s medical history is evaluated. A wound specialist will examine the wound thoroughly and may perform tests such as X-rays, MRIs, CT scans and noninvasive vascular studies to help develop a treatment plan. The goals of treatment are to relieve pain, speed recovery, and heal the wound. Each patient’s treatment plan should be individualized based on the patient’s health, medical condition, and ability to care for the wound.

Treatment options for all ulcers may include:

  1. Antibiotics, if an infection is present
  2. Anti-platelet or anti-clotting medications to prevent a blood clot
  3. Topical wound care therapies (including topical growth factors)
  4. Compression garments
  5. Prosthetics or orthotics, available to restore or enhance normal lifestyle function

Venous ulcers are treated somewhat differently with compression of the leg to minimize edema or swelling. Compression treatments may include wearing compression stockings, multilayer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician based on the characteristics of the ulcer base and amount of drainage from the ulcer.

The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer. Types of dressings include:

  1. Moist to moist dressings
  2. Hydrogels/hydrocolloids
  3. Alginate dressings
  4. Collagen wound dressings
  5. Debriding agents
  6. Antimicrobial dressings
  7. Composite dressings
  8. Synthetic skin substitutes
  9. Growth factor ointment

Treatments of arterial ulcer vary, depending on the severity of the arterial disease. Non-invasive vascular tests provide the physician with the diagnostic tools to assess the potential for wound healing. Depending on the patient’s condition, the physician may recommend invasive testing, endovascular therapy or bypass surgery to restore circulation to the affected leg. The goals for arterial ulcer treatment include:

  1. Providing adequate protection of the surface of the skin
  2. Preventing new ulcers
  3. Removing contact irritation to the existing ulcer
  4. Monitoring for signs and symptoms of infection that may involve the soft tissues or bone.

Neurotrophic ulcers are treated are treated by avoiding pressure and weight-bearing on the affected leg until the ulcer has started to heal. Regular debridement (the removal of infected tissue) is usually necessary before a neurotrophic ulcer can heal. Frequently, special shoes or orthotic devices must be worn.

Wound Care at Home

As stated in the aforementioned section, a proper wound care program including home wound care by the patient is critical to the healing process. Patients should be given careful instructions to care for their wounds at home. These instructions include:

  1. Keeping the wound clean
  2. Changing the dressing as directed
  3. Taking prescribed medications as directed
  4. Applying topical growth factors as directed
  5. Drinking plenty of fluids
  6. Following a healthy diet, as recommended, including plenty of fruits and vegetables
  7. Exercising regularly, as directed by a physician
  8. Wearing appropriate shoes
  9. Wearing compression wraps, if appropriate, as directed

The treatment of all ulcers begins with careful skin and foot care. Inspection of the feet and skin by the patient is very important, especially for people with diabetes. Detecting and treating foot and skin sores early can help prevent infection and prevent the sore from becoming worse. Here are some guidelines:

  1. Gently wash the affected area on your leg and your feet every day with mild soap and lukewarm water. Washing helps loosen and remove dead skin and other debris or drainage from the ulcer. Gently and thoroughly dry your skin and feet, including between the toes. Do not rub your skin or area between the toes.
  2. Every day, examine your legs as well as the tops and bottoms of your feet and the areas between your toes. Look for any blisters, cuts, cracks, scratches or other sores. Also check for redness, increased warmth, ingrown toenails, corns and calluses. Use a mirror to view the leg or foot if necessary, or have a family member look at the area for you.
  3. Once or twice a day, apply a lanolin-based cream to your legs and soles and top of your feet to prevent dry skin and cracking. Do not apply lotion between your toes or on areas where there is an open sore or cut. If the skin is extremely dry, use the moisturizing cream more often.
  4. Care for your toenails regularly. Cut your toenails after bathing, when they are soft. Cut toenails straight across and smooth with an emery board.
  5. Do not self-treat corns, calluses or other foot problems. Go to a podiatrist to treat these conditions.
  6. Don’t wait to treat a minor foot or skin problem. Follow your physcian’s guidelines.
  7. Ask your physician about using a growth factor ointment on the open sore area.

How can ulcers be prevented? Controlling risk factors can help you prevent ulcers from developing or becoming worse. Here are some ways to reduce your risk factors:

  1. Quit smoking
  2. Manage your blood pressure
  3. Control your blood cholesterol and triglyceride levels by making dietary changes and taking medications as prescribed
  4. Limit your intake of sodium (salt)
  5. Manage your diabetes and other health conditions, if applicable
  6. Exercise — start a walking program after speaking with your physcian
  7. Lose weight if you are overweight
  8. Ask your physcian about aspirin therapy to prevent blood clots

Skin Surgery Options and Treatment

The skin is susceptible to many diseases, discolorations, and growths. It may also be damaged by excessive exposure to the sun and the effects of aging. In most cases, skin problems requiring dermatologic surgery can be addressed in the dermatologist’s office or in an outpatient setting, usually under local anesthesia, with minimal pain, and low risk of complications. There are different types of skin surgeries enumerated below.

Types of Skin Surgery
Skin biopsy – Skin biopsies are performed to help with the diagnosis of your skin condition. Sometimes, different skin conditions can look similar to the naked eye so additional information is required. This is obtained by looking at the structure of the skin under the microscope after the cells have been stained with special coloured dyes.
Excision of skin lesions – A common reason why skin lesions are excised, is to fully remove skin cancers such as basal cell carcinoma, squamous cell carcinoma or melanoma. If the cancer is not cut out it may spread to the surrounding skin and to other parts of the body (metastasise).
Curettage & cautery – Curettage and cautery or electrosurgery is a procedure in which your dermatologist scrapes off a skin lesion and applies heat to the skin surface.
Skin grafting – A skin graft consists of skin taken from another part of the body and applied to the site where skin is missing. This might follow surgical removal of a skin cancer or a burn. A skin graft is thus a skin transplant. Skin grafts are performed by surgeons (including plastic surgeons) and by some dermatologists.
Mohs microscopically controlled excision – Mohs Micrographic Surgery, an advanced treatment procedure for skin cancer, offers the highest potential for recovery—even if the skin cancer has been previously treated. This procedure is state-of-the-art treatment in which the physician serves as surgeon, pathologist and reconstructive surgeon.
Laser Skin Resurfacing – A laser is a high-energy beam of light that can selectively transfer its energy into tissue to treat the skin. The laser makes it possible to change tissue without making an incision. So a surgeon can treat birthmarks or damaged blood vessels, remove port wine stains, and shrink facial “spider veins” without major surgery.
Photodynamic therapy – Applying a chemical called aminolevulinic acid to the skin and exposing the skin to a special light source.
Topical chemotherapy – Applying a chemical such as 5-fluorouracil, diclofenac sodium, or imiquimod to destroy pre-cancerous growths and some cancerous lesions.
Radiation therapy – Using x-rays to destroy tissue in certain types of skin cancer, as well as in selected individuals for whom surgery is not possible.
Dermabrasion – Removing the outer layers of skin and softening irregular edges. After the skin is frozen with a spray medication, a high-speed, rotary abrasive wheel is used.
Cryotherapy (liquid nitrogen) Applying or spraying liquid nitrogen onto the skin to freeze and destroy the tissue.
Precautions and care for Skin Surgery
Your skin growth will be removed surgically in the office and sent for microscopic examination to be certain it has been completely removed. Unless otherwise instructed, please eat normally and take all regularly prescribed medications.
After surgery, most patients may resume their usual activities; sometimes, there are temporary restrictions on sports, dancing, or other physical activity.
Aspirin makes people bleed more easily, and we prefer that patients not take it for seven days before surgery and for two days after surgery.
If you are taking aspirin, or a medicine containing aspirin, on your own, please stop it for seven days before surgery.
Antibiotics – People who have had hip replacements, have artificial heart valves, or who have mitral valve prolapse often have to take antibiotics before dental procedures.
In the medical literature, most studies show antibiotics are not needed before and after skin surgery. The best thing to do is to check with the doctor who has implanted one of the above devices or the doctor who sees you for this problem.
Stitches (sutures) are used to close the wound after surgery. The type of stitch we use depends on the surgery and your skin. Stitches that need removal are usually taken out 7 to 14 days after surgery. Stitch removal and takes only a few minutes.

Risk factors of stroke disease

 High blood pressure Hypertension (high blood pressure) is a major risk factor in both ischaemic and haemorrhagic strokes (Wolf and D’Agostino 1993).  Welin et al (1987) found that high blood pressure was a risk factor in 789 men, 57 of whom had had a stroke and had been monitored for up to 18 years.  Sandercock, Warlow and Jones (1989) studied risk factors in 224 first embolic strokes in an Oxfordshire population of 104,000 and found that high blood pressure was present in 52 per cent of the cases compared with a healthy group.

Studies in developing countries have suggested that high blood pressure is a major risk factor (Akbar and Mushtaq 1999; El Sayed et al 1999).  The most common risk factor was hypertension concomitant with diabetes mellitus in 40.4 per cent of hospitalised patients and hypertension alone for 24.9 per cent (El Sayed et al 1999).  Akbar and Mushtaq (1999) found that high blood pressure was present in 20 per cent of stroke survivors.  However, there were no comparisons with a healthy group in these two studies, making it difficult to draw conclusions from them.

Cigarette smoking  Several studies  have shown that cigarette smoking is a major risk factor for stroke (Shaper et al 1991; Wannamethee et al 1995; Wishant, 1997)  In a population of 7,735 British men monitored for eight years, cigarette smoking was found to be associated with a risk of having a stroke (Shaper et al 1991).  Shinton and Beevers (1989) found that cigarette smoking increased the risk of cerebral infarction among smokers compared to non-smokers.  However, the risk of stroke disappeared two to four years after stopping smoking  (Kawachi, Colditz and Stampfer 1993).  In the only study in Saudi Arabia, El Sayed et al (1999) found that 1.8 per cent of stroke survivors who been admitted to hospital were smokers, although these results should be carefully interpreted because there were no comparisons between smokers and non-smokers.

 Diabetes  Several studies have shown that diabetes is another major stroke risk factor (Burchfield, Curb and Rodrigues 1994; United Kingdom Prospective Diabetes Study Group 1998).  Among Japanese living in the USA, those with diabetes had twice the risk of an embolic stroke of non-diabetic subjects (Burchfield, Curb and Rodrigues 1994).  In the Arab population one-fifth of stroke survivors were found to suffer from diabetes (Al-Jishi and Mohan 1999; Al-Rajeh et al 1993a, Al-Rajeh et al 1998; El Sayed et al 1999).

Atrial fibrillation  Irregular heart beat (atrial fibrillation) is another risk factor associated with stroke (Goldstein 1998).  Benjamin et al (1998) found that there was a dramatic increase in the risk of strokes, which increased with age, associated with atrial fibrillation.  The risk factors increased from 1.5 per cent for those aged between 55 and 59 to 23 per cent for those aged between 80 and 89.

In a few studies carried out in developing countries, atrial fibrillation was found to be present in around 5 to10 per cent of stroke patients admitted to hospital (Akbar and Mushtaq 1999; Al-Rajeh et al 1993b; El Sayed et al 1995). 

 Hyperlipidaemia  Hyperlipidaemia (raised cholesterol levels) is another factor associated with the risk of stroke (Goldstein 1998).  It is well documented that lipid abnormalities are associated with coronary artery disease but there is very little research into the relationship between lipid abnormalities and cerebrovascular diseases, including strokes.  In a review of 45 papers Qizilbash et al (1998) reported that there was no association between cholesterol level and haemorrhagic stroke.  Other studies have looked at the relationship between cholesterol levels and ischaemic stroke and found a weak association (Benfante et al 1994).

Silent Heart Attack and Its Atypical Signs

During heart attack one might feel dizzy although is not a common symptom it has been observed at some people with heart attack. Heart attacks are more often in the morning because of the amounts of adrenaline in the blood. Too much adrenaline in the blood may determine formation of clot and rupture of plaque. Cardiac pain is dull, vague and has been described as pressure, fullness, squeezing and other sensation of discomfort. Studies have shown that heart attacks are more frequent in winter, diabetic people have silent heart attacks which means that there is no pain in the chest.

Symptoms

If you feel an intense and suffocating pain in the chest for more than 15 minutes and doesn’t stop at nitroglycerin it means that you are having a heart attack. It is indicated to take aspirin and drink water that helps the heart getting more blood if you are having a heart attack indeed. Sometimes the heart attack symptoms may act as an indigestion with a sensation of fainting and pain in the middle of the abdomen.

Silent heart attacks

Silent heart attacks are the most dangerous ones because people don’t know what’s happening they consider it’s only a state of moment and forget soon about the discomfort and indisposition felt and do not announce a doctor which has a vital risk. Silent heart attacks are those attacks that have no warning symptoms or signs, or may appear atypical signs such as: nausea, sweating, headache and dizziness. Silent heart attacks are common in people older than 65 years and diabetics and women.

American Heart Association and other experts suggest that we should pay attention to the following signals: pain, squeezing, fullness in the center of the heart, pain radiating in the shoulder and arms, burning, pressure, heavy weight. Other symptoms may be: fainting, nausea, sweating, shortness of breath, anxiety, irregular heart rate, pallor, anxiety, nervousness. If you notice any of these symptoms you should address immediately to the emergency medical services at 911 or begin the CPR.

The doctor will diagnose the heart attack after studying several tests: EKG a device that gives the graphical record of the heart’s electrical activity, a physical examination and knowing the complete medical history of the patient, high enzymes in the blood appear in heart attack, those steps are also helpfull. Cardiac enzymes may be determined later in the intensive care unit and urgent care setting so they confirm or infirm the suspicions of heart attack.

Often heart attack is slowly with mild pain and the person in cause doesn’t understand what’s happening, on the other hand the heart attack might be intense and movie-like. The most common signs are: chest discomfort which may be felt as pain, pressure, squeezing, fullness and which may last for minutes. Other symptoms are: pain in both arms, neck, stomach, back, shortness of breath, nausea, cold sweating.

If you want to find out more resources about heart attack symptoms or about vioxx heart attack please review this page http://www.heart-attack-guide.com

Heart Attack – Causes, Signs, Symptoms and Treatment

Any of a number of conditions that can affect the heart. Some examples include coronary heart disease, heart attack, cardiovascular disease, pulmonary heart disease and high blood pressure. Heart disease is a big problem in today’s society because of lifestyle issues such as poor diet, lack of exercise and smoking.

Heart attack (myocardial infarction or coronary thrombosis) is when part of the heart muscle dies because it has been starved of oxygen. . It can occur as a result of one or two effects of atherosclerosis:

(1) If the artery becomes completely blocked and ischemia becomes so extensive that oxygen-bearing tissues around the heart die.

(2) If the plaque itself develops fissures or tears. Blood platelets adhere to the site to seal off the plaque, and a blood clot (thrombus) forms. A heart attack can then occur if the formed blood clot completely blocks the passage of oxygen-rich blood to the heart.

Usually, this happens when a blood clot forms in one of the coronary arteries (blood vessels to the heart muscle), which blocks the blood supply. Occasionally, a blockage is caused by a spasm (sudden narrowing) of a coronary artery.

Cause of Heart attack:

A heart attack happens when a blood vessel in or near the heart becomes blocked. Not enough blood can get to that part of the heart muscle. That area of the heart muscle stops working, so the heart is weaker. During a heart attack, you may have chest pain along with nausea, indigestion, extreme weakness, and sweating

A heart attack occurs when there is a severe blockage in an artery that carries oxygen-rich blood to the heart muscle. The blockage is usually caused by the buildup of plaque (deposits of fat-like substances, or atherosclerosis) along the walls of the arteries. The sudden lack of blood flow to the heart muscle deprives the heart of needed oxygen and nutrients. If the blockage is not opened quickly, the heart muscle is likely to suffer serious, permanent damage as areas of tissue die.

Warning Signs for Heart Attack

• Chest discomfort: uncomfortable pressure, squeezing or fullness.
• Discomfort in other areas of the upper body: one or both arms or in the back, neck, jaw, or stomach.
• Shortness of breath, either with chest discomfort or alone.
• Other signs, including nausea, lightheadedness, or breaking out in a cold sweat.
Common Symptoms.
Other common symptoms of a heart attack include:
• Nausea, vomiting, and cold sweats
• A feeling of indigestion or heartburn
• Fainting
• A great fear of impending death, a phenomena known as angor animi
Medical Treatment
Medical treatment may be started immediately, before a definite diagnosis of a heart problem is made. General treatment measures include the following:
• Oxygen through a tube in the nose or face mask
• Nitroglycerin under the tongue
• Pain medicines (morphine or meperidine)
• Aspirin: Those with allergy to aspirin may be given clopidogrel (Plavix).

Surgery

After a heart attack, you will usually be offered an exercise test. If this suggests that your coronary arteries have narrowed, an angiogram will be carried out. This involves injecting a dye into the blood so that the coronary blood vessels show up on an X-ray. If your arteries are narrowed, you can sometimes be treated with angioplasty or coronary artery bypass grafting.

Three Times Weekly Anti-tuberculosis Treatment of Category 1 and Category 11 Patients of Pulmonary Tuberculosis Under Directly Observed Therapy (dots)

THREE TIMES WEEKLY ANTI-TUBERCULOSIS TREATMENT OF CATEGORY 1 AND CATEGORY 11 PATIENTS OF PULMONARY TUBERCULOSIS UNDER DIRECTLY OBSERVED THERAPY (DOTS) STRATEGY IN RURAL AREAS OF SINDH, PAKISTAN.

AUTHORS:

DR: BHURGRI GHULAM RASOOL

DR: SHAMIM-UR-REHMAN

DR: MOMINA TAKI MUHAMMAD

DR: SHAH MURAD MASTOEE.

DR: RAJ KUMAR CHOHAN.

DR: DAHRI GHULAM MUSTAFA.

DR: FAISAL KHAN.

DR: ATIF SHEIKH.

ABSTRACT:

OBJECTIVE:

The purpose of this study was to evaluate three times weekly anti-tuberculosis treatment (ATT) for both category 1 and category 11 patients of pulmonary tuberculosis under directly observed therapy to cut the cost and time required for ATT.

PLACE AND TIME:

This study was conducted at TB clinic, Muhammad Medical College Hospital Mirpurkhas, sindh, Pakistan, from July 2005 to June 2007

 Patients and Methods:

130 patients were enrolled for study. 70 patients of category 1 and 60 patients of category11 pulmonary TB who promised to come regularly for treatment three days a week for eight months. Patients were given antituberculosis drugs three days a week under strict observed therapy strategy for eight months according to World Health Organization guide lines for treatment of tuberculosis 2003.

Results:

At the end of eight months in category1, out of 70 patients 67 patients (96%) were cured, 3 patients (4%) who were sputum smear positive at the start of ATT remained sputum positive. In category 11 out of 60 patients, 53 patients (88%) were cured, 7 patients (12%) remained smear positive. Over all cure rates for both categories 1 and 11 was 92%.

CONCLUSION:

Three times a week ATT is as effective as daily regimen of ATT. It must be given under strict DOTS strategy. It saves 65-7-% of drug cost and time as compared to daily regimens.

Key words: Anti-tuberculosis treatment    ATT

          Directly Observed Therapy Short Course DOTS.

Address for correspondence:

(2) Dr:Ghulam Rasool Bhurgari

Assistant Professor

Department of Pharmacology and Therapeutics

Muhammad Medical College

Mirpurkhas, Pakistan

0333 2871918.

0345-3702876

E-mail drgr72@gmail.com

INTRODUCTION:

Nearly one third of the global population i.e. two billion people are infected with mycobacterium Tuberculosis and at risk of developing the disease. More than eight million people develop active tuberculosis (TB) every year and about million die (2).This problem is worse in Pakistan. There are no reliable data on the incidence and death caused by TB. It seems to be increasing every year. Although TB affects all classes of people, it is more prevalent in the poor especially of the productive ages of 22-55 years, causing great financial burden and misery to their families.

DOTS(Directly Observed Therapy Short course) was introduced in 1993 by World Health Organization(WHO) DECLARED TB A GLOBAL EMERGNCY IN RECOGNITION OF THE GROWING IMPORTANCE AS A PUBLIC HEALTH PROBLEM.(1)

A component of case management that helps to ensure that patients adhere to therapy is DOT.DOT means that a health care worker or another designated person watches the patient swallow each dose of TB medication. DOT ensures an accurate account of how much medication the patient really took. DOT should be considered for all patients because clinicians are often inaccurate in predicting which patient will adhere to medication regimens on their own. DOT has been shown to be effective when intermittent regimens are used. DOT can significantly reduce the frequency of development of drug resistant and of treatment failure or relapse after the end of treatment. Treatment for drug susceptible TB can be given intermittently if they are directly observed. Using intermittent regimens redress the total number of encounters with the Health worker, making these regimens more cost effective. (3)

Intermittent ATT given three times a week is as efficacious as daily therapy.Isoniazid; Rifampin, Pyrazinamide, and Streptomycin are all efficacious when given three times weekly as when given daily. This finding should not be surprising, because Mycobacterium tuberculosis doubles in 18-24 hours, compared with 12-20 minute for most bacteria(4).

DOTS has been employed with success UN many countries. We conducted this study under DOTS strategy to see the results of three days a week regimens to get better results with less cost.

PATIENTS AND METHODS:

Criteria for enrolling the patients for study:

1.  Patients who fulfilled the World Health Organization (WHO)diagnostic criteria for category 1(Patients who have never received treatment for TB) and category 11(Retreatment of ,relapse, treatment failure, smear positive who have taken ATT more than one month and defaulted)pulmonary tuberculosis (WHO) guidelines for national programmed treatment of tuberculosis 2003.

2.   Patients and their family promised to come regularly thrice a week for eight months.

130 patients were enrolled for study.70 patients of category 1 and 60 patients of category11.Out of 70 patients of category1, 40 patients (57%) were sputum smear positive and 30 patients (43%) were sputum smear negative.

In category 11 out of 60 patients, 10 patients (17%)were previously treated for 8 months,6 of these patients were sputum smear positive.50 patients had interrupted their treatment after more than one month. In category 11 36 patients (60%) was sputum smearing positive and 24 patients (40%) were sputum smear negative.

Out of the total 130 patients there were 70 male (54%) and 60 females (46%).Their ages ranged from 16-65 years. 80% of the patients were between 20 and 55 years of age.

MANAGMENT:

1.  COUNCILLING:

A. The patient and his family were informed about TB disease, its spread, progress and treatment. Regular treatment for 8 months will cure the patient. Irregular treatment or interruption of treatment before 8 months will make the disease resistant to treatment and chances of cure will diminish.

B. Diet: Advised to eat everything available. Diet should increase every day some patients are given drugs to stimulate appetite. Few patients needed short course of corticosteroids.

C. Emphasis was on regular visits and not to miss treatment at all.                    Patients and their family’s contact numbers and address were noted.

2. Drug Treatment: All the patients were given treatment 3 days a week under DOTS strategy. The drugs were given as separate drugs and doses were calculated according to weight of the patients as recommended by WHO guidelines for treatment of tuberculosis 2003 for 3 days week regimen.

In category 1 during initial phase months Rifamicin, Isoniazid, Pyrazinamide and Ethambutol were given and during continuation phase of six months Rifampcin, Isoniazid, and Ethambutol were given.

 In category 11 patients, during initial phase of two months Rifamicin,    Isoniazid, Pyrazinamide, Ethambutol and Streptomycin were given. In 3rd months initial phase Streptomycin was stopped and other four drugs were continued. During continuation phase of 5 months Ionized, Rifampin, and Ethambutol were continued

.

3. On every visit:

a. Patient was attended straight away on arrival with greetings and enquired about his health, family and job.

b. Temperature and weight recorded. Patients not gaining weight were advised to increase the diet. Some were given drugs to stimulate appetite and few given corticosteroids.

c. A glass of water and medicine given under supervision

d. Any co-existent illness was also treated.

e. On leaving, patient was reminded about the next visit. If he cannot come then medicine were given to his family member to give the patient under his supervision. The patient was made to feel that we care for him and want him to get better.

PROGRESS: X-RAY CHEST, ESR,Hb, and soutum smear for A.F.B were repeated at 2 months, 5 months and end of treatment at 8 months.

RESULT:

After completion of eight months of ATT, the following criteria were taken for cure.

                                                                                                                       Statistics

category type one patients of tuberculosis

categry two patients of tuberculosis

seventy patients in cat one

sixty patients in cat two

three patients missed

seven patients missed in cat two

N

Valid

70

60

70

60

3

7

 
Missing

2

12

2

12

69

65

Mean

1.0000

2.0000

3.0000

4.0000

5.0000

6.0000

Std. Error of Mean

.00000

.00000

.00000

.00000

.00000

.00000

Median

1.0000

2.0000

3.0000

4.0000

5.0000

6.0000

Std. Deviation

.00000

.00000

.00000

.00000

.00000

.00000

Frequency Table

                                      category type one patients of tuberculosis

Frequency

Percent

Valid Percent

Cumulative Percent

Valid

catone

70

97.2

100.0

100.0

Missing

System

2

2.8

Total

72

100.0

                                            categry two patients of tuberculosis

Frequency

Percent

Valid Percent

Cumulative Percent

Valid

cattwo

60

83.3

100.0

100.0

Missing

System

12

16.7

Total

72

100.0

                                                         three patients missed

Frequency

Percent

Valid Percent

Cumulative Percent

Valid

trees

3

4.2

100.0

100.0

Missing

System

69

95.8

Total

72

100.0

                                               seven patients missed in cat two

Frequency

Percent

Valid Percent

Cumulative Percent

Valid

svn

7

9.7

100.0

100.0

Missing

System

65

90.3

Total

72

100.0

FREQUENCIES

  VARIABLES=catone cattwo senty sixty tree svn

  /STATISTICS=STDDEV SEMEAN MEAN MEDIAN

  /PIECHART  FREQ

  /ORDER=  ANALYSIS .

Pie Chart

                

1. Sputum smear negative for AFB on three occasions.

2. Radiological opacities on x-ray chest had cleared or healed by fibrosis and calcification.

3.  Had gained weight.

4.  E.S.R had fallen to normal limits.

5.  Hb had risen.

6.  Patient was symptoms free and doing his job.

    In category 1 67 (96%) patients out of 70 cured.3 patients (4%) who were sputum positive at the start of ATT remained sputum smear positive. In category 11 53 patients (88%) out of 60 were cured.7 (12%) remained sputum positive as they were at the onset of ATT. Over all cure rate in both categories 1and 11 was 92%.

DISCUSSION:

The global target for successful treatment of new sputum smear patients is 85% or more (5) .Average treatment success among national DOTS programs is 82% close to the 85% global target. (6)We achieved the cure rate of 96% for category 1, 88% for category 11 pulmonary TB patients and overall cure rate in both categories 1 and 11 was 92%.

The result is better than the global target for national programs set by WHO. This may be because our total number of patients was small and few multi-drug- resistant (MDR) cases were enrolled.

We think our high cure rate is due to the fact that during this trail we did not let any patient miss even a single dose of medicine. Council ling on every visit was useful. We had to scare the patient that if, he misses even a single dose of medicine he will not be cured. He will die coughing up blood and no medicine will help.

Patient’s family was told that successful treatment of the patient is in their interest also otherwise they will catch the disease from the patient.

DIET ALSO PLAYED A BIG ROLE:

On every visit the patient was weighed and advised to increase his daily consumption of food. Some very anorexic patients were given tonics and steroids.

DOT’S strategy does not just mean giving medicines under peon’s supervision. Doctor and his team treating the patient should win the confidence of the patient by care, sympathy, concern and politeness so that patient can complete his ATT without interruption. This will increase the cure rate  and reduce development of MDR.

CONCLUSION:

3 days a week ATT for category 1 and category 11 pulmonary patients under a caring and strict DOTS strategy is more effective and less costly than half heartily supervised daily regimen.

If the total consumption of drugs for 8 months with 3 days a week regimen is compared with that of daily regimen for 8 months there is a saving of 65-70% in cost and time.

This means that with the amount allocated by Government for TB control, as many as three times more patients can be treated. It also means that only 40% sincere and dedicated personal can do better job than being done at present.

KEY MESSAGE:

a)                  All patients of category 1 and 11 pulmonary tuberculosis can be treated successfully with 3 days a week ATT regimen under DOTS strategy.

b)                  3 days a week ATT saves 65-70% money and time,

c)                  DOTS strategy can improve results if employed with sincerity and devotion.                                                  

REFERNCES:

1      Guideline for National tuberculosis programs on management of tuberculosis, World Health Organization 2003

2      Dye C etal. Global burden of tuberculosis:estimated incidence, prevelence and morbidity by country. JAMA 1999, 282(7):677-678

3      Core circulation on tuberculosis 4th edition 200 US Department of health and human services.

4    North RJ,Izzo AA,Mycobactrium Virulence J.EXP.Med 1993:177(6);1723-33.

5 An expanded DOTS framework for effective tuberculosis control WHO/CDS/TB/2002.297.Geneva:World Health Organization global tuberculosis programme; 2002.

6 Global tuberculosis control, planning,financing.WHOreport 2005. WHO/HTM/TB/2005.49.Geneva(Switzerland);World Heath Org.