Tuesday, 28 March 2017

The Gynecologyst and the Family Doctor as Lawyers



Obstetricians and Gynecologists manage to solve problems of health of the woman in state of pregnancy, puerperium and lactation as well as the physiological and clinical pathological states proper to its sex. They treat the diseases related to the genital apparatus of the woman benign or malignant and the alterations that compromise its functional state. They also provide care to women with ethics and a critical spirit that allows them to rationalize diagnostic methods for the study of their problems. The gynocologist proposes adequate guidelines for the therapeutic management of the problem at the collective or individual level. On the other hand, family doctors are the first point of entry for health-care delivery, with links to higher levels of the health system and other services. Family physicians do not treat diseases but take care of people. Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family within the context of community. Providing family-oriented primary care is one of the distinguishing features of this specialty. 

Gynecologists and family doctors are the two medical specialties that fundamentally share medical care for health problems and preventive actions in women. In this field, both have to work as a team. And they share the difficulties of managing women’s health problems. Both also have to face a major risk: overdiagnosis and overtreatment. Although this phenomenon occurs in all medical specialties, women take better care of their health, and they rely more on prevention than men, so it is not surprising that they are more affected by the excess of all types of health activities; the “excess medicine”.The clinical work is involved in the uncertainty because the application of the Truths of biomedical science in the life and in the circumstances of each individual patient will always be uncertain. So doctors, especially young doctors, are learning to fear to the uncertainty. We are asking for more and more evidence. To try to assure ourselves, often in vain, of what we are seeing. And because we are afraid that those who are in the kingdom of the healthy, perhaps should be in the realm of the sick, continually divert resources from the sick to the healthy, and so the overdiagnosis is inevitably linked to the insufficient treatment of those who are already sick. Overdiagnosis of the healthy and insufficient treatment of the sick are two sides of the coin of modern medicine.

 In this context, it can be logical that the concepts and theories that belonging to Interface between gynecology and family medicine are often difficult to explain and to understand. To show this interface, with an educational approach, we can do it through metaphors. Metaphors enable us to understand something that is unknown in terms of its familiarity. For this reason, they are used frequently in all sciences that adopt common words to name complex realities. The metaphors are analogue devices, used to illuminate reality. Metaphors can simplify expert knowledge, not by ignoring or reducing the inherent complexity, but by providing a point of entry for its comprehension. They are a means of generating ideas, promoting creativity, and constructing concepts and theories. Thinking based on metaphors and comparisons is a way of transforming a concept into something that is so suggestive, interesting, and surprising, that it reaches people more easily.

Monday, 27 March 2017

Role of QRS Complex Fragmentation in Patients at High Risk of Cardiovascular Events

                           http://www.mathewsopenaccess.com/cardiology-current-issue.html



The presence of fragmented QRS complexes (FQRS) on a routine 12-lead ECG is an interesting marker of depolarization abnormality. There is convincing data suggesting that the FQRS represents conduction delay from inhomogeneous activation of the ventricles due to myocardial scar. However, FQRS is not specific for coronary artery disease and is also encountered in other myocardial diseases such as cardiomyopathy and congenital heart disease. FQRS has also been described in other entities such as arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome. 


The significance and the predictive value of FQRS complex as an ECG marker of cardiovascular events seem to be different in different entities. In patients with stable coronary artery disease and in patients with acute MI, FQRS seems to be a good predictor of cardiac events. In patients with non-ischemic cardiomyopathy, fragmentation of narrow QRS complex seems to correlate with the degree of fibrosis and dys-synchrony, and importantly may influence the response for cardiac resynchronization therapy. However, based on clinical studies with larger number of patients with current indications for cardiac resynchronization, FQRS does not influence and is not associated with poor response of resynchronization therapy. In patients with LV dysfunction, there is no clear evidence that the presence of FQRS could predict arrhythmic events. On the other hand, there was a statistical significant difference in mortality associated to the presence of fragmented QRS in patients with acute coronary syndrome and myocardial necrosis.

Invasive and non-invasive tests for risk stratification of cardiovascular events were studied in the context of coronary artery disease, cardiomyopathy and heart failure. One of the recent non-invasive tests, microwave T-wave alternans and signal-averaged electrocardiogram have high negative predictive values but have a low positive predictive value in patients with history of myocardial infarction (MI) or cardiomyopathy. A low left ventricular ejection fraction in patients with structural heart disease is used routinely in clinical practice for risk stratification with a major limitation being the lack of desirable positive predictive value for the risk of cardiovascular events. The presence of fragmented QRS complexes (FQRS) on a routine 12-lead ECG is another marker of depolarization abnormality. There is convincing data suggesting that the FQRS represents conduction delay from inhomogeneous activation of the ventricles due to myocardial scar. However, FQRS is not specific for coronary artery disease and is also encountered in other myocardial diseases such as cardiomyopathy and congenital heart disease. FQRS has also been described in other entities such as arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome. In 1969, Flowers et al. named high-frequency components to the presence of fragmented QRS (FQRS) complexes. 

Friday, 24 March 2017

Open Dialogue-a Contribution to a Healthier World: Threat or Chance?






In this article the dilemma of psychiatry as a medical science is outlined as well as options, where we as psychiatrists should turn to. Open Dialogue as a therapeutic approach to severe mental health crisis is introduced and described in its principles and elements. A case description illustrates how principles and elements are set to work. Connections to the upcoming Peer Movement are drawn as well as to EU-Legislation about Deinstitutionalisation and the UN-Convention of Civil Rights for People with Disabilities (UN-CRPD). Finally the difficulties in implementing such a comprehensive approach are outlined to get closer to an answer, whether this kind of change has more of a chance or tends to be a threat.

Since a couple of years it is obvious, that psychiatry as a science is facing a fatal crisis, but resistance to acknowledge some facts, that showed up, is strong within the profession, and that for many reasons. Still like in the middle ages the ambassadors of the new knowledge get kind of “burnt” on the bonfires of certain journals, as if to kill the messenger who brings in bad news. It looks like some facts are too disturbing to have a closer look at them. And we don’t have to name it a “Copernican Turn” what is happening, it is more that we gathered knowledge that does not fit the mainstream assumptions in psychiatry. In this I follow Pat Bracken, Bob Whitaker  and Peter Gøtzsche as well as some others, who have been dealing with different aspects (Joanna Moncrieff [5], Volkmar Aderhold, Stefan Priebe and P. Bracken  sum up what we gained through what is called scientific research in the last decades and it is very sobering to imagine the billions of Euros spent. What for? Yes, as much as nothing. They could not lift any secrets of the brain as much as to be helpful for our patients. 

The same is true forbrain imaging techniques and genetics. Robert Whitaker has had a closer look at the longterm outcome of different kinds of studies concerning different kinds of psychiatric treatment and comes to the conclusion that following the guidelines of medical – pharmacological treatment as usual leads to an outcome worse, than we would have expected and those patients who manage not to fall into the desired “compliance” and refuse to take long term medication, have better chances to recover and be included in more sufficient working and living conditions. He also revealed the way that business interests of the psychiatric profession and big pharma met in a fatal way for the benefit of the two, unluckily it turned out to be a disadvantage for the patients. He also revealed through epedemiological data in western countries a fourfold rise of disability allowances for mental health problems and connects it to the dominant treatment system. Peter Gøtzsche as head of the Northern European Cochrane Association investigated the scientific background of the admission of certain substances to the market and revealed criminal power behind it. Joanna Moncrieff managed to show, that theories about a chemical imbalance in the brain in the case of mental illness is nothing but a fairy tale, just a seemingly plausible invention. Stefan Priebe as a socially oriented psychiatrist has become the “mockingbird” of Psychiatry. He writes about the missing results of the investments in research over the last decades and its meaninglessness for the therapeutic endeavors. So we work in a mental health system that is built on wrong assumptions, produces more problems than it can solve, is more devoted to money and its implications than to those citizens, who are facing severe crisis and thus getting dependend on support. What a mess, we might say, and yes, it is. But the situation is far from being hopeless. 

Luckily we know a lot about how we could improve our attempts to offer help, that can be not only accepted but also helpful!! By now, we know from the experiences in the Soteria Movement,(Mosher Ciompi the results from longterm studies(Huber, Ciompi und Müller, Vermont Study, Harrows, Wunderinck, West- Lappland)the acknowledgement of human wisdom through philosophy, Buber  Bateson  Developmental Psychology (Trevarthen Stern [18] Reflective Processes and Open Dialogue (J. Seikkula, T. E. Arnkil enough to know, in which direction we should go. science made the race and we have to admit, they had and still have fantastic results in medicine as well as other disciplines. But then there came up the idea to apply this approach of looking at smaller and smaller parts of living organisms as human beings, first brain architecture, than nerves, followed by research on cells and synaptic connections, now on an intracellular level of mitochondria or membranes. 

Thursday, 23 March 2017

Acid-Coagulated Cheese Making by Streptococcus Thermophilus and Lactobacillus Delbrueckii Subsp. Bulgaricus Fermetation as a Helpful Technology


                             http://www.mathewsopenaccess.com/nutrition-current-issue.html





Acid coagulated cheese plays an important role in the food of peoples living in the areas or counties with large amount of fresh milk production. The quality and safety could not be guaranteed by the present traditional processing technologies with natural fermentation. In the present study, five different kinds of lactobacteria mixtures were used as the starters of the acid coagulated cheese. To determine better starter, the effects of the five groups of starters were compared and then the processing parameters of the cheese were optimized. The starter consists of two kind of Streptococcus thermophilus (SP1.1:TM11) and Lactobacillus delbrueckii subsp. bulgaricus (34.5) with a mass ration of starter powders of SP1.1 and TM11 to 34.5 is 90: 10: 1, which was proved to be the best starter mixtures. The cheese made according to the optimal processing parameters, starter addition 0.003%, fermentation temperature 40o C, CaCl2 0.03% and the appropriate cutting time is 0.5 h when the pH value of whey reached 4.6, showed better properities. These results will provide some fundamental data to promote the industrialization process of the traditional acid coagulated cheese with manufactured lactobacterial starters.

Acid coagulated cheese is a kind of fresh cheese and well known for its smooth texture, sour taste and distinctive flavor. Different from enzyme coagulated cheese, the curdling of milk in acid coagulated cheese relies on the acid produced by lactobateria or the addiction of edible acid. Acid coagulated cheese is a traditional food in many minorities in China or many areas famous for raw milk production, including the milk lump in Xinjiang Kazakhs, the milk tofu in Mongolia, Qula in Tibet, the milk cake in Yunnan Yi and the dairy fan in Yunnan Bai. Acid coagulated cheese is about 25% percent of the total amount of the global cheese products, which indicates its important role in the cheese industry. Also, acid coagulated cheese will be well developed due to its simple process, low-intensity labor, low costs and high production efficiency. However, in the traditional process, the acid coagulated cheese will be naturally fermented. The bacteria compositions in atmosphere in different areas are varied significantly, the processing technology varied in tools and container, temperature, processing parameters, etc, in different scale household workshop, and these conditions contribute to the varied product qualities, especially on the aspects of flavor, taste, texture and shelf life. 

In this present study, the optional compound strains for acid coagulated cheese making was determined from five different compound lactic acid bacteria, and the optional processing parameters were investigated by designing orthogonal experiments, which provides theoretical directions for large-scale industrial production. 

Wednesday, 22 March 2017

Case Report the Muscle Loss in the Intra Operative Strabismus Surgery



A lost muscle is one of the most devastating complications that a strabismus surgeon can face in the intra-operative period. Rectus muscles can be lost due to trauma or surgery, including sinus surgery, strabismus surgery, and other ocular surgeries. A lost medial rectus muscle is usually expected in the presence of an overcorrection after exotropia surgery or under correction after exotropia (XT) surgery, resulting in limited duction in the field of action of the muscle. If not treated, a lost muscle will lead to consecutive strabismus, diplopia, and a large limitation of eye movement in the direction of the lost muscle.

A 31 years old man, native of Sao Luis, was referred to the strabismus service due to XT complaints ever since the age of 10, in addition low vision in the right eye. On ophthalmological examination was verified best-corrected visual acuity 0.05/1.0; with preference for the left eye. Concerning extrinsic eye muscles presented XT 25^ concomitant. On monocular rotation tests we found +2 right lateral rectus with ametropic in both eyes. Bio microscopy and funduscopy unaltered in both eyes. The surgical plan was 6.0 mm right medial rectus (MR) resection and a 5.0 mm withdrawal of the right lateral rectus. Due to its friability and lack of support for suturing, the right MR muscle was lost during surgery. Therefore, a transposition of superior rectus to the MR was performed, using a technique similar to that of Jensen’s. The post-operative results after a month were XT 40 (on Hirschberg test) and -2 right medial rectus on monocular rotation tests, besides of normal bio microscopy and funduscopic evaluations (Figure 1).

Upon six months of post-operative, the patient presented concomitant XT 25^ and 12 of right hypertropia (on Krimsky test) and -2 right MR on monocular rotation. One year after the first surgery, a second approach was done with the initial plan being. It was receded right lateral rectus 12.0mm plus 1.0mm anterior dislocation of the right lower oblique ahead of the right inferior rectus (peribulbar). However, due to the increased risk of anterior chamber ischemia, a triple marginal myotomy was performed on the right lateral rectus including anterior dislocation right lower oblique (1.0mm ahead of the right inferior rectus edge) and innervation (recede of the left lateral rectus 8.0 mm). On the seventh post-operative day, the patient presented XT 12^ with right hypertropia 10^, monocular rotation tests showed -2 and -3 right MR and -2 right lateral rectus. Three months after the second intervention, the patient displayed good healing, right hypertropia 15ˆ, and -2 right lateral rectus and -2 right MR (Figure 2), monocular rotation tests with the patient now being discharged.

Monday, 20 March 2017

Antimicrobial Efficacy of Callus and in Vitro Leaf Extracts of Sapindus Mukorossi Gaertn. Against Pathogenic Microbes




Sapindus mukorossi is well known medicinal and economical plant. Antibacterial and antifungal activities were evaluated from various extracts (ethanolic, methanolic and aqueous) of callus and in vitro leaf against several Gram positive and Gram negative bacteria and clinically isolated fungus. Antimicrobial activities were more in in vitro leaf extracts. Callus extract have showed antibacterial activity against S. aureus and E. coli. Maximum inhibition zone (8.06±0.17 mm) was observed against C. tropicalis from methanolic extracts of in vitro leaf. In vitro leaf extracts have shown efficient antifungal activity. Callus and in vitro leaf extract can be used for production of different phytochemicals and plant based antibiotics.

Plants are rich source of secondary metabolites and have great therapeutic potential to treat various diseases. A large population of world uses plant based principles for their primary health care. Medicinal plants may be proved as best source of a variety of drugs. About 20% of plants present in the world have been examined for pharmaceuticals and biological tests. The commonly present antibiotics are either derived from natural or synthetic resources. Several researchers have reported the various biological activities such as antimicrobial, anti-inflammatory, anti-HIV, anti-cancer, antidiabetic etc. from different group of plants. Current research shows that researchers and medical professionals are more interested in the use of indigenous drugs for the cure of human health ailments. Due to expensiveness and more side effects of synthetic drugs clinical microbiologists are paying their attention for screening of medicinal plants for phytochemicals and antimicrobial activity as potent therapeutics.

Antimicrobial activities of medicinal plants are due to presence of different groups of phytochemicals such as alkaloids, polyphenolic compounds, terpenoids, lignans etc. Human pathogens are developing drug resistance against commonly used antibiotics have compelled researchers for searching new antimicrobial substances from other natural sources including plants. So, there is an essential need to develop a new generation of antibiotics from natural source. S. mukorossi Gaertn. is a popular medicinal and economical tree and well-known for their therapeutic values. S. mukorossi plant is rich in antioxidants and polyphenolic compounds and exhibiting antioxidants properties. Earlier, Aneja et al. have assessed the antibacterial activity of fruit extract against dental caries causing pathogen. Antimicrobial activities of leaf and fruit extracts of this plant were also evaluated on some bacteria and fungus. For the validation of antimicrobial potential of this plant this research study was undertaken. This is the first report of antimicrobial activity by using callus and in vitro leaf (IVL) extracts.

Leaves of S. mukorossi were collected from the campus of Banaras Hindu University, Varanasi, in the month of April. Callus and IVL were regenerated by following the protocol of Singh et al. Callus was shade dried at room temperature for 4-5 days and at 40-45°C for 2 h and grinded in mechanical grinder to make coarse powder. Five gram of callus powder was extracted in 150 ml of solvents for 10 h using Soxhlet apparatus. Ethanol, methanol and double distilled water were used as solvents for the extraction. Extracts were then dried at 40°C in rotary evaporator and stored at -20°C for further use. Test samples were prepared in different concentrations for further experiments in their respective extraction solvents. In vitro leaf (200 mg) was collected and grinded in mortar and pestle by adding the solvents. Finally, volume of extract was maintained about 20 ml.








Friday, 17 March 2017

The Rapid and Sensitive Hplc-Ms/Ms-Method of Determination of Mebeverine Metabolites in Human Plasma




The rapid and sensitive method for quantifying mebeverine metabolites in human plasma was developed using HPLC-MS/ MS. Mebeverine acid-D5 and desmethyl mebeverine acid-D5 were used as internal standards. Sample preparation was performed by protein precipitation. The chromatographic separation was achieved on Phenomenex Luna C8 Mercury (20 x 4.0 mm, 5 μm) and Phenomenex Luna 5u C8 (150 x 4.6 mm, 5 μm) under gradient conditions of mobile phase. The calibration range of mebeverine acid and desmethyl mebeverine acid was 10 – 2000 ng/ml. The method was applied to conduct a pharmacokinetic study of 200 mg prolonged-release capsules Duspatalin on 24 healthy participants.

Mebeverine is myotropic antispasmodic agent which effect is based on blockade of fast sodium channels and slow calcium channels on membrane of myocytes. It slows down depolarization of the membrane and prevents contraction of muscle fibers. The drug has high selectivity to smooth muscles of the gastrointestinal tract. Therefore it is primarily used to relieve spasms of organs of the digestive system. Mebeverine being an ester is rapidly hydrolyzed in step of first-pass elimination by esterases to 3.4-dimethoxybenzoic (veratric) acid and mebeverine alcohol. The main metabolites of the drug are mebeverine acid (MA) and desmethyl mebeverine acid.

The half-life of DMA after administration of prolonged-release capsules of mebeverine is 5-6 h, maximum concentration in blood (Cmax) after a single dose is 679 ng/ml, after repeated doses 804 ng/ml, time-to-peak concentration (Tmax) is about 2.92 hours. The area under the curve “concentrationtime” from last blood sampling procedure (AUC0-t) for DMA is 4552 ng∙h/mL, the elimination constant is 0.147. The values of pharmacokinetic parameters for MA were not published. Therefore, obtaining new data about pharmacokinetic of mebevere in the form of prolonged-release capsule is actual. Several analytical methods of quantitative determination of mebeverine metabolites in plasma using HPLC and HPLC-MS/ MS were reported. However, these methods have some disadvantages, such as necessity of complex sample preparation, using solid-phase and liquid-liquid extraction, and lack of sensitivity (high LLOQ).