Morning Medtalks With Dr KK

1. The Centers for Disease Control and Prevention once again issued a warning to pet ownerson Friday that recent cases of Salmonella have been linked to pet hedgehogs — and the agency is warning pet owners to take precautions to avoid infection.
2. A petition filed before the Delhi High Court has sought directions to the Centre and the Medical Council of India (MCI) to ensure that doctors prescribe generic medicines. The petition filed in public interest by advocate Amit Sahni contends that the Pradhan Mantri Bhartiya Janaushdhi Pariyojana (PMBJP) was introduced in 2008 to lower healthcare costs by providing quality generic medicines at affordable prices.
3. Definition: Light smokers (ie, smoking fewer than 10 cigarettes per day)
4. Heavy smokers: Heavy smokers are those who smoke greater than or equal to 25 or more cigarettes a day.
5. Traditionally, experts have recommended not exercising at night as part of good sleep hygiene. Now a new study, published Oct. 29, 2018, in Sports Medicine, suggests that you can exercise in the evening as long as you avoid vigorous activity for at least one hour before bedtime.

Low sodium

Is my patient hyponatraemic: Na <135 mEq/L

1. Is hyperglycemia present? : Corrected serum Na: Sodium concentration will fall by 2 mEq/L for each 100 mg/100 mL increase in glucose concentration.
2. Rule out pseudohyponatremia: Lipemic serum, severe obstructive jaundice, or a known plasma cell dyscrasia
3. Rule out Lab artefact: Na measured with flame photometry
4. Recent prostate surgery: utilizing large volumes of electrolyte-poor irrigation fluid (or intrauterine procedures)
5. Recent drugs: mannitol, glycerol, or intravenous immune globulin [ISOTONIC OR HYPERTONIC HYPONATREMIA].
6. Hypotonic hyponatremia: Severely reduced GFR and thiazide (or thiazide-type) diuretics
7. Is oedema or ascites present: advanced heart failure or cirrhosis
8. Non-edematous patients with hypotonic hyponatremia: euvolemic or hypovolemic.

Treatment

1. Hyponatremia represents a relative excess of water in relation to sodium.
2. Acute: <48 hours. Results from parenteral IV administration in postoperative patients (who have ADH hypersecretion associated with surgery) and from self-induced water intoxication (as in, for example, competitive runners, psychotic patients with extreme polydipsia, and users of ecstasy).
3. Chronic: > 48 hours
4. Severe hyponatremia: Na <120 mEq/L
5. Moderate hyponatremia: 120 to 129 mEq/L
6. Mild hyponatremia: 130 to 134
7. Severe symptoms: seizures, obtundation, coma, and respiratory arrest.
8. Mild to moderate symptoms – Mild to moderate symptoms of hyponatremia are relatively nonspecific and include headache, fatigue, lethargy, nausea, vomiting, dizziness, gait disturbances, forgetfulness, confusion, and muscle cramps.
9. Patients with acute hyponatremia, most patients with severe hyponatremia (< n 120) and most patients with symptomatic hyponatremia should be treated in hospital settings that allow frequent assessments of the patients neurologic condition
10. 4 goals: to prevent further declines in the serum sodium concentration, to decrease intracranial pressure in patients at risk for developing brain herniation, to relieve symptoms of hyponatremia, and to avoid excessive correction of hyponatremia in patients at risk for osmotic demyelination syndrome
11. Goal of initial therapy; Raise Na by 4 to 6 mEq/L in a 24-hour period.
12. Acute hyponatremia or severe symptoms: , this goal in < 6 hours
13. Chronic, severe hyponatremia, the maximum rate of correction should be 8 mEq/L in any 24-hour period.

Clinical situations

9. Asymptomatic acute hyponatremia Na < 130 mEq/L: 50 mL bolus of 3% hypertonic saline to prevent the serum sodium from falling further. Remeasure Na hourly to determine the need for additional therapy. Do not give these patients hypertonic saline if the hyponatremia is already autocorrecting due to a water diuresis.
10. Symptomatic acute hyponatremia Na < 130 mEq/L: Symptoms that might be due to increased intracranial pressure (seizures, obtundation, coma, respiratory arrest, headache, nausea, vomiting, tremors, gait or movement disturbances, or confusion) with a 100 mL bolus of 3% saline, followed, if symptoms persist, with up to two additional 100 mL doses (to a total dose of 300 mL) over the course of 30 minutes.
11. Chronic hyponatremia and Na < 130 mEq/L

Severe symptoms of hyponatremia (seizures, obtundation, coma, respiratory arrest) or in those with known intracranial pathology (such as recent traumatic brain injury, recent intracranial surgery or haemorrhage, or an intracranial neoplasm or other space-occupying lesion), we treat with a 100 mL bolus of 3 percent saline followed, if symptoms persist, by up to two additional 100 mL doses (to a total dose of 300 mL).

Asymptomatic or have mild to moderate symptoms (headache, fatigue, nausea, vomiting, gait disturbances, confusion) and who have moderate hyponatremia (serum sodium 120 to 129 mEq/L): Take only those measures that are broadly applicable to all hyponatremic patients (identify and discontinue drugs that could be contributing to hyponatremia; identify and, if possible, reverse the cause of hyponatremia; and limit further intake of water).

12. Asymptomatic or have mild to moderate symptoms (eg, headache, fatigue, nausea, vomiting, gait disturbances, confusion) and who have severe hyponatremia (serum sodium <120 mEq/L), give IV 3 percent saline beginning at a rate of 15 to 30 mL/hour. In addition, among those with reversible causes of hyponatremia who are likely to develop a water diuresis during the course of therapy, or in those who are at high risk of developing ODS, we simultaneously initiate desmopressin (dDAVP) to prevent overly rapid correction.

Follow up

1. Hypertonic saline should be discontinued once the daily correction goal of 4 to 6 mEq/L has been achieved.
2. Fluid restriction to below the level of urine output is indicated for the treatment of symptomatic or severe hyponatremia in edematous states (such as heart failure and cirrhosis), syndrome of inappropriate ADH (SIADH), advanced renal impairment, and primary polydipsia. In patients with a highly concentrated urine (eg, 500 mosmol/kg or higher), fluid restriction alone may be insufficient to correct hyponatremia.
3. Depending upon the aetiology: Loop diuretics, oral salt tablets, urea, K supplementation, or vasopressin receptor antagonists (tolvaptan for upto 30 days, not in liver disease).

Oral salt

9 g of oral salt provides a similar quantity of sodium as 1 L of isotonic saline (154 mEq) but without any water; 1 g of oral salt is equivalent to 35 mL of 3 percent saline. Oral salt tablets should not be given to edematous patients (eg, those with heart failure, cirrhosis).

Vedic discourse: Today’s question on Akshar Yoga

One of my patients wanted to know whether her name Sheeba needs to be changed?

In Akshara Yoga the word ‘Sheeba” has an ‘ushma’ sound ‘Sh”, a long vowel “ee”, a consonent ‘b” and a short vowel ‘a’

Ushma sounds producers heat or energy in the body and is often used in Shakti mantras or Shakti sounds.

The consonant ‘b’ is from ‘pavarg’ and is a voiced or vibratory sound and provides vibrations to the ushma sound ‘sha’.

This makes it a total Shakti sound. If one wants to reduce some energy from this name (add shanti akshara) that the best will be to add ‘m’’ or ‘n’. For examples the name ‘shama’ or ‘shanno.

The 6 general professional competencies are:

• Patient Care that is compassionate, appropriate, and effective for treating health problems and promoting health;
• Medical Knowledge about established and evolving biomedical, clinical, and cognate (epidemio-logical and social-behavioral) sciences and the application of this knowledge to patient care;
• Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal, and assimilation of scientific evidence, and improvements in patient care;
• Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals;
• Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population;
• Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.