#AskDrKK:What physiological changes occur during orgasm?

#DrKKAnswers:
In volunteers (1,2)
1. Peak heart rate reaches 140-180 beats per minute
2. The mean increase in blood pressure is 80/50 mmHg
3. Respiratory rates and tidal volumes increases to values seen in moderately severe physical exertion
4. The exertion is enough stable angina patients to develop chest discomfort during or immediately after sexual act.
In real life partners the hemodynamic changes are (3,4)
1. Mean heart rate at the time of orgasm is 117 beats per minute (mean heart rate during normal daily activities is 120 beats per minute).
2. The mean estimated blood pressure is 162/89 mmHg.

References
1. Masters, WH, Johnson, VE. Human sexual response, Little, Brown, and Co, Boston 1966.
2. J Appl Physiol 1956; 9:469.
3. Arch Intern Med 1970; 125:987.
4. Am Heart J 1976; 92:274.

#AskDrKK: What is the physiology of sexual act?

#DrKKAnswers: 
 Sexual act includes arousal, erection, ejaculation, orgasm, refractory period, and resolution and depend on changes in the autonomic nervous system. Arousal and erection in men results from stimulation of parasympathetic nerves in the male penile organ; reduced activity of sympathetic pathways and release of nitric oxide from the endothelium (1). In women early sexual arousal results from activation of sympathetic nervous system (2).

References
1. Am J Cardiol 2000; 86:19F.
2. Am J Cardiol 2000; 86:30F.

Emedinews: Dr Good Dr Bad:A patient with diabetic nephropathy was found to have a high homocysteine levels.

Situation: A patient with diabetic nephropathy was found to have a high homocysteine levels.
Dr Bad: Homocysteine has no correlation with nephropathy.
Dr Good: You should control your homocysteine levels.
Lesson: Results of a nested case–control study suggest that hyperhomocysteinemia has an etiologic role in the pathogenesis of diabetic nephropathy. In the study, baseline plasma homocysteine concentrations and mean HbA1c levels during follow–up were significantly higher in patients who developed microalbuminuria than in those who remained normoalbuminuric. Multivariate logistic regression analysis showed that baseline plasma homocysteine level and mean HbA1c were independent predictors of microalbuminuria in type 2 diabetes (Korean Diabetes J 2010 June; 34(3): 200–206).

Emedinews : Hepatitis B Vaccination update

• The regimen for the vaccine is three doses at one and six months apart.

• Longer than recommended intervals between doses do not reduce final antibody concentrations, although protection might not be attained until the recommended number of doses has been administered.(1-5)

• A positive immune response to the vaccine is defined as the development of hepatitis B surface antibody (anti-HBs) at a titer of >10 mIU/mL.

• An interruption in the vaccine schedule does not require restarting the entire series of vaccination or adding extra doses.(6,7)

• If the vaccination schedule is interrupted after the first dose, the second dose should be administered as soon as possible.(8)

• The second and third doses should be separated by an interval of at least two months.

• If only the third dose is delayed, it should be administered when convenient.

• Protective anti-HBs titers may be attained in some after only one or two doses of vaccine, completion of the full course (three doses) is recommended to maximize the anti-HBs titer and duration of protection.

• Anti-HBs titers decrease with time but the duration of protection is long (15 -22 years after the primary vaccination schedule).(9-13) Routine booster injections are not required.(14,15)

• Patients with serologic markers of past HBV infection (anti-HBc and anti-HBs positive) do not need HBV vaccination even if they have low titers of anti-HBs.

• Vaccines should be given intramuscularly since deposition of the vaccine into adipose tissue result in a lower seroconversion rate.(16)

• Deltoid is the preferred site in adults for vaccination.

• Longer needles should be used in overweight individuals.

• Hepatitis B vaccine is effective not only in preventing HBV infection but also in preventing the sequelae of chronic HBV infection.

• It is the first example that cancer can be prevented by vaccination.

References

1. Wiström J, Ahlm C, Lundberg S, et al. Booster vaccination with recombinant hepatitis B vaccine four years after priming with one single dose. Vaccine 1999;17:2162.

2. Zechowy R, Rubin LG. Effect of the time interval between the first and second doses of hepatitis B vaccine on the antibody titer achieved after the third dose. Child Hos Q 1997;9:67.

3. Middleman AB, Kozinetz CA, Robertson LM, et al. The effect of late doses on the achievement of seroprotection and antibody titer levels with hepatitis b immunization among adolescents. Pediatrics 2001;107:1065.

4. Halsey NA, Moulton LH, O'Donovan JC, et al. Hepatitis B vaccine administered to children and adolescents at yearly intervals. Pediatrics 1999;103:1243.

5. Heron LG, Chant KG, Jalaludin BB. A novel hepatitis B vaccination regimen for adolescents: two doses 12 months apart. Vaccine 2002;20:3472.

6. Saito K. Introductory remark of Dr. Rokuzo Kobayashi's achievements. Keio J Med 2002;51 Suppl 2:2.

7. Hepatitis B vaccine: What you need to know. Available at: www.cdc.gov/vaccines/pubs/vis/downloads/vis-hep-b.pdf (Accessed on October 20, 2009).

8. Hoofnagle JH. Toward universal vaccination against hepatitis B virus. N Engl J Med 1989;321:1333.

9. Liao SS, Li RC, Li H, et al. Long-term efficacy of plasma-derived hepatitis B vaccine: a 15-year follow-up study among Chinese children. Vaccine 1999;17:2661.

10. Lin HH, Wang LY, Hu CT, et al. Decline of hepatitis B carrier rate in vaccinated and unvaccinated subjects: sixteen years after newborn vaccination program in Taiwan. J Med Virol 2003;69:471.

11. Yuen MF, Lim WL, Chan AO, et al. 18-year follow-up study of a prospective randomized trial of hepatitis B vaccinations without booster doses in children. Clin Gastroenterol Hepatol 2004;2:941.

12. McMahon BJ, Bruden DL, Petersen KM, et al. Antibody levels and protection after hepatitis B vaccination: results of a 15-year follow-up. Ann Intern Med 2005;142:333.

13. Zanetti AR, Mariano A, Romanò L, et al. Long-term immunogenicity of hepatitis B vaccination and policy for booster: an Italian multicentre study. Lancet 2005; 366:1379.

14. Lu CY, Chiang BL, Chi WK, et al. Waning immunity to plasma-derived hepatitis B vaccine and the need for boosters 15 years after neonatal vaccination. Hepatology 2004;40:1415.

15. Jan CF, Huang KC, Chien YC, et al. Determination of immune memory to hepatitis B vaccination through early booster response in college students. Hepatology 2010;51:1547.

16. Shaw FE Jr, Guess HA, Roets JM, et al. Effect of anatomic injection site, age and smoking on the immune response to hepatitis B vaccination. Vaccine 1989;7:425.

Emedinews:Makesure: A neonate in an ICU being administered IV calcium exhibits signs of inflammation and necrosis at injection site.

Situation: A neonate in an ICU being administered IV calcium exhibits signs of inflammation and necrosis at injection site.
Reaction: Oh my God! Why didn't you observe the IV site carefully?
Lesson: Make sure that all hypocalcemic neonates are put on a cardiac monitor while receiving calcium infusions and the IV site is closely observed, as extravasation of calcium can produce severe interstitial necrosis.

Emedinews: Dr Good Dr Bad: A patient with painful diabetic neuropathy came with postural hypotension.

Situation: A patient with painful diabetic neuropathy came with postural hypotension.
Dr Bad: The two are unrelated conditions.
Dr Good: It is due to autonomic dysfunction.
Lesson: Painful diabetic neuropathy is associated with significantly greater autonomic dysfunction than painless diabetic neuropathy. The greater autonomic dysfunction seen in painful diabetic peripheral neuropathy (DPN) may reflect more predominant small fiber involvement and also adds to the growing evidence of its role in the pathophysiology of painful DPN 
(Diabetes Care 2010;33(7):1585-90).

Emedinews :Soul does not leave the body immediately after the death

According to Prashna Upanishad, at the time of death, the Prana Vayu (respiration) merges with Udana Vayu (brain stem reflexes) and leaves the body. But this does not happen immediately after clinical death which is defined as stoppage of heart and respiration. Medically the term used for clinically dead patients is cardiac arrest.

As per the modern medicine, in cardiac arrest, the brain does not die for the next ten minutes and during this period, if the heart can be revived, life can be brought back.

The revival of patient during this period can be remembered by the formula of ten which is that within ten minutes of the stoppage of heart (cardiac arrest), if effective chest compression are given for the next ten minutes with a speed of 100 per minutes (10X10), 80% of the cardiac arrest victims can be revived.

This period can be much longer in hypothermia state. If the temperature of the body is low, the soul does not leave the body till the temperature is brought back to normal. Today, this property of soul is also used as therapeutic measure where patients who cannot be revived in the first ten minutes of clinical death are put in a freezing chamber and artificial hypothermia is produced and these patients can then be transported to an advance cardiac centre where even after 24 hours resuscitation measure can be applied after re-warming the body. Many people have been revived even after 24 hours of cardiac arrest with such a technology.

There are instances in literature where a newborn with hypothermia was declared dead and got revived in the cremation ground when the heat of the atmosphere brought his temperature to normal and the pressure of the wood worked like cardiac massage. 

This aspect of “life after death” is a contribution of the modern science to the Vedic science. Though in Vedic literature, it was well known phenomenon as Savitri brought life back into Satyavan even after his clinical death.

Take home message is that one should not declare a patient dead in the first ten minutes if cardiac massage and try reviving him with chest compression cardio pulmonary resuscitation.

Emedinews:Makesure: A patient died after receiving 30 ml IV KCL bolus.

Situation: A patient died after receiving 30 ml IV KCL bolus.
Reaction: Oh my God! Why was KCL given as bolus?
Lesson: Make sure that IV KCL is not given at a rate more than 10 mEq per hour.

Emedinews: Dr Good Dr Bad:A patient of CAD developed dengue.

Situation: A patient of CAD developed dengue.
Dr Bad: Start paracetamol.
Dr Good: Start paracetamol and stop low-dose aspirin.
Lesson: In dengue, lose-dose aspirin needs to be stopped.

Emedinews :One can predict acute lung injury

The lung injury prediction score (LIPS) should be used to predict patients who are unlikely to develop ALI/ARDS.

• LIPS >4 predicts ALI with a sensitivity and specificity of 69 and 78 %, respectively.
• LIPS <4 has a negative predictive value of 97%. Score: Sum up the assigned points
1. Shock (2 points)
2. Aspiration (2 points)
3. Sepsis (1 point)
4. Pneumonia (1.5 points)
5. Orthopedic spine surgery (1.5 points)
6. Acute abdominal surgery (2 points)
7. Cardiac surgery (2.5 points)
8. Aortic vascular surgery (3.5 points)
9. Traumatic brain injury (2 points)
10. Smoke inhalation (2 points)
11. Near drowning (2 points)
12. Lung contusion (1.5 points)
13. Multiple fractures (1.5 points)
14. Alcohol abuse (1 point)
15. Obesity (BMI >30, 1 point)
16. Hypoalbuminemia (1 point)
17. Chemotherapy (1 point)
18. Fraction of inspired oxygen >0.35 or >4 L/min (2 points)
19. Tachypnea >30 breaths/min (1.5 points)
20. Oxyhemoglobin saturation <95 percent (1 point)
21. Acidosis (pH <7.35, 1.5 points)
22. Diabetes mellitus (-1 point)

 (Ref : Gajic O, Dabbagh O, Park PK, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2011;183:462).

Emedinews:Makesure:A 7-month-old infant presented with grunting respiration, fever, anorexia and irritability. On chest x-ray, pneumatoceles was present.

Situation: A 7-month-old infant presented with grunting respiration, fever, anorexia and irritability. On chest x-ray, pneumatoceles was present.
Reaction: Oh my God! Why did you not start erythromycin immediately?
Lesson: Make sure to remember that erythromycin is an effective drug for Staphylococcal acquired pneumonia.

Emedinews: Dr Good Dr Bad: In how many patient of DVT does embolization occur? (JR to SR)

Situation: In how many patient of DVT does embolization occur? (JR to SR)
Dr Bad: Rare!
Dr Good: Common!
Lesson: Embolization occurs in about 50% of patients having proximal vein DVT.

Emedinews:Another Bomb Blast in Delhi

A powerful bomb exploded outside Delhi High Court gate number 5 on Wednesday morning. The blast took place at around 10.15 am. It left 11 people dead and more than 100 injured. This is the second such incident at the High Court this year.

Half of all early casualties seek medical care over first hour. To know the total number of casualties, double this number after one hour. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs.

The most severely injured arrive after the less injured who self–transport to the closest hospitals, so always expect upside down triage.

It is important that we as doctors know how bomb blast cause injuries in order to tackle the repercussions of bomb blasts. Bomb blast injuries can be categorized into four types:

• Primary blast injuries are a direct result of the impact of the over pressurized blast wave on the body. It involves injuries to the hollow gas–filled organs like the lungs, ear drum or intestines leading to their rupture.

• Secondary blast injuries occur due to flying debris and bomb fragments causing penetration or penetrating injuries to organs such as eyes.

• Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures due to the fall.

• Quaternary blast injuries are due to direct effect of burn or crush injuries.

The most important aspect is not to waste energies and resources on patients with non-serious injuries.

Look for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non–serious injury.

• If the ear drums are intact, the patient can be discharged with first–aid treatment.

• If ear drum is ruptured, immediately do an X–ray chest. Keep the patient under observation for eight hours as primary blast injuries may have a delayed presentation.

Hence, otoscopic ear exam can be used as a screening procedure for triage. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent.

Emedinews :Makesure: A patient who had multiple blunt trauma on his abdomen is admitted for management.

Situation: A patient who had multiple blunt trauma on his abdomen is admitted for management.
Reaction: Oh my God! Why did you not do a peritoneal lavage?
Lesson: Make sure to perform a peritoneal lavage in patients of multiple blunt trauma to exclude peritoneal haemorrhage from ruptured abdominal organs as the peritoneal reaction is often mild and a thorough clinical examination is not possible.

Emedinews: Dr Good Dr Bad: A diabetic patient was diagnosed with sarcopenia.

Situation: A diabetic patient was diagnosed with sarcopenia.
Dr. Bad: It is related to diabetes.
Dr. Good: It is not related to diabetes
Lesson: In the Korean Sarcopenic Obesity Study (KSOS), type 2 diabetes was associated with increased risk of sarcopenia. These characteristics may contribute to physical disability and metabolic disorders in older adults with diabetes
Source: Diabetes Care 2010 July; 33(7): 1497-9.

Emedinews: Strenuous exercise may increase risk of cardiac disorders

Strenuous exercise, whether performed by elite athletes or competitive weekend warriors, comes with a risk of developing cardiac disorders, including atrial fibrillation, according to a study presented at the European Society of Cardiology meeting.

Investigators found that among people who exercise four hours or more during the week, there was about a 39% increased risk of developing atrial fibrillation that required medical treatment.

Among elite cross-country endurance skiers, the risk of developing arrhythmias increased by 37% when compared with athletes in the same race that skied at a more moderate pace.

Source: MedPage Today

Emedinews: Dr Good Dr Bad: An asymptomatic patient with no obvious underlying cardiac disease shows ventricular premature contractions (VPCs).

Situation: An asymptomatic patient with no obvious underlying cardiac disease shows ventricular premature contractions (VPCs).
Dr Bad: Anti-arrhythmics should be given.
Dr Good: No treatment is needed.
Lesson: In the absence of cardiac disease, isolated asymptomatic VPCs regardless of configuration and frequency need no treatment.

Emedinews:Makesure: A patient with fever developed melena.

Situation: A patient with fever developed melena.
Reaction: Oh my God! why was platelet count not done?
Lesson: Make sure in all patients with fever platelet counts are done.

Emedinews: Dr Good Dr Bad: A diabetic HIV patient came with A1c of 6.5.

Situation: A diabetic HIV patient came with A1c of 6.5.
Dr Bad: It’s perfect.
Dr Good: It is not 100% reliable for your situation.
Lesson: A1c may not be accurate for assessing glycemia among HIV-infected patients on NRTI–based therapy, especially those with macrocytosis or those on abacavir. In a prospective study evaluating the accuracy of A1c in HIV–infected patients with diabetes, glucose levels were significantly higher than anticipated by A1c levels when compared with HIV–uninfected control subjects and established reference values. Relative to the control subjects, A1C underestimated glucose by 29 ± 4 in the HIV–infected subjects (Diabetes Care 2009;32(9):1591–3).

Emedinews:Makesure: A 28–year–old male presents with increased frequency and occasional blood in urine. Urine examination shows sterile pyuria.

Situation: A 28–year–old male presents with increased frequency and occasional blood in urine. Urine examination shows sterile pyuria.
Reaction: Oh my God! Why didn’t you check for TB?
Lesson: Make Sure to rule out TB in patients with frequency, dysuria, hematuria. A sterile pyuria is the first clue to diagnosis.