Dr. Singh Cardio-Diabetes Center

23/11/2020

Clinical guidelines irreparably characterize contemporary medicine. Referring to guidelines has become routine in both medical literature and daily clinical activity, with the risk of becoming the only—or at least the main—inspiring element of the physician's behaviour. This would lead to the mortification of clinical reasoning, a term that is synonymous with an individualized approach, focused on the single patient, and not on a population.

Abstract. Clinical guidelines irreparably characterize contemporary medicine. Referring to guidelines has become routine in both medical literature and daily cl

27/08/2020

HFrEF

06/10/2019

🎉🎉🎉🎉

🌺दुर्गा अष्टमी - देवी महागौरी पूजन।🌺

🌺सनातन धर्म की तीन शक्ति रात्रियों - कालरात्रि, महारात्रि एवं मोहरात्रि में आज आदिशक्ति की महारात्रि है।🌺

🌺मां दुर्गा जी की आठवीं शक्ति का नाम महागौरी है।🌺

🌺 नारद पंचरात्र की कथा अनुसार,परमात्मा शिवजी को पति रूप में पाने के लिए मां ने कठोर तपस्या की, फलत: उनका शरीर धूल-मिट्टी से मलिन हो गया था। तब शिवजी ने गंगाजल से इनके शरीर को स्नान कर गौरवर्ण का बना दिया। इसीलिए उनका नाम महागौरी पड़ा।🌺

🌺वैसे तो नवरात्र के दसों दिन कुवारी कन्या भोजन कराने का विधान है परंतु अष्टमी के दिन का विशेष महत्व है ।महाष्टमी के दिन सुबह स्नान करने के बाद व्यक्ति को देवी भगवती की भक्तिभाव से यथासंभव विधिवत पूजा करनी चाहिए।मां के तेज से संपूर्ण सृष्टि प्रकाशमान होती है इसलिए इनकी भक्ति अमोघ फलदायिनी है। यह धन, वैभव और सुख-शांति की अधिष्ठात्री देवी हैं अतः भक्तों के लिए यह अन्नपूर्णा स्वरूपा हैं।महागौरी की अराधना से भक्तों के सभी कष्ट दूर हो जाते हैं तथा देवी का भक्त जीवन में नैतिकता ,पवित्रता और अक्षय पुण्यों का अधिकारी बनता है।माँ अपने भक्तों के दुख-क्लेश को तुरत समाप्त कर जीवन में असीम शांति प्रदान करती हैं।🌺

🌺"या देवी सर्वभू‍तेषु माँ महागौरी रूपेण संस्थिता।
नमस्तस्यै नमस्तस्यै नमस्तस्यै नमो नम:"।।🌺

🌺महागौरी का ध्यान🌺

🌺वन्दे वांछित कामार्थे चन्द्रार्घकृत शेखराम्।
सिंहरूढ़ा चतुर्भुजा महागौरी यशस्विनीम।

पूर्णेन्दुनिभां गौरी सोमचक्रस्थितां अष्टमं महागौरी त्रिनेत्राम्।
वराभीतिकरां त्रिशूल डमरूधरां महागौरी भजेम्॥

पटाम्बर परिधानां मृदुहास्या नानालंकार भूषिताम्।
मंजीर, हार, केयूर किंकिणी रत्नकुण्डल मण्डिताम्॥

प्रफुल्ल वंदना पल्ल्वाधरां कातं कपोलां त्रैलोक्य मोहनम्।
कमनीया लावण्यां मृणांल चंदनगंधलिप्ताम्॥🌺

🌺महागौरी का स्तोत्र पाठ🌺
सर्वसंकट हंत्री त्वंहि धन ऐश्वर्य प्रदायनीम्।
ज्ञानदा चतुर्वेदमयी महागौरी प्रणमाभ्यहम्॥

सुख शान्तिदात्री धन धान्य प्रदीयनीम्।
डमरूवाद्य प्रिया आद्या महागौरी प्रणमाभ्यहम्॥

त्रैलोक्यमंगल त्वंहि तापत्रय हारिणीम्।
वददं चैतन्यमयी महागौरी प्रणमाम्यहम्॥🌺

🌺महागौरी का कवच मंत्र🌺

🌺ओंकारः पातु शीर्षो मां, हीं बीजं मां, हृदयो।
क्लीं बीजं सदापातु नभो गृहो च पादयो॥
ललाटं कर्णो हुं बीजं पातु महागौरी मां नेत्रं घ्राणो।
कपोत चिबुको फट् पातु स्वाहा मा सर्ववदनो॥

🌺मंत्र- ऊँ ऐं ह्रीं क्लीं चामुण्डाये विच्चे नम:।
ऊँ महागौरी देव्यै नम:। 🌺

🌺🌺🌺🌺🌺🙏🙏🌺🌺🌺🌺🌺

DrMahendra Pratap Singh

16/08/2019

Hyperacute T wave
The earliest sign of AMI
Acute myocardial infarction (AMI) is a life-threatening disease that needs accurate and rapid diagnosis followed by appropriate treatment. Electrocardiogram is an inexpensive and commonly used tool in the diagnostic work up of AMI which provide diagnostic and prognostic information. Among other electrocardiographi signs of cardiac ischemia, tall and broad-base T waves, especially in the anterior precordial leads of 12 lead ECG may be the earliest and the only electrocardiographic sign of AMI. In this case, they are called Hyperacute T waves (HATWs). It
occurs within seconds after total occlusion of a coronary artery and usually resolve within minutes (they are succeeded by ST-segment elevations). Hyperacute T-waves are often bulky, and wide at the base and are localized to an anatomic area of infarct. The widening of the T-wave may also lengthen the QT interval. It must be emphasized that hyperacute T-waves are not necessarily always tall, they may only be relatively large when compared to the R-wave. This means that even a small T-wave can still be hyperacute if paired with a low-voltage QRS. It is important to note that there is no acceptable universal definition of hyperacute T-waves, but there can be other clues on the ECG. During the development of hyperacute T-waves, there can be associated ST-segment depression in the reciprocal leads.

05/03/2019

21/01/2019

💐💐COMPLETE HEART BLOCK (3rd degree AV-block):

💐💐DEFINITION:In complete heart block, there is complete absence of AV conduction – none of the supraventricular impulses are conducted to the ventricles.
Perfusing rhythm is maintained by a junctional or ventricular escape rhythm. Alternatively, the patient may suffer ventricular standstill leading to syncope (if self-terminating) or sudden cardiac death (if prolonged).
Typically the patient will have severe bradycardia with independent atrial and ventricular rates, i.e. AV dissociation.
💐💐CAUSES:
The causes are the same as for Mobitz I and Mobitz II second degree heart block. The most important aetiologies are:
*Inferior myocardial infarction
*AV-nodal blocking drugs (e.g. calcium-channel blockers, beta-blockers, digoxin)
Idiopathic degeneration of the conducting system (Lenegre’s or Lev’s disease)

💐💐CLINICAL SIGNIFICANCE:
Patients with third degree heart block are at high risk of ventricular standstill and sudden cardiac death.
They require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker.

💐 diagnosis:

Complete heart block should not be confused with:
💐*High grade AV block: A type of severe second degree heart block with a very slow ventricular rate but still some evidence of occasional AV conduction.
💐*AV dissociation: This term indicates only the occurrence of independent atrial and ventricular contractions and may be caused by entities other than complete heart block (e.g. “interference-dissociation” due to the presence of a ventricular rhythm such as AIVR or VT).

💐

Complete heart block is essentially the end point of either Mobitz I or Mobitz II AV block.It may be due to progressive fatigue of AV nodal cells as per Mobitz I (e.g. secondary to increased vagal tone in the acute phase of an inferior MI).Alternatively, it may be due to sudden onset of complete conduction failure throughout the His-Purkinje system, as per Mobitz II (e.g. secondary to septal infarction in acute anterior MI).The former is more likely to respond to atropine and has a better overall prognosis.

13/01/2019

💐 💐
:
Main factors which determine treatment is severity of disease activity, organs involved and patients associated health conditions such as pregnancy etc. General principles are discussed here.
Drugs required are mainly targeting for following reasons:
1: immunosuppressive drugs
2: antiplatelets &/or anticoagulation for APLS or TTP related issues
3: CVS risk factors modification &/or
4: symptom based therapy

HYDROXYCHLOROQUIN:
Every patient of SLE should be on HCQ unless it’s contraindicated . It works as being immundomodulator by getting stored in macrophages and alkalikising the pH and reducing their ability for inflammation. In addition to its effects on reducing inflammation, it also reduces thrombotic tendency, osteoporosis and disease progression. Renal disease or liver disease will need dose reduction as its metabolism & excretion will be affected.
Main side effect is dose and duration dependent retinal deposition especially in Macula requiring annual monitoring which usually causes issues after several (more than 5-6 years of use). It’s usually enough for mild SLE affecting skin & musculoskeletal system. It’s SAFE in pregnancy.

METHOTREXATE:
Being antifolate,it reduces cell division & hence reduces blood cells including immune cells.
It’s mainly used & is drug of first choice for musculoskeletal manifestations (Joint, muscles & skin) of any Rheumatological diseases including SLE, RA, Psoriasis etc. It’s usually added to HCQ if the later alone isn’t enough for musculoskeletal features of SLE or RA. Also Anything more than Mild disease of musculoskeletal parts need MTX unless contraindicated.
Internal organ involvement usually doesn’t benefit much from MTX. It’s not safe for pregnancy. Patients needs folate replacement too to save normal body cells. Maximum dose is 25mg/week.
S/E include cytopenia, liver damage (fibrosis etc ) , penuominitis and Lung fibrosis, teratogenic and also cause abortion, GI upset etc.

ORGAN INVOLVEMENT in SLE (KIDNEY, LUNG, CNS, VASCULITIS etc ):
It needs aggressive immunosuppressive therapy to save permanent damage by inflammation and /or thrombosis. Two phases of treatment include Induction followed by maintainance. Induction is achieved by Steroids with Cyclophosphamide or steroids with Mycophenolate. Maintainince is by MMF or Azathioprine or MTX.

INDUCTION by 1 OR 2:
1: Generally speaking IV Methylprednisolone pulse therapy (1 gm daily for 3-5 days) followed by oral prednisolone 1mg/kg ideal weight/day along with Cyclophosphamide (C*C) monthly pulse therapy (750-1000 mg /m2 body surface area/month ) is treatment of choice. Low dose C*C such as 500 mg/m2 body area/ fortnight for 6 doses etc can also be considered for European descent patients whose response to low dose is almost similar to high dose. Oral C*C daily has almost similar efficiency but significantly more cumulative toxicity but is often used in resource limited countries. Main side effects are cytopenia, infections, haemorrhagic cystitis & bladder TCC, vasoconstriction related side effects, teratogenicity and infertility. Not safe in reproductive age patients who can be pregnant or want children. MESNa is antidote usually given with C*C.

2: In the above regimen if C*C toxicity is major concern such as young patients with fertility related aspects etc, MYCOPHENOLATE (MMF) (2-3gm/day) can be substituted for C*C but steroids regimen would remain the same. MMF has similar efficacy as C*C but with much lesser toxicity. Mycophenolic Acid or Mycophenolic Na has relatively lesser GI upset than Mycophenolate. Main dude effects are cytopenia & teratogenicity. It’s Not safe in pregnancy.

MAINTAINANCE THERAPY:
Once disease remission is achieved by induction therapy, maintainince is preferably by MMF (2 gm/day). Second choice is Azathioprine (2-3 mg/kg/day & used only if TPMT enzyme assay is normal) & third choice is by MTX. This preference is due to efficacy.

AZA (Azathioprine) is safe in pregnancy so it’s preferred for reproductive age or pregnant patients. However it’s not as effective as MMF. Check TPMT enzyme assay before using AZA as if it’s low patients marrow toxicity is greatly increased. Main side effects are cytopenia & liver derangement in addition to malignancies in long term use.

FAILED INDUCTION THERAPY or RESISTANT TO C*C /MMF & Steroids:
Options are switching to C*C if MMF failed OR switching to MMF if C*C failed but Steroids would be given along with each option.
Second option is biological agents such as Rituximab or Belimumab therapy.

Severe life threatening emergencies such as TTP, Pulmonary Haemorrhage, hyper gamma globulinemia, biological resistant disease etc may need plasmapharesis or IVIG.

CYTOPENIA & LUPUS
Use CNI (Cyclosporine), IVIG etc (but avoid C*C, AZA, Leflunomide & MTX if possible as they cause cytopenia).

PREGNANCY & SLE:
HCQ, Prednisolone, sulfasalazine with folic acid, Azathioprine up to 2 mg/kg/day , low dose calcinurin inhibitors (Cyclosporine & Tacrolimus ) & IVIG are safer. Details in a separate post.

10/12/2018

🔵 Spiked Helmet” Sign:🛎
New ECG Marker of
Critical Illness and High Risk of Death


=================================
WHAT IS HEMLET SIGN ⁉️

During the routine ECGs of hospitalized patients,
ECG showed apparent ST-segment elevation but with the upward shift starting before the onset of the QRS complex (Figure).

ECG showed a dome-and-spike pattern,
giving the appearance of Pickelhaube,
the German military spiked helmet
introduced in 1842 by Friedrich Wilhelm IV,
King of Prussia (Figure).

CASE EXAMPLE
~~~~~~~~~~~~
A 58-year-old woman was hospitalized for diarrhea, nausea, vomiting, and dehydration. On hospital day 2, she experienced severe abdominal pain but no chest pain. She had tachycardia, tachypnea, and diffuse abdominal tenderness. Telemetry suggested ST-segment elevation, and a subsequent 12-lead ECG with computer interpretation indicated inferior STEMI.

Careful analysis of the ECG revealed that the upward baseline shift started before the onset of the QRS complex (Figure, last strip), which would be inconsistent with STEMI.

Furthermore, an emergent echocardiogram demonstrated no wall motion abnormality, and cardiac serum markers were negative. A repeat ECG 2 hours later showed no ST-segment elevation.

Within 12 hours, the patient had evidence of acute abdomen. Emergent laparotomy revealed perforated bowel with extensive bowel necrosis. Despite aggressive surgical and medical management, the patient died 24 hours after the ECG was obtained that exhibited the “spiked helmet” sign.

Clinical and Electrocardiographic Characteristics of Patients With the “Spiked Helmet” Signa
We think that the pseudo-ST segment elevation possibly occurred at the time and may have been a reflection of the bowel perforation.

MECHANISM
~~~~~~~~~~
The exact mechanism of the spiked helmet ECG pattern and its association with critical illness is uncertain, but several observations point to the possible role of the diaphragm.

Certain pathological conditions can rarely result in repetitive contraction of the diaphragm that is in concert with the cardiac cycle.

Postulated mechanisms of this pulsatile diaphragmatic motion include direct stimulation of the diaphragm by the inferior wall of the left ventricle or triggering of the left leaf of the diaphragm by the left phrenic nerve.

Such diaphragmatic contractions may result in alteration of the ST segment, which is best seen in the inferior leads.

A possible mechanism to explain pseudo-ST segment elevation is repetitive epidermal stretch in association with nearby pulsatile flow or due to an acute rise in the intrathoracic or intra-abdominal pressure.

CONCLUSION
~~~~~~~~~~
The spiked helmet sign is a potential novel ECG marker of a very high risk of impending death,
but the prevalence, mechanism, and clinical applicability remain uncertain at this time.

Repetitive signals in the ECG that are not generated by cardiac depolarization or repolarization have previously been shown to provide important clues to patients’ clinical conditions and guidance on their treatment.

Further experience is needed to determine whether the spiked helmet sign will eventually change clinical management or just remain an electric curiosity.

🔻Reference
Laszlo Littmann, MD, PhD and Michael H. Monroe, MD
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228627/

21/11/2018

💐PERSISTANT ST ELEVATION in ECG💐
...what to think & know!

The development of a is a late complication of myocardial infarction, seen (to varying degrees) in about 10 per cent of survivors.

The presence of an aneurysm can lead to persistent ST segment elevation in those chest leads that 'look at ' the affected region.

History:
Ask the patient about a history of previous myocardial infarction and assess the patient for symptoms and signs related to the aneurysm itself.

Risks:
Aneurysms, being non-contractile, can lead
to left ventricular dysfunction and thrombus formation.
They can also be a focus for arrhythmia generation.
Presenting symptoms can result from:
- Heart failure
- Embolic events
- Arrhythmias

Signs:
The clinical signs of a left ventricular aneurysm are a 'double impulse ' on precordial palpation and a fourth heart sound on
auscultation.

Investigations:
A chest radiograph may reveal a bulge on the cardiac outline.
The investigation of choice is echocardiography, which will reveal the site of the aneurysm and the presence of mural thrombus, as well as allowing assessment of overall left ventricular function.

Treatment:
Patients with left ventricular aneurysms may benefit from treatment for heart failure and use of anticoagulation and anti-arrhythmic drugs.
Consideration may also be given to surgical removal of the aneurysm (aneurysmectomy) or even cardiac transplantation where appropriate.
Specialist referral is therefore recommended.

Image & Text source: Making Sense of the ECG - A Hands-on guide

Pratap Singh

19/11/2018

💐जिन्होंने आपका संघर्ष देखा है, सिर्फ वही आपकी कामयाबी की कीमत जानते है💐

💐औरों के लिए आप केवल भाग्यशाली व्यक्ति हैं|💐