Retinopathy, Purtscher & Still's disease

http://emedicine.medscape.com/article/1225431-overview
Purtscher retinopathy is a hemorrhagic and vasoocclusive vasculopathy, which, in 1912, was first described as a syndrome of sudden blindness associated with severe head trauma. These patients had findings of multiple white retinal patches and retinal hemorrhages that were associated with severe vision loss. Since its original description, Purtscher retinopathy has been associated with traumatic injury, primarily blunt thoracic trauma and head trauma, and numerous nontraumatic diseases. Characteristic fundus findings of Purtscher retinopathy. Multiple cotton-wool spots surround the optic nerve after blunt thoracic trauma. Purtscher-like retinopathy is seen in diverse conditions, including acute pancreatitis; fat embolization; amniotic fluid embolization; preeclampsia; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; and vasculitic diseases, such as lupus.

The original findings of white lesions in the retina associated with intraretinal and preretinal hemorrhages and papillitis were believed to be caused by lymphatic extravasation from trauma. These lesions are known as Purtscher flecken (larger infarcts of the retinal capillary bed) and cotton-wool spots (small retinal microinfarcts at the level of the nerve fiber layer). Fluorescein leakage in Purtscher retinopathy suggests that an acute endothelial cell injury is caused by trauma, possibly predisposing the retinal vessels to occlusion.

The exact pathophysiology remains somewhat controversial, and different mechanisms have been proposed. The most accepted mechanism is leukoembolization that causes arterial occlusion and infarction of the microvascular bed. Leukocyte aggregation, which is induced by complement C5a, is believed to be the most likely mechanism of embolization because of its known association with trauma, acute pancreatitis, and vasculitic diseases.

Other possible sources of emboli include fat emboli in cases of long bone fractures and perhaps pancreatitis from enzymatic digestion of omental fat, amniotic fluid embolization during childbirth and postpartum, air emboli from traumatic chest compression, and granulocyte aggregation resulting from complement activation.

Other proposed mechanisms of vascular occlusion include angiospasm resulting from an acute rise in venous pressure from compressive chest injuries or possibly acute head injuries and endothelial cell damage resulting from acutely increased intraluminal pressure.

Presentation:
1. Patients with traumatic Purtscher retinopathy present with a recent history of blunt chest trauma or head trauma. The severity of chest trauma is not correlated directly with the incidence or severity of retinopathy, which is observed in these patients.
2. Patients may present with unilateral or bilateral vision loss (possibly severe) generally within 2 days.
M3. acular cotton-wool spots and intraretinal hemorrhages in patients with this history of trauma are diagnostic of the condition. Larger capillary bed infarcts (Purtscher flecken) are also seen in the macula and region surrounding the optic nerve. Typically, there is sparing of the retina whitening immediately adjacent to the larger retinal vessels.
4. Patients also may present with a Purtscher-like retinopathy in the absence of trauma. Various systemic conditions have been associated with developing the following characteristic retinal findings:
- Patients with acute pancreatitis are at risk for developing Purtscher-like retinopathy.
- Patients with long bone fractures are at risk for developing fat embolization and Purtscher-like retinopathy.
-Childbirth
i. Purtscher-like retinopathy may be seen in the postpartum period.
ii. Purtscher-like retinopathy may be due to amniotic fluid embolization with a catastrophic presentation, including shock and disseminated intravascular coagulopathy (DIC).
iii. Retinal arterial occlusions with microvascular infarcts and labor-associated hemorrhage have been reported in patients with preeclampsia and Purtscher-like retinopathy.
iv. Protein C and protein S deficiency have been reported.
-Purtscher-like retinopathy has been observed in patients with certain types of systemic vasculitides.
i. The most likely etiology is microvascular infarction due to complement C5a-induced leukocyte aggregation.
ii. Unexplained vision loss in patients with these conditions (eg, systemic lupus erythematosus, dermatomyositis, scleroderma) should raise the possibility of Purtscher-like retinopathy.

Regarding relationship of Purtscher retinopathy and Still's disease
Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology. It is characterized by daily high spiking fevers associated with an evanescent rash, arthritis, and multiorgan involvement. Here we report a patient with AOSD-associated thrombotic microangiopathy (TMA) combining central nervous system and renal involvement, associated with 2 severe and unusual complications: Purtscher-like retinopathy and extremity gangrene. Interestingly, renal biopsy showed decreased expression of glomerular vascular endothelial growth factor (VEGF), which could have triggered the TMA and may represent a new pathophysiologic mechanism in human TMA
http://onlinelibrary.wiley.com/doi/10.1002/art.24826/pdf

Things to learn

1. Management of acute exacerbations of chronic obstructive pulmonary disease
Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines an exacerbation of chronic obstructive pulmonary disease (COPD) as an acute increase in symptoms beyond normal day-to-day variation and includes one or more of following cardinal symptoms: cough increases in frequency and severity, sputum production increases in volume and/or changes character and dyspnea increases. Constitutional symptoms, an unchanged chest radiography, a variable decrease in pulmonary function and tachypnea are typical in acute exacerbations. Est that 70-80% of COPD exacerbations are due to respiratory infections. Viral and bacterial infections cause most exacerbations. Others are due to environmental pollutants or unknown etiology.

2. Serum creatinine
Serum creatinine = ARF - 1) Pre-renal 2) Vascular 3) Renal 4) Post-renal

3. http://medresidents.stanford.edu/TeachingMaterials/Shock%20and%20Sepsis/Sepsis%20and%20SIRS%20Examples%20-%20Key.doc
Sepsis: In patient with sever sepsis/septic shock, in fact in Jefferson hospital, the antibiotic being used is Vanc + Zosyn (Piperacillin and Tazobactam Injection). Vanc to cover Gram-positive while either a beta-lactam/beta-lactamase inhibitor (Piperacillin and Tazobactam), a third or fourth-generation cephalosporin (ceftriaxone) or a carbapenem such as imipenem for Gram-negative coverage.

4. Still disease
aka Systemic-onset juvenile arthritis
Early pattern of prominent systemic complaints and extra-articular involvement. Boys more common.

BIG - Bone Injection Gun

http://www.actnt.com/BIG/Bone_Injection_Gun.htm

Bone Injection Gun - The B.I.G.
National Distributor for EMS & Healthcare


National distributor for EMS and Healthcare



"The BIG provides an effective alternative IV access for critical patients in whom a peripheral IV line
cannot be readily obtained in the pre-hospital setting."
Journal of Trauma-Injury Infection & Critical Care. 64(3):650-655, March 2008.
Schwartz, Dagan MD; Amir, Lisa MD; Dichter, Reuven MA; Figenberg, Zvi MD

Medical studies have proven that survival rates for serious injuries or illnesses are significantly improved by prompt treatment. Rapid administration of fluids to stabilize shock and quick access for life-saving medications are key factors for survival. And when every second counts, delays in placing an IV line can be fatal. When you cannot find a vein, use the B.I.G. (Bone Injection Gun) -- a novel, automatic intraosseous infusion device.
B.I.G. Advantages
For administering fluids and medications in time critical conditions, B.I.G. provides the perfect solution.
Infusion established in less than 20 seconds
No parts to assemble or replace (100% disposable)
No batteries to fail or replace
Very reliable - 96% success rate
Pre-set needle depth (Adult), depth by age (Pediatrics)
Five (5) year shelf life
Extra safe - no direct contact with patient's blood
Can be used by Physicians, Nurses & Paramedics
Over 10 years of use in over 40 countries
FDA (adult & pediatric) and CE approvals
Completely mechanical, no need for any energy source (e.g. batteries)
B.I.G. Indications For Use
The BIG (Bone Injection Gun) is used by thousands of militaries, paramedics, nurses and physicians in countries around the world. In hospitals, in many cases, it is eliminating the need to place Central Venous Catheter (CVC), while in pre-hospital and military, the BIG (Bone Injection Gun) provides a safe, quick and easy solution when patient’s condition makes IV placement difficult or impossible.
BIG- Bone Injection Gun, is a novel, automatic intraosseous infusion device that provides rapid, safe and easy intravascular access through the bone marrow. The BIG is an effective answer to unsuccessful intravenous access during adult Trauma and Emergencies, which dramatically increases the caregiver's ability to save lives.
The BIG (Bone Injection Gun) Intraosseous Injection device completely eliminates delays in IV access. For administering fluids and medications under field conditions in the Military scene, BIG (Bone Injection Gun) provides the perfect solution.
In addition to the pre-hospital application, the BIG offers a good solution for in hospital emergencies.

Serratiopeptidase

http://serratiopeptidase.weebly.com/
http://www.ehow.com/about_5130452_serratiopeptidase-side-effect.html

If you suffer from pain to any extent – occasionally, chronically or somewhere in between – an enzyme known as serratiopeptidase may just be the answer for you. This is especially true if you have an aversion to, or are experiencing any side effects of, the medication you currently use for pain management. Whether you take prescription or over-the-counter “painkillers,” serratiopeptidase is a safe, natural alternative with no known side effects.

Serratiopeptidase, also known as serrapeptase, is a proteolytic (that is, having the ability to break down proteins into simpler compounds) enzyme which is naturally present in the silkworm intestine. Now, before you go running for cover, screaming, “I’m not swallowing anything that came from a worm’s innards!” – let me just emphasize: The type that is available to consumers today is processed through fermentation of plant-grown enzymes, and is generally of such purity that it is suitable even for consumption by vegetarians.

Serrapeptase has been widely used for over 30 years in many Asian and European countries. In Austria and Germany for instance, it is available by prescription only. Fortunately, in the U.S. – and elsewhere – this is not the case. It is so safe, in fact, that it can be taken by children, pregnant women, and has even been successfully used on pets.

Chronic inflammation lies at the heart of a myriad of ailments, including headaches, muscle and joint pain (from exercise, or in conditions such as arthritis or fibromyalgia) – and ultimately, even more serious diseases such as cancer and heart disease. Unlike conventional pain med’s, which are designed to only relieve the inflammation, serratiopeptidase actually breaks down the protein deposits (known as fibrin) which often remain – and continue to cause pain and discomfort – even after your body has healed from an injury or other irritation.

And, as stated, serrapeptase has no known side effects – unlike aspirin, ibuprofen, naproxen, and other over-the-counter NSAIDs – as well as acetaminophen (which is not classified as an NSAID.) These non-prescription drugs have been proven in clinical studies to cause stomach, kidney, liver, and even heart problems, especially when used regularly, and for prolonged periods. What’s worse, certain prescription med’s – especially in the NSAIDs category – have had even more serious side effects, which have been well-documented in the media in recent years.

So for the millions of pain sufferers who turn to these medications on a regular basis, the emergence of serratiopeptidase as a viable alternative is most welcome, to put it mildly. In upcoming articles, we will be keeping you informed of exciting news and developments on this incredible enzyme – as well as the best source for obtaining it – so bookmark this site, and check back often.

This is a drug that I found out in my clinic. Before this, I never get to know this drug. Never have I know that this drug exist and it's so "natural". I really thought this is something artificial or some sort of complex channel blockers. [Most of the clinical studies conducted do not document any side effects. In the few that do document side effects, there is not enough data to determine if they are caused by the serratiopeptidase or if they were just a coincidence. With the positive results of the preliminary data, there is sure to be more studies to document the benefits and side effects.]

Conditions I Learnt Today

After looking at so many articles, the condition is actually named Chronic Fatigue Syndrome to replace other names like I mentioned below. I guess it's the difference between how the Americans and British call them? PVS seems to be written by UK people...
Post-Viral Syndrome: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1710789/pdf/jroyalcgprac00029-0021.pdf

I am going to share some conditions I witnessed today. First, post-viral syndrome. There is one patient who complains of whole body-ache after a viral infection.
Quote: "The syndrome typically follows an upper respiratory tract infection from which the sufferer fails to make a full recovery, complaining of a multitude of symptoms which may persist for months or even years. The cardinal symptom is profound
muscular fatigue and this is often accompanied by muscle pain, headache, paraesthesiae, dizziness, urinary frequency, cold extremities, bouts of sweating and fainting attacks. Other symptoms are poor memory, lack of concentration, sleep disturbance, mild expressive and receptive dysphasia, hyperacusis and emotional lability. Clinical examination usually shows no abnormalities, nor do routine laboratory investigations. The diagnosis is therefore one of exclusion. The illness follows one of three courses: many patients recover completely, in others there is a relapsing and remitting course and in some there is chronic illness. Relapses are precipitated by undue physical or mental stress: patients who rest adequately in the early stages are said to have the best chance of an early, complete recovery without relapse."

There is another term which I want to bring up: Neurasthenia. 'Neurasthenia is a condition of nervous exhaustion, characterised by undue fatigue on slightest exertion, both physical and mental, with which are associated symptoms of abnormalfunctioning, mainly referable to disorders of the vegetative nervous system. The chief symptoms are headache, gastrointestinal disturbances, and subjective sensations of all kinds'. (The term has remained in use in some European countries including France and Russia, but has become virtually obsolete in the United States.)

The doctor told me that there are people who suffer from this condition and landed up in their most downs in their life. It took one year for that person to finally decided to find the meaning of his life and strife to rid of this syndrome and become a normal person again. That was how debilitating this condition can do to a person.