Sweetening the future for diabetic patients

While PI provides a faster snapshot of specific sites, whole-body MRI takes a broader view, and has recently shown its ability to assess risk of heart attack and stroke in diabetic patients. Fabian Bamberg, MD, MPH, of Ludwig Maximilian University of Munich, and colleagues designed a study aimed to establish the predictive value of whole-body MRI for the occurrence of cardiovascular and cerebrovascular events in a cohort of patients with diabetes mellitus (DM). The study was published online Sept. 10, 2013, in Radiology.

Diabetic patients are known to develop atherosclerosis, which is the thickening of the arterial walls at an accelerated rate. This can result in a higher rate of major adverse cardiac and cerebrovascular events (MACCE).

The authors followed up with phone interviews for 61 patients with DM types 1 and 2 who underwent comprehensive, contrast-enhanced whole-body MR imaging protocol, including brain, cardiac, and vascular sequences at baseline. The primary endpoint was a MACCE, such as composite cardiac-cerebrovascular death, myocardial infarction, cerebrovascular event, or revascularization. Fourteen of the 61 patients suffered a MACCE during the follow-up period.

MR images were assessed for the presence of systemic atherosclerotic vessel changes, white matter lesions, and myocardial changes. The researchers found that while subjects without any pathologic findings on whole-body MRI did not experience an event over the follow-up period, the risk for MACCE was substantially higher among diabetic patients with any finding on whole-body MRI. Among those, a cumulative event rate of 20 percent at three years and 35 percent at six years was demonstrated.

“This discovery shows that a comprehensive, whole-body MR acquisition provides accurate assessment of the underlying disease burden in patients with diabetes mellitus that has very relevant prognostic information,” says  Bamberg. “Also, the prognostic value may be higher than only limited protocols, such as those tailored to the heart.” 

Lebanese diva Myriam Fares skintight outfit

Lebanon diva under fire over skintight outfit

 

Controversy crept up on Lebanese diva Myriam Fares this week when she posted up photos of herself in a skintight jumpsuit to Instagram, garnering a host of harsh responses.

What are some of the potential uses of cardiac MRI?

Once certain limitations are overcome - and that day seems to be rapidly approaching - the uses of cardiac MRI will greatly increase.

MRI has the potential (and has been used in the research setting) to diagnose heart attacks in patients presenting with chest pain. Not infrequently, a patient coming to the emergency room with chest pain will not have the typical ECG changes seen with myocardial infarctions, and the doctors end up waiting for an hour or two for the results of cardiac enzyme tests. If a heart attack is actually occurring, critical time is thus lost before therapy can begin. MRI can detect myocardial infarction immediately, and can reduce the time it takes to begin definitive treatment.

Strides are being made toward being able to diagnose coronary artery disease with MRI. A new MRI processing technique called "black-blood" MRI (so called because it produces an image of an artery in which the blood appears black, and the wall of the artery appears white) seems to be able to distinguish very nicely between normal and atherosclerotic coronary arteries. While further refinements are necessary, such techniques are bringing us very close to the day in which MRI will be able to replace cardiac catheterization for diagnosing coronary artery disease.

MRI can help distinguish between "stable atherosclerotic plaques and "vulnerable" plaques. Vulnerable plaques are those that are prone to rupture, thus suddenly occluding a coronary artery and causing a myocardial infarction. If vulnerable plaques can be identified (and this is something the cardiac catheterization cannot do), those particular plaques can be targeted for intervention (angioplasty, stent, or bypass surgery), while leaving the stable plaques alone. MRI has already proven useful in the research setting for identifying restenosis after angioplasty. MRI might thus prove an accurate, noninvasive means of following patients after angioplasty.

MRI has the potential of detecting changes in the tiny blood vessels of the heart the microvascular circulation that are completely missed by cardiac catheterization. Detecting such changes seem to be useful in predicting the outcome of patients after a heart attack, and may prove to be useful in assessing patients with cardiac syndrome x, diabetes, and certain other conditions.

Ultimately, MRI may replace the x-ray tube in both diagnostic and therapeutic situations. Research is already being done in animals using MRI to image the coronary arteries instead of using x-rays for angioplasty procedures. The technology that allows these potential uses of cardiac MRI is presently being tested and refined. Within a few years, at least some of these uses will come into widespread clinical application.

Treating Gallstones and Bile Duct Stones

Gallstones and bile duct stones may be treated first with antibiotics to help control infection. They also can be treated at the time of diagnosis with miniaturized surgical instruments inserted through an ERCP. Alternatively, stones may be treated with medications that dissolve them, with lithotripsy that uses sound waves to break them up, or with surgery to remove the gallbladder.

ENDOSCOPIC TECHNIQUES
When a stone has been identified on x-ray, ultrasound or MRI imaging as blocking a bile or pancreatic duct, it can be removed with miniaturized instruments inserted through the ERCP. These surgical instruments gently enlarge the ductal opening that then allows the stone to be removed.

MEDICATIONS
Medications can be given that dissolve gallstones but they are not always effective and are not indicated in all cases. The most common medication is a bile salt (ursodiol) that slowly dissolves cholesterol within the stones. However, the stones can return when the medication is discontinued.

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
This treatment employs high-frequency sound waves to break up gallstones. Patients then take bile salt tablets, sometimes indefinitely, to dissolve the pieces and to ensure that the stones do not return. Only a minority of patients are candidates for this type of treatment, however. The best candidates have a single small stone. If an infection (cholangitis) or inflammation (cholecystitis) of the gallbladder is present, lithotripsy is not an option. Extracorporeal (meaning outside of the body) shock wave lithotripsy is performed by directing pulsating, high-intensity sound waves at the area where the stone is located, identified first by ultrasound. The procedure takes about 45 minutes and patients are usually lightly sedated before treatment.

SURGERY
Surgery to remove the gallbladder, called cholecystectomy, is a common procedure in the United States for individuals with symptoms caused by gallstones. Virginia Mason was one of the first medical centers in the country to remove the gallbladder by the minimally invasive laparoscopic approach, called laparoscopic cholecystectomy.

This minimally invasive surgery for removing the gallbladder is one of the most common procedures performed at Virginia Mason and is, in fact, the preferred approach today for removal of the gallbladder. In cases in which a gallstone or bile stone has blocked a bile duct - a situation that can lead to infection or inflammation of organs within the biliary tract - surgeons will likely recommend removal of the gallbladder.
Laparoscopy
During laparoscopy, the surgeon makes several ¼ to ½ inch incisions in the abdomen. He or she then inserts miniaturized endoscopic and surgical instruments, and a small camera, through these "ports." Images from the camera are sent to a video monitor that allows the surgeon to "deflate" and then remove the gallbladder through one of the ports. Individuals return to their regular activities often within a few days.

Open surgery
Sometimes the surgeon must revert to an open surgical procedure during a scheduled laparoscopy to remove the gallbladder. These occurrences happen infrequently and are most often caused when the gallbladder is found to be infected or when the gallbladder lining is hardened, making it more difficult for the organ to be removed laparoscopically.

At other times, the surgeon may make the decision that the open surgical procedure is the best option for the patient based on the severity of the individual's gallbladder disease. Open surgery involves making a large incision in the abdomen and removing the gallbladder. Recovery time is longer, five to seven days in the hospital, and there is a longer return to daily activities: two to three weeks, for example.

Symptoms of Gallstones and Bile Duct Stones

Gallstones can be miniscule in size or as large as a ping-pong ball. You may have one stone or develop many of them. Not all gallstones or bile stones cause symptoms. Some are discovered incidentally during imaging studies for other reasons.

The most common symptom is upper abdominal pain on the right side of the body, where the liver and gallbladder are situated. The pain may start suddenly and be intense. Or it may be a slow, dull pain or occur intermittently. The pain may shift from the abdominal area to the upper back or shoulder.

Prolonged blockage of a bile duct can cause a buildup of waste products in the biliary tract and in the bloodstream, leading to an infection called cholangitis. It also can prevent the release of bile into the small intestine to help digest food or cause a serious bacterial infection in the liver called ascending cholangitis.

A blocked bile duct may result in inflammation of the gallbladder, called cholecystitis. A gallstone or bile stone in the common bile duct may block the pancreatic duct, causing painful inflammation of the pancreas or pancreatitis.  

If a stone completely blocks the ducts of the gallbladder, liver, common bile duct or pancreas, other symptoms may include:

• Nausea
• Fever
• Chills
• Yellow skin or eyes (from the build up of bilirubin, a waste product in blood)
• Dark urine
• Itching
• Fatigue
• Weight loss
• Night sweats
• Loss of appetite
• Greasy or light-colored stools

Patients who develop gallstones are at a slightly increased risk of developing gallbladder cancer, called cholangiocarcinoma. However, this is a rare disease and most people with gallstones do not go on to develop cancer.

സെക്‌സിന് ശേഷം

പങ്കാളിയുമൊത്തെ സെക്‌സ് ആസ്വദിച്ചശേഷം നിങ്ങള്‍ എന്ത് ചെയ്യും? സെക്‌സിലൂടെ പങ്കാളിയെ സന്തോഷിപ്പിക്കുകയെന്നത് പോലെ തന്നെ പ്രധാനപ്പെട്ടതാണ് സെക്‌സിന് ശേഷവും ആ സന്തോഷം നിലനിര്‍ത്തുകയെന്നത്.
സെക്‌സിന് ശേഷം മനപൂര്‍വമല്ലെങ്കിലും നിങ്ങള്‍ ചെയ്യുന്ന ചില കാര്യങ്ങള്‍ പലപ്പോഴും പങ്കാളിയുടെ മനസിന് വേദന നല്‍കുന്നതാണ്. അത് പങ്കാളിയുടെ സെക്ഷ്വല്‍ മൂഡ് തന്നെ ഇല്ലാതാക്കും.
സെക്‌സിന് ശേഷം മറ്റെന്തെങ്കിലും ജോലിയില്‍ മുഴുകുന്ന പങ്കാളികളില്‍ പലരും സെക്‌സിനെ ഒരു കടമയായാണ് കാണുന്നതെന്ന് സെക്‌സ് തെറാപ്പിസ്റ്റായ ഡോ. പുഷ്‌കര്‍ ഗുപ്ത കുറ്റപ്പെടുത്തുന്നു. ലൈംഗികബന്ധം ആസ്വദിക്കാനുള്ളതാണ്. സെക്‌സിന് ശേഷവും ആ മാനസികാവസ്ഥ നിലനിര്‍ത്താന്‍ പലകാര്യങ്ങളും ചെയ്യാമെന്നിരിക്കെ പലരും സീരിയസായ ജോലികളില്‍ മുഴുകുകയാണ് പതിവ്. ഇത് തങ്ങള്‍ ചെയ്യുന്ന വലിയ തെറ്റുകളിലൊന്നാണെന്ന് പലരും തിരിച്ചറിയില്ലെന്നും പുഷ്‌കര്‍ ഗുപ്ത വ്യക്തമാക്കി.
പങ്കാളിയുടെ ഈ പ്രവൃത്തി മറ്റെയാളെ അപമാനിക്കുന്നതിന് തുല്യമാണെന്നാണ് അമിത് മിശ്ര ചൂണ്ടിക്കാണിക്കുന്നു.
സാധാരണയായി പല ദമ്പതികളും ആവര്‍ത്തിക്കാറുള്ള ‘സെക്‌സിന് ശേഷമുള്ള തെറ്റ്’ ഇവയാണ്.
കിടന്നുറങ്ങുക:
പല ദമ്പതികള്‍ക്കിടയിലും ഈ പ്രശ്‌നം കാണാം. ഒന്നുകില്‍ പങ്കാളികളില്‍ ഒരാള്‍ അല്ലെങ്കില്‍ രണ്ടുപേരും സെക്‌സിന് ശേഷം കിടന്നുറങ്ങും. ഇന്ന് ലൈംഗിക ബന്ധത്തിന്റെ ആനന്ദം കെടുത്തും.
വൃത്തിയാക്കാന്‍ പോകുക: ശാരീരിക ബന്ധം കഴിഞ്ഞാലുടന്‍ വാഷ്‌റൂമിലേക്ക് പോകുന്ന ശീലം ചിലര്‍ക്കുണ്ട്. പലപ്പോഴും പങ്കാളി സെക്‌സ് ആസ്വദിക്കുന്ന മൂഡിലാവും ഉണ്ടാവുക. നിങ്ങള്‍ ഉടന്‍ തന്നെ വാഷ്‌റൂമിലേക്ക് പോകുമ്പോള്‍ മറ്റേയാളില്‍ അത് വിഷമമുണ്ടാക്കും. തന്റെ ഭാഗത്തുനിന്നുണ്ടായ മോശമായ പ്രവൃത്തിയാണ് ഇതിന് കാരണമെന്ന തോന്നല്‍ അവരിലുണ്ടാകും. ഇത് സെക്‌സിന്റെ സന്തോഷം ഇല്ലാതാക്കും.
സുഹൃത്തിനെ വിളിക്കുക:
പലപ്പോഴും ഔദ്യോഗിക കാര്യങ്ങള്‍ക്കും മറ്റുമാകും നിങ്ങള്‍ സുഹൃത്തിനെ വിളിക്കുന്നത്. എങ്കിലും അതിന് പിറ്റേദിവസം രാവിലെ വരെ കാത്തിരുന്നുകൂടെ? സെക്‌സ് ആസ്വദിക്കാനുള്ള സമയത്ത് നിങ്ങളുടെ മൊബൈല്‍ ഫോണിലെ മെസേജില്‍ നിന്നും മിസ്ഡ് കോളില്‍ നിന്നും കണ്ണെടുക്കണം. അല്ലാത്തപക്ഷം നിങ്ങള്‍ക്ക്  സംതൃപ്തി നല്‍കാനായില്ലെന്ന തോന്നല്‍ പങ്കാളിയിലുണ്ടാക്കും.
പഠനത്തിലോ ജോലിയിലോ മുഴുകുക:
സെക്‌സിന് ശേഷം പങ്കാളിയെ തനിച്ചാക്കി പഠനത്തിനോ അല്ലെങ്കില്‍ ജോലിയിലോ മുഴുകുന്ന ശീലം ചിലര്‍ക്കുണ്ട്. ഇത് ഒരിക്കലും നല്ല ലൈംഗികബന്ധത്തിന് യോജിച്ചതല്ല.
രണ്ടിടത്ത് ഉറങ്ങുക:
സെക്‌സിന് ശേഷം ചിലര്‍ ഗസ്റ്റ് റൂമിലോ, ടെറസിലോ പോയി കിടന്നുറങ്ങും. ഈ ശീലവും ആരോഗ്യകരമായ ലൈംഗികജീവിതത്തിന് യോജിച്ചതല്ല.
കുട്ടികളെ അടുത്ത് കൊണ്ടുവന്ന് കിടത്തുക:
സെക്‌സിന് ശേഷം നിങ്ങളുടെ സ്വകാര്യതയിലേക്ക് മറ്റാരെയെങ്കിലും കൊണ്ടുവരുന്നത് ഒരിക്കലും നല്ലതല്ല. ചില അമ്മമാര്‍ കുഞ്ഞുങ്ങളെ അടുത്തെടുത്ത് കിടത്താറുണ്ട്. എന്നാല്‍ ഇതെല്ലാം പങ്കാളിയുടെ ആനന്ദത്തെ തകര്‍ക്കും.
ഭക്ഷണം കഴിക്കുക:
നിങ്ങളുടെ പങ്കാളിയുമൊത്ത് ഭക്ഷണം കഴിക്കുന്നത് നല്ലകാര്യമാണ്. എന്നാല്‍ സെക്‌സിന് ശേഷം നേരെ അടുക്കളയിലേക്ക് പോയി എന്തെങ്കിലും തിന്നുന്നത് മോശമായ കാര്യമാണ്. നിങ്ങള്‍ വിശപ്പ് കാരണം സെക്‌സ് ആസ്വദിച്ചില്ലെന്ന തോന്നല്‍ ഇത് പങ്കാളിയിലുണ്ടാക്കും.

Myasthenia Gravis

Myasthenia gravis is a disease of the junctions where nerves that control muscle function meet the muscles themselves (the neuromuscular junction).  In myasthenia gravis patients, antibodies form within the neuromuscular junction that make the transmission of nerve impulses from nerve to muscle less efficient.  This creates a variety of problems which may include weakness of the peripheral muscles (usually worsening with repetitive contraction of the muscles), droopy eyelids (ptosis), double vision, and swallowing or breathing difficulties.

Drug therapy, which usually is initiated with pyridostigmine (mestinon) alone, often helps these symptoms of myasthenia gravis. Other, immunosuppressive drugs, such as prednisone or azathioprine, are added in some cases.

Surgical removal of the thymus gland (thymectomy) has had a role in the management of patients with thymoma for over 70 years.  Although it has never been studied versus medical therapy in a randomized trial (where patients are “randomized” to either have surgery or have no surgery),  many non-randomized studies suggest that the operation is beneficial.  While very few patients have a complete remission of the disease without thymectomy, 30-40% of patients will have a complete remission after surgery.

At Stanford, we are able to perform thymectomy for most myasthenia gravis patients through a single, 5 cm long incision at the base of the neck. This operation, called transcervical thymectomy can be performed with very little risk or discomfort. Patients return home the day of surgery or the following day, and they generally return to their usual activities within a week. The alternative procedure – thymectomy through a median sternotomy – has a substantially increased complication rate in patients with myasthenia gravis, who are susceptible to lung and other complications due to their muscle weakness.

Before coming to Stanford, Division Chief Dr. Joseph Shrager published the world’s largest series of extended transcervical thymectomy. This study demonstrated that the operation provides very similar remission rates to those achieved by thymectomy by median sternotomy, with far less complications and faster recovery. We are among the centers that has the greatest experience with this operation, and we are pleased to be able to offer it to myasthenia gravis patients in the greater San Francisco Bay Area as well as those from around the country.