NSTEMI vs STEMI

NSTEMI (Non–ST-segment elevation myocardial infarction) and STEMI (ST-segment elevation myocardial infarction) are commonly known as heart attack. But they are different from each other in some extent. NSTEMI account for about 30% and STEMI about 70% of all heart attack (myocardial infarction).

• NSTEMI (Non–ST-segment elevation myocardial infarction)
• STEMI (ST-segment elevation myocardial infarction)

Pathophysiology of NSTEMI vs STEMI:

Pathophysiologically, NSTEMI is somewhat different from STEMI. NSTEMI occurs by developing a complete occlusion of a minor coronary artery or a partial occlusion of a major coronary artery previously affected by atherosclerosis. This causes a partial thickness damage of heart muscle.

STEMI occurs by developing a complete occlusion of a major coronary artery previously affected by atherosclerosis. This causes a full thickness damage of heart muscle.

Diagram: NSTEMI vs STEMI

Symptoms of NSTEMI vs STEMI:

There is no difference between NSTEMI and STEMI in clinical presentation. In both cases, patients usually present with similar type of symptoms such as chest pain, nausea, vomiting, sweating, breathing difficulty.

• Chest Pain, 
• Nausea, 
• Vomiting, 
• Sweating, 
• Breathing difficulty.

ECG of NSTEMI vs STEMI:

The usual ECG findings of NSTEMI are ST-segment depression or T-wave inversion. NSTEMI does not show ST segment elevation in ECG (due to partial thickness injury of heart muscle) and later does not progress to a Q-wave. For this reason, it is also called a non–Q-wave myocardial infarction (NQMI).

On the other hand, STEMI shows ST segment elevation in ECG (due to full thickness injury of heart muscle) and later progress to a Q-wave.  For this reason, it is also called a Q-wave myocardial infarction (QWMI). The ultimate ECG findings of STEMI are ST-segment elevation, pathological Q-wave formation and T-wave inversion.

nstemi vs stemi ECG

Figure: ECG findings of nstemi and stemi

Cardiac markers of NSTEMI vs STEMI:

Cardiac markers including CK-MB (creatine kinase myocardial band), troponin I and troponin T, all elevate both in cases. But the elevation of these markers is often mild in NSTEMI compared with STEMI.
Diagnosis of NSTEMI vs STEMI:

The diagnosis of a NSTEMI is based on a typical history of chest pain, no ST segment elevation in ECG plus elevation of cardiac markers in serum, and the diagnosis of a STEMI is based on a typical history of chest pain, ST segment elevation in ECG plus elevation of cardiac markers in serum.
Complications of NSTEMI vs STEMI:

Complications occur both in cases. But some complications like cardiogenic shock, left ventricular failure, severe mitral regurgitation due to papillary muscle rupture, cardiac tamponade due to ventricular wall rupture are more in STEMI (due to full thickness heart muscle damage) than NSTEMI.
Treatment of NSTEMI vs STEMI:

Antiplatelets (Aspirin, Clopidogrel, Ticagrelor), anticoagulants (Enoxaparin, Dalteparin, Fondaparinux), beta-blockers (atenolol, metoprolol, bisoprolol), nitrates (isosorbide dinitrate, glyceryl trinitrate), statins (atorvastatin, rosuvastatin, simvastatin, pitavastatin), ACE inhibitors (ramipril, enalapril, captopril, lisinopril) or ARBs (valsartan, candesartan, losartan, olmesartan) are given both in NSTEMI and STEMI.

In case of reperfusion therapy, primary PCI (percutaneous coronary intervention) is the treatment of choice for STEMI. Where primary PCI cannot be achieved within 120 minutes of diagnosis or PCI is not available, thrombolytic therapy such as streptokinase, tenecteplase, alteplase or reteplase should be given. On the other hand, early coronary angiography and revascularization, either by PCI or by CABG (coronary artery bypass grafting) is the treatment of choice for medium to high risk patients with NSTEMI. Drug treatment is appropriate in low risk patients with NSTEMI, and coronary angiography and revascularization reserved for those who fail to settle with drug treatment (low, medium and high risk patients are categorized in nstemi by GRACE score) . Thrombolytic therapy is harmful in NSTEMI. The aggregate data suggest that patients with NSTEMI may be put at risk of reinfarction if thrombolytic therapy is used.
Prognosis of NSTEMI vs STEMI:

Short-term (in-hospital or one month) mortality is lower in NSTEMI (3-5%) compared to STEMI (10-15%). Re-infarction rate (further heart attack) is higher in NSTEMI (15-25%) after hospital discharge compared to STEMI (5-8%). Long-term mortality is similar or higher in NSTEMI compared to STEMI (two year mortality is approximately 30% in both cases).


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Yeast infections during pregnancy : Online Medical Help

What is a yeast infection?

Yeast infections are a common type of vaginal infection that are particularly common in pregnant women. These infections — also called monilial vaginitis or vaginal candidiasis — are caused by microscopic fungi in the Candida family, most commonly Candida albicans.

Video

Inside pregnancy: Weeks 15 to 20

 

A 3D animated look at a baby in the second trimester of pregnancy.

It's not uncommon to have a certain amount of yeast in your vagina, as well as in your intestinal tract. Yeast only becomes a problem when it grows so fast that it overwhelms other competing microorganisms.
Your higher level of estrogen during pregnancy causes your vagina to produce more glycogen, making it even easier for yeast to grow there. Some researchers think estrogen may also have a direct effect on yeast, causing it to grow faster and stick more easily to the walls of the vagina.
You're also more likely to get a yeast infection when you take antibiotics, particularly if you take them frequently or for a long time. That's because in addition to killing off the bacteria they're targeting, these drugs may affect the normal protective bacteria in your vagina, allowing yeast to overgrow.

What are the symptoms?

If you develop symptoms from a yeast infection, they're likely to plague you (and may get worse) until you treat the infection, though sometimes they come and go on their own. Symptoms may include:

• Itchiness, irritation, soreness, burning, and redness in your vagina and labia (and sometimes swelling)
• An odorless vaginal discharge that's often white, creamy, or cottage-cheesy
• Discomfort or pain during sex
• Burning when you urinate (when the urine hits your already irritated genitals)

What should I do if I think I have a yeast infection?

If you think you have a yeast infection, see your practitioner. She'll take a sample of your vaginal discharge and check it to confirm the diagnosis and rule out other things that may be causing your symptoms.
By the way, although antifungal medication is available over the counter, it's not a good idea to try to diagnose and treat yourself without seeing a practitioner. Your symptoms may be caused by something else, such as a sexually transmitted infection, instead of or along with yeast.
Studies show that the majority of women who treat themselves for a presumed yeast infection miss the real cause. As a result, they often delay getting proper treatment.
If you do have a yeast infection, your practitioner will give you a prescription or recommend a specific over-the-counter antifungal vaginal cream or suppository that's safe during pregnancy.
For most yeast infections, creams and suppositories with clotrimazole are more effective than those containing nystatin.
You'll need to insert the cream or suppository into your vagina seven days in a row, preferably at bedtime so it won't leak out. (The shorter-course regimens that you might have used before aren't as effective when you're pregnant.) It's also a good idea to apply some of the antifungal cream to the area just outside your vagina.
It may take a few days of treatment before you begin to feel some relief. In the meantime, you can soothe the itching with an ice pack or by soaking for ten minutes in a cool bath.
If you find the medication irritating or it doesn't seem to be working, let your practitioner know. She may have to switch you to another medication. Be sure to complete the full course of treatment to make sure the infection is gone.

Will a yeast infection affect my baby?

No, a yeast infection won't hurt or affect your developing baby. If you have an infection when you go into labor, though, there's a chance that your newborn will contract it as he passes through the birth canal. If he does, he may develop a yeast infection in his mouth, known as thrush.
Thrush is characterized by white patches on the sides and roof of the mouth and sometimes on the tongue. This condition isn't serious and is easily treated. (By the way, babies can get thrush even if you don't have a yeast infection.)

How can I reduce my chances of getting a yeast infection?

It's less likely you'll get a yeast infection if you keep your genital area dry (yeast thrives in a warm, humid environment) and your vaginal flora in balance. Not all of the following suggestions are supported by hard evidence, but they're easy enough and worth a try:

• Wear breathable cotton underwear and avoid pantyhose and tight pants, particularly synthetic ones.
• Get out of your wet bathing suit promptly after swimming, and change your underwear after exercising if you break a sweat.
• Try sleeping without underwear at night to allow air to get to your genital area. If you prefer to wear something to bed, a nightgown without underwear allows more air circulation than pajama bottoms.
• Avoid bubble baths, perfumed soaps, scented laundry detergent, and feminine hygiene sprays. While it's not clear whether these items contribute to yeast infections, they can cause bothersome genital irritation so are best avoided.
• Clean your genital area gently with warm water. (Never douche during pregnancy – or any other time.)
• Always wipe from front to back.
• Eat yogurt that contains a live culture of Lactobacillus acidophilus, which can theoretically help maintain the proper bacterial balance in your gut and vagina. There's conflicting evidence as to whether yogurt helps prevent yeast infections, but many women swear by it. And in any case, it's a good source of protein and calcium!

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Spinal Nerve Function : Online Medical Help

Spinal Nerve Function

The term spinal nerve generally refers to a mixed spinal nerve, which carries motor, sensory, and autonomic signals between the spinal cord and the body. Humans have 31 left-right pairs of spinal nerves, each roughly corresponding to a segment of the vertebral column: 8 cervical spinal nerve pairs (C1-C8), 12 thoracic pairs (T1-T12), 5 lumbar pairs (L1-L5), 5 sacral pairs (S1-S5), and 1 coccygeal pair. The spinal nerves are part of theperipheral nervous system (PNS).

Normal Blood Gases : Arterial Blood Gases : Online Medical Help

Arterial Blood Gases Arterial blood gas analysis provides information on the following: 1] Oxygenation of blood through gas exchange in the lungs.  2] Carbon dioxide (CO2) elimination through respiration.  3] Acid-base balance or imbalance in extra-cellular fluid (ECF).   Normal Blood Gases
	Arterial	Venous
pH	7.35 - 7.45	7.32 - 7.42
Not a gas, but a measurement of acidity or alkalinity, based on the hydrogen (H+) ions present. The pH of a solution is equal to the negative log of the hydrogen ion concentration in that solution: pH = - log [H+].
PaO2	80 to 100 mm Hg.	28 - 48 mm Hg
The partial pressure of oxygen that is dissolved in arterial blood. New Born – Acceptable range 40-70 mm Hg.  Elderly: Subtract 1 mm Hg from the minimal 80 mm Hg level for every year over 60 years of age:  80 - (age- 60)  (Note: up to age 90)
HCO3	22 to 26 mEq/liter (21–28 mEq/L)	19 to 25 mEq/liter
The calculated value of the amount of bicarbonate in the bloodstream. Not a blood gas but the anion of carbonic acid.
PaCO2	35-45 mm Hg	38-52 mm Hg
The amount of carbon dioxide dissolved in arterial blood.  Measured.  Partial pressure of arterial CO2.  (Note: Large A= alveolor CO2).  CO2 is called a “volatile acid” because it can combine reversibly with H2O to yield a strongly acidic H+ ion and a weak basic bicarbonate ion (HCO3 -) according to the following equation: CO2 + H2O <--- --> H+  +  HCO3
B.E.	–2 to +2 mEq/liter Other sources:  normal reference range is between -5 to +3.
The base excess indicates the amount of excess or insufficient level of bicarbonate in the system.  (A negative base excess indicates a base deficit in the blood.) A negative base excess is equivalent to an acid excess. A value outside of the normal range (-2 to +2 mEq) suggests a metabolic cause for the abnormality.  Calculated value.  The base excess is defined as the amount of H+ ions that would be required to return the pH of the blood to 7.35 if the pCO2 were adjusted to normal.  It can be estimated by the equation: Base excess = 0.93 (HCO3 - 24.4 + 14.8(pH - 7.4)) Alternatively: Base excess = 0.93×HCO3 + 13.77×pH - 124.58 A base excess > +3 = metabolic alkalosis a base excess < -3 = metabolic acidosis
SaO2	95% to 100%	50 - 70%
The arterial oxygen saturation.

Intravenous Paracetamol : Online Medical Help

1 Intravenous (IV) paracetamol should be prescribed carefully, according to the weight, age and co-morbidities
of the patient. The upper dose limit for each single dose and in each 24-hour period should not be exceeded.
2 50ml vials of IV paracetamol should be used for patients less than 33kg. In infants and small children, doses
should be measured accurately using a syringe.
3 Enquiry about recent paracetamol ingestion should form part of routine pre-operative assessment. All doses
of paracetamol administered in the operating theatre should be recorded on the ward drug administration
chart and in the anaesthetic record.
4 Advice should be sought from the local poisons information service in all cases of overdose of intravenous
paracetamol. Treatment with acetylcysteine is suggested following a single dose greater than 60mg/kg.
5 Intravenous paracetamol (Perfalgan®) remains under intensive monitoring by the MHRA. All suspected
adverse reactions to IV paracetamol should be reported to the Yellow Card Scheme and discussed with the
local poisons information service.

 Background
A Fatal Accident Inquiry in Scotland in 2011 concluded that a young adult died from liver failure due to an overdose
of paracetamol. The Sheriff found ‘there was, at the time of the death, a prevailing culture of assumed familiarity with
the administration of IV paracetamol, a familiarity derived from the common use of oral paracetamol’. The patient,
who weighed 35kg, died nine days after receiving paracetamol 1g IV on a sustained and regular basis.1
Intravenous paracetamol was licensed in the UK in 2004 and is used routinely in anaesthetic practice. Since
introduction, there have been concerns about accidental overdose of IV paracetamol due to errors in drug prescription
and administration, particularly in children, small adults, the elderly, alcoholics and those with pre-existing
hepatocellular insufficiency.
Reported errors include incorrect dose in adults with high or low body mass index; accidental overdose in children
associated with use of 100ml-vials; 10-fold drug calculation errors; confusion between dose volume in millilitres and
dose of drug in milligrams; errors when setting up infusion pumps; and duplication of doses between the ward and
the operating theatre or recovery.2-5
Examples of recent reports to the NRLS include:
➤ Patient had a dose of paracetamol before going to theatre and then was given another dose whilst in theatre. Fifth
dose in 24 hours.
➤ Paracetamol not given on the ward post op due to double dose given in theatre...
➤ Patient was given the prescribed 1gram paracetamol on the ward at 08:13hrs as part of pre-med. On return to ward
after procedure it was noted on the anaesthetic chart that 1gram of IV paracetamol had been given at 09:30 hrs...
The MHRA issued a Patient Safety Update in 2010 that raised concerns about accidental overdose of IV paracetamol
(Perfalgan®), especially in infants and neonates. Perfalgan® is presented in a concentration of 10mg/ml, and in
most cases, a 10-fold overdose was reported. The MHRA advised vigilance when prescribing and administering
Perfalgan®, to adhere to recommended doses and dose intervals, to avoid concomitant administration by different
routes, and to use 50ml vials for infants and children who weighed less than 33kg.3
The NPSA issued a Signal alert in 2010 that raised concern about the risk of inadvertent overdose of IV paracetamol
in children, and described 206 incidents relating to IV paracetamol, two associated with severe harm and 14 with
moderate harm.5

recoMMended dose of iv paracetaMol
The dose of IV paracetamol recommended by the MHRA for children and adults is shown in the table below.
Paracetamol should be given by infusion over 15 minutes, and the minimum dose interval should not be less than four
hours (six hours in patients with renal impairment).

*The dose of IV paracetamol is controversial in neonates and infants. The BNF for Children (BNFC) suggests a dose of
7.5mg/kg every 8 hours (maximum 25mg/kg daily) in preterm neonates over 32 weeks postmenstrual age, 10mg/kg
every 4-6 hours (maximum 30mg/kg daily) in neonates.6
**The British National Formulary (BNF) suggests caution in patients with hepatocellular insufficiency, chronic
alcoholism, chronic malnutrition or dehydration, and to administer a maximum daily infusion dose of 3g in adults in
these patient groups.