Anti-vitamins found in food

Several food items contain chemical substances which act against or act as antagonists for vitamins. Such substances are known as ant-vitamins.

Some decaying plant parts contain anti-vitamins. Dicoumarin found in decaying or spoiled sweet clove is one of the anti-vitamins. Dicoumarin is chemically related to vitamin K. Dicoumarin acts as an antagonist to vitamin K. Therefore ingestion of Dicoumarin can result in relative deficiency of vitamin K. Vitamin K is essential for blood clotting mechanism (hemostasis). Therefore consumption of spoiled sweet clove can result in hemorrhagic disease. There no human cases were reported but there are cases reported on cattle, which fed on spoiled sweet clove develop a hemorrhagic disease.

Thiamine deficiency is relatively common due to consumption of thiamine anti-vitamins. Plants such as ferns and bracken contain antimetabolites of thiamine, if eaten in quantity, can lead to thiamine deficiency. But this is not for human as they do not consume ferns or bracken plants. But this is again important for cattle.

Some micro-organisms found in gut can produce thiaminase (anti-vitamin for thiamine) which can destroy thiamine. If thiamine intake is adequate, this will not be a problem. In Japan it is believed that infection with such organisms is a cause of thiamine deficiency. Thiaminase is also present in raw and fermented fish (carp:above picture), relished in the Japan and china.

Natural food colors (colours)

Food coloring (colouring) is a special art in food industry. Any substance which is added to a food or a drink to change its color (colour) is known as food color (colour). There are two types of food colors (colours); natural food colors (colours): artificial food colors (colours).

Even though modern day artificial food colors (colours) are safe, natural food colors (colours) have a more demand. Following are some basic reasons for usage of food colors;

• Offsetting color loss due to light, air, extremes of temperature, moisture, and storage conditions.
• Masking natural variations in color.
• Enhancing naturally occurring colors.
• Providing identity to foods.
• Protecting flavors and vitamins from damage by light.
• Decorative or artistic purposes such as cake icing.

Most of the natural food colors (colours) are spices and condiments. Other natural food colors (colours) are sugars and dyes. Following is a list of natural food colors (colours)

1. Caramel coloring (caramelized sugar)
2. Annatto, a reddish-orange dye
3. Cochineal, a red dye
4. Betanin extracted from beets
5. turmeric
6. saffron
7. paprika
8. Elderberry juice
9. ß-Carotene
10. Beta APO 8 Carotenal
11. Black Currant

Spices and condiments

Since antiquity, spices and condiments have been indispensable in the culinary arts. They have also played an important role in early medicine. They add savour to insipid dishes, tang to beverages and zest to appetizers. Some of the spices and condiments are also used in cosmetics and perfumes and ointments to soothe and heal. They also have preservative and anti-oxidant properties. In ancient times spices were valued more than gold, determined policies of nations and served as incentives for the discovery of new trade routes and of new continents.

Spices and condiments come from various parts of plants:

1. fruits (capsicum, black pepper, cardamom)
2. seeds (aniseed, coriander, cumin, fennel, fenugreek, mustard, caraway, celery)
3. rhizomes and roots (ginger, turmeric)
4. leaves (bay leaves, parsley, sage, thyme)
5. barks (cinnamon, cassia)
6. bulbs (onion, garlic, shallot)
7. floral parts (cloves, saffron)

Among the commonly used spices and condiments are the following;

1. pepper (Piper nigrum)
2. cinnamon (Cinnamomum zeylinicum)
3. capsicum (Capsium anuum)
4. ginger (Zingiber officinale)
5. coriander (Coriandrum sativum)
6. turmeric (Cucurma domestica )
7. cardamom (Eletteria cardomomum)
8. vanilla (Vanilla fragrans)
9. cloves (Syzygium aromaticum)
10. mustard (Brassica juncea)

Zinc (Zn) deficiency

Zinc (Zn) is an essential element for all species of animals. Zinc (Zn) plays a key role in many vital enzymes. More than 200 Zinc (Zn) containing enzymes have been identified, at least one in every enzyme class, spanning a broad range of metabolic activities. It is essential for nucleic acid and protein synthesize.

Therefore zinc (Zn) deficiency can result in dysfunction of those enzymes which containing Zinc (Zn) as a component. Although available data is insufficient to make a conclusion but those data suggest that sexual maturation, growth and development depends on the dietary zinc (Zn) consumption. So zinc (Zn) deficiency can lead to problems in those functions.

Primary nutritional zinc (Zn) deficiency in humans results in growth failure, hypogonadism (a medical term for a defect of the reproductive system that results in lack of function of the gonads (ovaries or testes)) and sexual infantilism (a syndrome of delayed or arrested development of sexual organs) in teenage individuals. Egypt and Iran is the main region where zinc (Zn) deficiency is common due to high consumption of unleavened bread prepared fro high extraction flour. Ankylostomiasis, schistosomiasis, geophagia (the practice of eating earthy or soil-like substances such as clay, and chalk) and profuse sweating are the other features present in those patients. They respond well to zinc (Zn) supplements.

Zinc (Zn) deficiency leads to severe growth depression in all species studied, probably associated with failure in protein synthesize. Zinc (Zn) deficiency can also cause depression of food consumption which in turn, will result in growth failure. Other evidence or features of zinc (Zn) deficiency are as follows;

1. Hypogeusia (poor taste sensitivity)
2. Dysgeusia (a persistent unpleasant taste)
3. Hyposmia and dysosmia ( disturbances of the sense of smell)
4. recurrent infections (respiratory, urinary)
5. delayed wound healing

Treatment for atopic dermatitis (AD)

Atopic dermatitis (AD) is a skin disease and it has a hypersensitivity or allergic basis. It is considered as the skin expression of the atopic state. Most of the patients with atopic dermatitis (AD) are also suffering from asthma as well. Atopic dermatitis (AD) is common during school age.

Avoidance of skin or cutaneous irritants, adequate moisturizing, rational use of topical anti-inflammatory agents and prompt treatment of secondary infections remain the mainstay of treatment for atopic dermatitis (AD).

Commonest skin irritant is the soap. Therefore avoidance or limiting of usage of soap helps to control atopic dermatitis (AD). A patient with atopic dermatitis (AD) should take daily bath with warm, but not hot, water. Following the bath, while skin is moist, patient should apply a cream or an ointment containing an anti-inflammatory (usually a steroid) agent over the affected areas of skin. Approximately 30 g of a topical agent is required to cover the entire body surface of an average adult. Until recently, low- to midpotency topical glucocorticoids was employed in most treatment regimens for AD.

Tacrolimus ointment and pimecrolimus cream contain non-glucocorticoid anti-inflammatory agents therefore these creams are good for those who are having side effects of glucocorticoid anti-inflammatory agents such as skin atrophy and wrinkling. Control of pruritus is essential for treatment, since AD often represents “an itch that rashes.” Antihistamines are most often used to control pruritus, and mild sedation may be responsible for their antipruritic action. Sedation may also limit their usefulness.

Skin biopsy

Skin biopsy is indicated in various skin disorders and some systemic disorders as well. Following are some indications for skin biopsy;

1. Basal cell carcinoma of the skin
2. Squamous cell carcinoma
3. Skin infections like leishmaniasis

Skin biopsy is not a common investigation as most of the skin disorders are diagnosed clinically. It is a simple and straightforward minor surgical procedure. However, it is important to biopsy a lesion that is most likely to yield diagnostic findings. This decision may require expertise in skin diseases (dermatologists) and knowledge of superficial anatomic structures in selected areas of the body. In this procedure, a small area of skin is anesthetized with 1% lidocaine with or without epinephrine. The skin lesion in question can be excised with a scalpel or removed by punch biopsy. In the latter technique, a punch is pressed against the surface of the skin and rotated with downward pressure until it penetrates to the subcutaneous tissue. The circular biopsy is then lifted with forceps, and the bottom is cut with iris scissors. Biopsy sites may or may not need suture closure, depending on size and location.

type of skin biopsy

1. Shave biopsy
2. Punch biopsy
3. Incisional biopsy
4. Excisional biopsy
5. Curettage biopsy
6. Fine needle aspirate
7. Saucerization biopsy

Gotu kola medical benefits

Gotu kola or Centella asiatica is an herbaceous plant found in Indian subcontinent especially Sri Lanka. Gotu kola is the sinhala term of Centella asiatica. It has several medical benefits.

Main medical benefits of gotu kola is that its ability to increase the body's resistance to stress, trauma, anxiety and fatigue (adaptogen). Other pharmacological effects of gotu kola are antibacterial, anti-viral, anti-inflammatory, anti-ulcerogenic, anxiolytic, a cerebral tonic, a circulatory stimulant, a diuretic, nervine and vulnerary.

Usually gotu kola is consumed raw as a salad, a mixture of gotu kola, coconut, chilies, table salt and lemon. So it consists of various nutrients that are essential for us. This gotu kola salad is thought to help maintain youthfulness.

Several scientific studies have been done to find out its medical benefits. The results are very encouraging.

Gotu kola or Centella asiatica has a special place in ayurveda medicine. It is a major component of most of the ayurvedic remedies prepared for gastrointestinal disorders.

Haldi (turmeric) treatment for acne

Haldi (turmeric) remedy/treatment for acne/pimples

Acne or pimples is a skin condition and it mainly affects the skin of the face. Acne or pimple is a social and a psychological problem especially during adolescence. There are several effective ayurvedic remedies available for acne or pimples. Among those, the ayurvedic remedy made of haldi or turmeric is very effective against acne or pimples.

Haldi or turmeric (Curcuma longa) is an herb which belongs to ginger family. It grows in tropical areas of south asian region.

Antiseptic or antibacterial property of haldi or turmeric makes it a good herb against acne/pimples. Because of these ayurvedic properties of haldi or turmeric, it is used to treat many skin conditions including acne/pimples.

You can make a paste using haldi or turmeric to apply over the face. This haldi paste should include bit of water and aloe vera as well. You can apply the paste over your face twice a day. Avoid around the eyes. There are reports of consumption of 1 teaspoon in 1/4 of warm water 3x a day reduce the occurrence of acne and acne inversa as well.

Most of the modern facial washes and sunscreen contain haldi or turmeric as a component. Antioxidant property of haldi or turmeric is used in sunscreen and facial washes.

Mouthwash for bad breath (halitosis)

Bad breath or halitosis is the exhalation of unpleasant odors with breathing. Bad breath or halitosis is a social and a psychological problem. Several treatment options are available for bad breath (halitosis). Among those mouthwashes are the popular methods of treating bad breath (halitosis).

Before prescribing a mouthwash for bad breath (halitosis), physician should identify the underlying cause for this condition. Common causes for bad breath (halitosis) are as follows:

• Abscesses or unclean dentures
• Inter-dental and sub-gingival niches
• Faulty dental work
• Food-impaction areas in-between the teeth
• periodontal diseases
• sinus infections (sinusitis)
• diabetes mellitus
• respiratory tract infections
• renal diseases

most of the time bad breath or halitosis is due to the bacterial infections. Predisposing factors or aggravating factors of bad breath (halitosis) are eating certain foods (such as garlic, onions, meat, fish, and cheese), obesity, smoking, and alcohol consumption.

mouthwash usually contains antibacterial agents such as cetylpyridinium chloride, chlorhexidine, zinc gluconate, essential oils, and chlorine dioxide.

Type of mouthwashes available for bad breath (halitosis)

1. antibacterial mouthwashes
2. oil-containing mouthwashes
3. oxidizers containing mouthwashes

How to use mouthwashes for bad breath (halitosis)

Wash the mouth with a mouthwash at least three times a day. Brush teeth with a tooth brush and a tooth paste twice a day. Most of the mouthwashes should be used as directed by your physician. Common use involves rinsing the mouth with about 20ml (2/3 fl oz) of mouthwash two times a day after brushing.

Bacterial sinusitis in children

Bacterial sinusitis in children is one of the commonest infections during childhood. Sinusitis is infectious or non infectious inflammation of one or more sinuses. The inflammation can be caused by infectious (bacterial, viral, fungal) or non infectious (allergic) triggers.

Types of bacterial sinusitis in children

There are several classifications available for bacterial sinusitis in children. Factors used classify bacterial sinusitis are time period and the causative organisms. Following classification is based on the time period.

1. Acute bacterial sinusitis; Infection lasts less than four weeks and symptoms resolve completely with treatment (duration range 10-30 days).
2. Sub-acute bacterial sinusitis Infection lasting four to twelve weeks yet resolves completely with treatment.
3. Recurrent acute bacterial sinusitis Episodes last less than four weeks and are separated by intervals of at least ten days during which the patient is totally free of symptoms.
4. Chronic bacterial sinusitis Symptoms last more than twelve weeks with or without treatment.

Common bacteria causing bacterial sinusitis in children

1. Streptococcus pneumoniae 30%
2. Haemophilus influenzae 20%
3. Morexella catarrhalis 20%,
4. Streptococcus pyogenes (occasionally)
5. Staphylococcus aureus (occasionally)

Sign and symptoms of bacterial sinusitis in children

Nasal congestion and discharge, fever, cough, bad breath (halitosis), decreased sense of smell, periobital edema, headache and facial pain are the common symptoms of bacterial sinusitis in children.

Mild erythema in the nasal mucosa, Swelling of the nasal mucosa with nasal discharge, Sinus tenderness may be detected in adolescents and Anatomical anomalies (deviated nasal septum, polyp, large turbinate) are the common signs of bacterial sinusitis in children.

Predisposing factors for bacterial sinusitis in children

Pre-existing rhinitis (viral respiratory infections, allergic, intrinsic factors), Nasal foreign body, Upper respiratory tract infections (tonsillitis, adenoiditis), Nasal anatomical variations (septal deviations, abnormal turbinates), Gastro-oesophageal reflux,Exposure to cigarette smoking (air pollution), Immunocompromised host and Mucocilliary disorders (Kartagener syndrome) are the common local and general predisposing factors for bacterial sinusitis in children.

Aims of treatment of bacterial sinusitis in children

1. to resolve and limit the course of the acute infection
2. to prevent complications
3. to correct any precipitating factors.

Bitter gourd remedy for diabetes mellitus

Bitter gourd (Momordica charantia) remedy for diabetes is one of the important ayurveda remedy available for treatment of diabetes mellitus. The basic pathology behind diabetes mellitus is lack of insulin, increased resistance to insulin or both. Therefore any substance which is capable of reducing insulin resistance, increasing insulin secretion by the pancreas or both is a good candidate for diabetes mellitus treatment.

In ayurveda and most of other forms of complementary physician believe that bitter gourd (Momordica charantia) contains a such substance so it is used in treatment of diabetes.

Bitter gourd (Momordica charantia) has been used for medicinal purposes in several countries, especially asian countries. The fruit is consumed raw or crushed to extract juice. In diabetic patients, 50 ml of the juice improved oral glucose tolerance without altering the insulin response. Daily consumption of 0.23 kg fried bitter gourd for 8 to 11 weeks reduced the percentage of glycosylated hemoglobin and improved glucose tolerance. It may be additive to or be able to potentiate the action of sulphonylurea, so that there is a risk of hypoglycemia, if both are taken together.

The mode of action of bitter gourd has been studied. A decreased glucose absorption in the intestine has been demonstrated. This is due to the fibers available in bitter gourd and fiber do interfere with glucose absorption. Incubation of extracts with isolated pancreatic islets (site where insulin produced) increased insulin release. In the isolated hepatocytes (liver cell), the extract reduced glucose production by suppression of gluconeogenesis (glucose production). So bitter gourd remedy for diabetes mellitus is a good treatment.

Ayurveda remedy/treatment for diabetes mellitus

Ayurveda remedy or treatment for diabetes mellitus is becoming highly popular in these days. According to the western medicine diabetes mellitus can not be cured completely but it can be controlled successfully. But ayurveda physician believes that diabetes can be cured completely. To support this assumption, there are several reports also available.

In all cultures there have been beliefs that certain food can cure diabetes mellitus, making the urine sugar free. Some of these beliefs have been tested. And results of these tests are very encouraging.

Herbs and spices for diabetes mellitus

There are several herbs and spices used as ayurveda remedy or treatment for diabetes mellitus. Goat’s rue (Galega officinalis) is a renowned traditional food for diabetes mellitus. Glucose lowering effects of has been proved experimentally in animals. This plant is rich in guanidine, a hypoglycemic substance (decreases blood sugar by decreasing insulin resistance). Chemical derivatives from the biguanide class of medication include metformin (Glucophage, commonly prescribed for diabetics) and the older, withdrawn agent phenformin.

Seeds, fruits and leaves for diabetes mellitus

Ayurveda remedy or treatment for diabetes made of seeds and fruits of the java plum (Syzigum jumbos or Eugenia jambolana) are reported to have a blood glucose lowering (hypoglycemic) effects. Extracts of leaves of Rhus typhia is used to make ayurveda remedy or treatment for diabetes mellitus. Tarragon (Artemisia dracdranculus) and coriander (Coriandrum sativum) are also used to prepare ayurveda remedy for diabetes mellitus.

Vegetables for diabetes mellitus

Vegetables such as cabbage, beans, lettuce, potato and turnip increase the fiber content of the diet thus help to reduce absorption of sugar from the gut thus reduce the blood sugar level. One aspects of ayurvedic management of diabetes mellitus is the modification of dietary habits.

Ayurvedic diet for diabetes mellitus

Diet consists of high fiber content and low starch favorable for diabetes mellitus.

Ayurveda remedy/treatment for hair loss

Ayurveda remedy or treatment for heir loss is becoming very popular among people as the western medicine fails to produce a good answer for this matter. Hair is a part of skin or it is one of the skin appendages. But in ayurveda hair is considered as a byproduct of bone formation. According to this theory the tissues which are responsible for formation of bones are also responsible for your hair growth.

According to the ayurveda hair loss may be due to several causes such as body type (hot, cool) and stability of the mind. Hair loss occurs with aging could be physiological so premature hair loss is the matter at hands of ayurveda physician.

Ayurveda remedy or treatment for hair loss consists of several components such as diet, herbs, meditation, yoga, breathing, aromatherapy, and oil massage. Therefore life style modification is one of the important steps in management of hair loss.

Ayurveda remedy/treatment for hair loss – diet

Dietary habits of the patients should be asked to find out whether it is healthy or not. Any food which increases the pitta dosha should be stopped. Food containing minerals (magnesium and calcium) and protein are good for these patients. So they must consume sesame seeds, fruits, milk, etc. other nutrients essential for hair growth are sulfur, zinc, vitamin-B complex, vitamin C and essential fatty acids.

Ayurveda remedy/treatment for hair loss – massaging

Massaging is one of the important things in ayurveda as it can help in hair growth. Ayurveda remedy used for massaging contains vitamin E. oiling is also good. Coconut oil or mustard oil, 'Mahabhringraj oil', 'Amala oil', and 'Arnica oil' can be used for oiling and massaging. Massaging should be done atleast twicw a day and 10-15 minutes for each session.

Ayurveda remedy/treatment for hair loss – herbs
Herbs play a major role in treatment of hair loss in ayurveda. Aloe vera is very important herb used for hair growth. A paste of licorice made by grinding it in milk can be applied in the bald patches. It induces hair growth. A paste of seeds of lemon and black pepper may also be applied on the bald patches. Daily application of coconut oil mixed with lime juice on the hair is also beneficial. Applying juice of green coriander leaves on the head is also good.Washing the hair with a paste of cooked Urad dal (black beans) and fenugreek (methi) 2-3 times a week, is also good

Breath holding attacks in infants

Breath holding attacks during infant period is common. It should be differentiated from seizure attacks. Some time it is difficult to differentiate breath holding attacks from seizures. This condition is not a life threatening diseases but it can really upset the parents. No special treatments are required other than reassurance of parents. There are two types of breath holding attacks;

1. Blue breath holding attacks
2. Pallid breath holding attacks

Blue breath holding attack

This is started or provoked by upsetting an infant. Followings are the key features of blue breath holding attacks;

• Provoked by upsetting an infant.
• Episode starts with crying.
• Followed by breath holding and apnea.
• Loss of consciousness may be associated with a few clonic jerks( a type of abnormal movements of limbs) and bradycardia (low heart rate) .
• May occur repeatedly or sporadically.
• Usually occur after 6 months of age with a peak incidence at 2 years.

Pallid breath holding attack

This is also started or provoked by upsetting an infant. Followings are the key features of pallid breath holding attacks;

• Provoked by upsetting an infant.
• Crying prior to episode may not be apparent.
• Become pale and bradycardic (low heart rate).
• Loss of consciousness may be associated with tonic jerks.
• Usually occur after 6 months of age with a peak incidence at 2 years.

How to collect urine for culture and sensitivity test?

Collection of urine for culture and sensitivity test should be done with utmost care as the way of collecting the urine can greatly affect the out come of the test thereby the management of the patient. Therefore “how to collect urine for culture and sensitivity test?” is one of the frequently asking questions by the care givers specially mothers. So it is the duty of the physician to educate the care givers on “how to collect urine for culture and sensitivity test?”

The collection method depends on several factors such as age of the patient, condition of the patient (how severely ill) and the type of urine sample. And this is a special topic in the pediatric practice as well.

It is very difficult to collects urine sample from infants, young children and debilitated patients. Type of urine sample could be mid stream catch, catheter sample or supra pubic aspiration.

First you have to obtain a container from the laboratory. There are special containers for urine culture samples and some time they may contain preservatives as well. Hands of the collector should be washed with water and soap. Then the genitalia (penis and vagina) should be cleaned. In men fore skin should be retracted and clean the area with water and soap. In women labia majora should be made apart and clean the area with water and soap. Mothers of infants and young children should take care of this step. Using of antiseptic could be problem in some occasions as it may interfere with the viability of organisms. Therefore you should take advice from the relevant physician regarding antiseptic.

Then patients should void urine out. First few drops of urine are not collected and let them go out. Then open the lid of the container and collect sufficient amount of urine. Do not keep the container open for long period and never wash the container as well. Then close the container with the lid and wipe off the urine present outside the container with a clean paper. Hand over the urine sample to the laboratory as soon as possible.

Collection of catheter sample and supra pubic aspiration is done by health care personals. So you do not need to worry about that.

CSF culture and sensitivity test

CSF culture and sensitivity test is one of the important diagnostic tests for central nervous system (CNS) infections such as meningitis, encephalitis and meningo-enchepalitis. CSF culture and sensitivity test helps to detect the organism which causes central nervous system (CNS) infection and it also helps to identify the sensitivity pattern of the particular organism for antibiotics. Therefore CSF culture and sensitivity is important in the management of meningitis, encephalitis and meningo-enchephalitis.

Time period, culture medium and accuracy of the CSF culture and sensitivity test depend on the clinically suspected organisms.

Culture medium for CSF

Culture medium depends on the suspected organisms. Sheep blood agar (5%) or chocolate agar is the culture medium for Standard CSF bacterial culture. mannitol salt agar (MSA) which is selective for Gram-positive bacteria and differential for mannitol.

Results of CSF culture and sensitivity test

If the result is negative it means that no organism was found. Abnormal or positive results are recorded as follows;

1. bacterial meningitis with “aaa” organism and it sensitive to “sss” antibiotic

Collection of urine sample from infants and young children

Collection of urine sample from infants and young children is a challenging task for both the parent and physician. But, still it is necessary to have a good urine sample for an accurate urinalysis. The mother or the father should be carefully educated on how to collect a proper urine sample from an infant or from a young child. Usually supra pubic sample may be indicated for infants as it is very difficult to collect a urine sample when they are voiding. Followings are some important steps to practice when collecting urine sample fro infants and young children;

• Mother is instructed to clean the external genitalia of the child with soap and water (in boys foreskin should be retracted and in girls labia majora should be apart
• Give plenty of fluid to drink before collection of urine.
• Open the lid of the container just after starting the voiding ( do not keep it open for a long time)
• Mother can collect as much urine as possible avoiding contamination when the child urinates.
• In very small children urine bags may be used and sample should be collected as soon as the child urinates and send to the lab within 2 hours.
• Supra-pubic aspiration is occasionally necessary in infants.

Collection of a sample of urine/urine specimen

Collection of a sample of urine or urine specimen should be done with utmost care. Because the collection method of urine affects the result of urine analysis. Amount of urine, timing of collection and type of sample are some facts that should be considered when collecting a sample of urine or urine specimen. Followings are some facts regarding collection of urine;

Type of urine sample

Usually the sample size is about 10 ml unless it is a 24 hour urine collection.

• early morning urine sample – collected from the first void
• Double voided urine sample – collected about 1-2 hours after the first void
• random urine sample – collected at any time of day
• spot urine - a sample of urine collected at the same time as blood.

Collection of Timed urine sample
Timed urine sample is a sample of urine collected over a calculated time period or all the urine passed within a stipulated time period is collected. The commonest is a 24-hour collection of urine. A prior appointment may be needed from the laboratory.

Steps- collection of a sample of urine/urine specimen

• Obtain a container from the laboratory to collect urine. The container will have a preservative; do not wash it off. If a preservative is not recommended, the sample needs to be refrigerated during the collection period.
• Empty the bladder fully, discarding the urine – (usually at about 7 am) and note the time.
• Collect all the urine passed until the same time the next day (i.e 7 am on following day) into the container issued by the laboratory. (The patient may use a separate clean bowl to collect and transfer the urine sample in to the given container.)
• The final sample is passed at 7 am (in above example) and is collected into the container.
• Label the container (name, age sex, name of test, start time, finish time, date)
• Hand over the sample to the laboratory without delay.
• If a clearance test has been ordered (eg. Creatinine clearance), a blood sample too will be collected on submitting the urine sample.

Side effects of oral iron (Fe) therapy

Side effects of oral iron therapy are a common problem. Usually side effects are due to excess oral iron. Excess oral iron can affect almost all the body system. Gastrointestinal irritation is common and it occurs with iron salts like ferrous sulphate and ferrous fumarate. Nausea and epigastric pain are another common side effects of oral iron therapy and are dose related but the relationship between oral iron dose and altered bowel habits (constipation and diarrhea) is less clear. Oral iron, particularly modified release preparations, may exacerbate diarrhea in patients with inflammatory bowel disease. Care is also needed in patients with intestinal strictures and divertcula.

Oral iron preparation may be constipating, particularly in older patients, occasionally leading to fecal impaction.

If side effects occur, the dose may be reduced; alternatively, another iron salt may be used but an improvement in tolerance may simply be a result of a lower content of element iron. The incidence of side effects due to ferrous sulphate is no greater than with other iron salts when compared on the basis of equivalent amounts of element iron.

Oral iron preparations are an important cause of accidental overdose in children

Oral iron (Fe) therapy for anemia

There can be hundred of reasons for anemia. Among those iron deficiency is the major cause for anemia. Therefore iron therapy might be indicated for iron deficiency anemia. But the first step of treating iron deficiency anemia is the identification of the cause for iron deficiency and correction of it. Most of the time it is due to dietary deficiency of iron.

Oral iron (Fe) therapy is indicated in this case. Preparations of oral irons available are as follows;

Iron salt	Amount	Ferrous iron
Ferrous fumarate	200mg	65mg
Ferrous gluconate	300mg	35mg
Ferrous succinate	100mg	35mg
Ferrous sulphate	300mg	60mg
Ferrous sulphate,dried	200mg	65mg

Iron salt should be given by mouth unless there are good reasons for using another route. Ferrous salts show only marginal differences between one another in efficiency of absorption of iron, but ferric salts are much less well absorbed. The oral iron (Fe) dose for iron deficiency anemia should be 100 to 200mg daily.

The hemoglobin concentration should rise by about 100-200 mg/100ml (1-2g/l) per day over 3-4 weeks. When the hemoglobin is in the normal range, treatment should be continued for a further 3 months to replenish the iron stores.

Side effects of Methotrexate

Side effects of methotrexate vary from mild to severe. Methotrexate is a cytotoxic drug. Methotrexate belongs to antimetabolites class of cytotoxic drug. Methotrexate inhibits an enzyme which involves in the DNA synthesis pathway. The enzyme is dihydrofolate reductase. Methotrexate is used to treat variety of diseases such as leukemia, lymphoma and rheumatoid arthritis. Methotrexate is given orally, intravenously, intramuscularly or intrathecally.

Side effects of methotrexate could be due to its inhibitory effect on the enzyme mentioned above. Mere presence of methotrexate can also cause several side effects because it is a cytotoxic drug. Some of the side effects of methotrexate are common to all the cytotoxic drugs whereas some are essentially the side effects of methotrexate. Following are some common side effects of methotrexate;

1. Oral mucositis; a sore mouth is a common side effect of methotrexate. Good mouth care (rinsing the mouth frequently and effective brushing of the teeth with a soft brush 2-3 time daily) is probably effective.
2. nausea and vomiting
3. Bone marrow suppression; this is a common side effect of methotrexate. It occurs 7-10 days after the commencement of methotrexate. Full blood count should be performed regularly and dose of the drug should be changed according to the results of the full blood count.
4. pneumonitis
5. Anemia and neutropenia due to bone marrow suppression
6. Malaise, undue fatigue, chills and fever, dizziness and lowered resistance to infection

Prevention of side effects of methotrexate

1. Lowest effective dose of the methotrexate should be used.
2. Folic acid supplements should be given following methotrexate treatment. This will help to prevent mucositis and bone marrow suppression.
3. Regular blood count check should be done and dose should be changed accordingly.
4. Avoid methotrexate treatment if kidney function is impaired.
5. consider contraindication for methotrexate commencement (impairment of kidney function, severe liver impairment, pleural effusion, ascities)
6. avoid if pregnant
   

CT scan of the chest

CT scan of the chest is one of the major applications of CT scan. There are several indications for CT scan of the chest. Most of the mediastinal and lung paranchymal diseases are required CT scan to come in to a diagnosis and to define the extensions of the diseases. Lung paranchymal and mediastinal tumors or cancers are the conditions detected by CT scan of the chest.

CT is much more sensitive than plain radiographs for the detection of mediastinal and parenchymal lung disease. CT scan of the chest is used to stage or to grade lung cancer and identify nodal disease (metastais to lymph nodes). However, CT and MRI use size as the only criteria for malignant involvement of lymph nodes;

• nodes <1 cm are considered normal (even if there are metastasis)
  
• nodes >1 cm are considered malignant (even if they are reactive).

Therefore, patients will be over- and understaged and a metabolic method such as positron emission tomography (PET) using fluorine- labelled fluorodeoxyglucose 18F FDG will aid more accurate staging. This is one of the drawbacks of CT scan of the chest. The development of hybrid machines combining PET and CT has improved the anatomic localization of PET. MRI is as good as CT for the mediastinal staging of lung cancer, but is less effective for parenchymal lung disease and is usually reserved for staging Pancoast tumours and assessing invasion of the vertebral or chest wall in lung cancer. The assessment of parenchymal lung disease is best performed using high-resolution CT for the diagnosis of fungal disease in the immunosuppressed and in identifying lung metastases. CT is used to rapidly assess the thoracic aorta in suspected dissection and it has modified the investigation and diagnosis of pulmonary thromboembolic disease. Ventilation/perfusion lung scans are very accurate if the chest radiograph is normal, but their diagnostic efficacy falls if it is abnormal. In these instances, a CT pulmonary angiogram can be performed with identification of emboli in the main and segmental arteries, but limited visualization of subsegmental emboli. The improved spatial and temporal resolution of the newer scanners will allow coronary angiography to be undertaken, though conventional angiography is required for the very distal arterial branches.

Complications of peritoneal dialysis (PD)

Peritoneal dialysis is one of the renal replacement therapies. Peritoneal dialysis helps to remove waste products found in blood secondary to renal or kidney failure. It is cheap and easy to perform than that of hemo-dialysis. But there are several complications are found with peritoneal dialysis. Following are some of complications of peritoneal dialysis

1. peritonitis
2. exit site infection
3. peri catheter leak
4. outflow failure
5. membrane function failure

Peritonitis due to peritoneal dialysis is one of the major complications of peritoneal dialysis. Usually it is due to bacteria so an antibiotic is required to treat it. The risk for such an infection is nowadays low (on average one episode every 3-5 years) due to improvements in the design of the products used. Also, following the instructions about how to exchange the fluids will further reduce the risk. Usually, a patient with peritonitis has fever, abdominal pain and a cloudy appearance of drained dialysis fluid.

Another main complication of peritoneal dialysis is the exit site infection. It is also due to bacterial infection. Changing clothes daily and hand washing prior to handling the catheter set will help to reduce the incidence of exit site infection.

Chemotherapy causes nausea and vomiting

Chemotherapy causes nausea and vomiting. It is a matter of fact. Most of the drugs use for the cancer treatment are potentially causing nausea and vomiting. There are several reasons for this. Stomach irritation by the chemotherapy drugs is one of the causes of nausea and vomiting in patients with cancers.

But the main factor which triggers nausea and vomiting in cancer patients is the stimulation of the vomiting center by anticancer drugs (chemotherapy). Some drugs are capable of stimulating the vomiting center directly whereas most of the anticancer drugs cause nausea and vomiting by stimulating the vomiting center indirectly. The vomiting center is stimulated directly by afferent input from the vagal and splanchnic nerves, the pharynx, the cerebral cortex, cholinergic and histamine stimulation from the vestibular system, and efferent input from the chemoreceptor trigger zone (CTZ). The CTZ is in the area postrema, outside the blood-brain barrier, and is thus susceptible to stimulation by substances present in the blood or cerebral spinal fluid. The neurotransmitters dopamine and serotonin stimulate the vomiting center indirectly via stimulation of the CTZ.

Management of nausea and vomiting caused by chemotherapy

Dolasetron, Granisetron, Ondansetron and palonosetron are the most effective antiemetics that can be used to reduce nausea and vomiting caused by chemotherapy. These drugs belong to the drug class called 5-HT3 inhibitors. These are effective because the most sensitive signal during the first 24 hours after chemotherapy appears to be 5-HT3.

aprepitant is one of the newest drugs which are very effective in the management of the nausea and vomiting caused by cancer chemotherapy.

There are some reports available that suggestive of the effectiveness of marijuana as an antiemetic during cancer chemotherapy.