STRESS OF DISEASES: DR. SHRINIWAS KASHALIKAR
How to overcome the stress of diseases?

During our medical student days we read and learned extensively about the symptoms, signs, investigations and treatment of various diseases. We also learned about prevention of diseases. We read slogans like �health for all by 2000� and so on.

But we continue to observe diseases, debility and disability.

In fact; due to the information explosion, we read and see dreadful aspects of diseases and become miserably concerned stressed about physical health.

Our stress is further intensified by contradictory information and health tips given in print and electronic media! We are often agonized by questions such as �Why did I get this disease, even when I never did such and such a thing?� or we become guilt ridden by thoughts such as; �Why did I do that thing and got into this trouble?�

But let us not despair!

We have immeasurable and infinite storehouse of vitality inside us, which is not described or highlighted in media. Hence; this immense storehouse of globally benevolent potential within us escapes our attention and we assume ourselves to be fickle, frail and fragile.

The best way to overcome the stress of diseases; is to realize this globally benevolent eternal light within us; and begin to express it to the best of our capacity. The diseases will come and go. But we would never be shattered.

How to realize and express this innate and universally beneficial power?

The answer is; NAMASMARAN!

We have to practice NAMASMARAN; and further; propagate its universal benevolence; which enables and empowers everyone; to live symbiotically and triumphantly; in any given field and in any given circumstance.

What are you to do if you have a heart attack

While you are alone.

If you've already received this,

It means people care about you.

The Johnson CityMedicalCenter staff actually

Discovered this and did an in-depth study

On it in our ICU.

The two individuals that discovered this then did

An article on it, had it published and have had it incorporated into ACLS and CPR classes.

It is very true and has and does work.

It is called Cough CPR.

A cardiologist says it's the truth,

If everyone who gets this sends it to 10 people,

You can bet that we'll save at least one life.

It could save your life!
Let's say it's 6:15 p.m. And you're driving home

(alone of course), after an usually hard day on the job.

You're really tired, upset and frustrated.

Suddenly you start experiencing severe pain

In your chest that starts to radiate out

Into your arm and up into your jaw.

You are only about five miles from the hospital

Nearest your home.

Unfortunately you don't know if you'll be

Able to make it that far.

What can you do?

You've been trained in CPR

But the guy that taught the course didn't tell

You what to do if it happened to yourself.
Since many people are alone when they suffer a heart attack, this article seemed to be in order.

Without help, the person whose heart is beating improperly and who begins to feel faint,

Has only about 10 seconds left before losing consciousness.

However, these victims can help themselves by coughing repeatedly and very vigorously.

A deep breath should be taken before each

Cough, and the cough must be deep

And prolonged, as when producing sputum

From deep inside the chest.

A breath and a cough must be repeated

About every two seconds without let up

Until help arrives, or until the heart is felt to be beating normally again.

Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and

Keep the blood circulating.

The squeezing pressure on the heart also helps it regain normal rhythm. In this way, heart attack victims can get to a hospital.

Orthopaedic surgeon Dr. A.K. Venkatachalam, of the Madras Joint Replacement Center in Chennai, India, has introduced customized knee replacement. He is offering a concept called 'patient specific instrumentation' to help prolong the life of knee implants.
Oxinium implants are a highly rated knee replacement joint prosthetic. Oxinium joints are designed of special metal composites coated with ceramic. Then, they're fused and coated with oxygen to create very durable and long-lasting joint replacements. The latest concept to be introduced is the �Visionaire�, patient specific instrumentation from Smith & Nephew, an orthopedic implant company based in Warsaw, Indiana, USA. It provides the surgeon a customized device derived from the individual patient�s anatomy. This data is derived from pre-operative x rays and MRI scans of the individual patient. The images are sent online to the research and development engineers of the Smith & Nephew. Based on the scans, the design engineers fabricate a customized mould from Nylon. These are shipped to the surgeon within a gap of four weeks. Armed with these customized cutting blocks, the surgeon is confident of shaping the patient�s bone very accurately.
Dr. Venkatachalam performed the latest surgeries utilizing this customized approach at the Chettinad Health city�s super-specialty hospital.
Benefits of Oxinium Implants and Patient Specific Surgery
While Oxinium prosthetic joints are believed to last nearly 90 times longer than a traditional knee joint, Dr. Venkatachalam wants to ensure that his patients have the best experiences with joint replacements as possible. With this combined technology, the implants can be expected to last for thirty years versus the ten to fifteen years with traditional cobalt chrome implants.
The new approach to knee replacements offers a variety of patient benefits including but not limited to conservation of existing bone and added stability of the knee joint. Utilizing patient specific instrumentation during the implant process, the surgeon is able to make anatomically precise cuts of the knee bone for a much-customized fit of the Oxinium knee implant. The implant is then aligned to fit the specific patient's knee anatomy. Reduction of pain and increased mobility and range of motion are just a few of the added benefits of such stability.
In addition, the implants, designed by Smith & Nephew, are used in combination with Visionaire instruments, utilizing OXINIUM� technology. In addition to their strengths and longevity, Oxinium implants are lightweight and hypoallergenic.
The Oxinium implant with Visionaire patient specific instruments offers minimally invasive procedures that reduce the risk of bleeding, complications, infections and postoperative pain. Patients are able to return to an active lifestyle faster than with traditional total knee replacement procedures, enhancing healing, mobility, and range of motion.
Finally, minimally invasive procedures such as the Visionaire patient specific instrument approach reduces the time a patient needs to be kept under anesthesia, again minimizing risk of complications as well as bleeding during the procedure.
The two patients who received the Oxinium total knee replacement with Visionaire patient specific instruments are both middle-aged women diagnosed with severe osteoarthritis and gross deformities.
Dr. Venkatachalam is a board certified, highly trained and experienced orthopedic surgeon in Chennai, India. He and staff members at Madras Joint Replacement Center have gained extensive experience in joint replacement surgeries throughout the United Kingdom, Belgium, the Middle East and Asia. Dr. Venkatachalam is a pioneer in minimally invasive procedures for total knee replacements.
For more information regarding Dr. Venkatachalam, the Madras Joint Replacement Center, or Oxinium implants and prosthetic knee replacements and surgeries, visit www.kneeindia.com

Unusual case of poly articular gout-a case report.

Abstract-
Gout is a common inflammatory arthritis caused by deposition of monosodium urate crystals in the joints. It classically affects the first metatarsophalangeal joint and less commonly other joints, such as wrists, elbows, knees and ankles.
We report the case of a 65-year-old man with tophaceous polyarticular gout, soft-tissue involvement of elbow joint with secondary infection leading to septicemia.
Key words�
Gout, monosodium urate crystals, tophi, arthropathy,Febuxostat,Colchicine
Introduction-

Gout is a common disorder of uric acid metabolism, characterized by recurrent episodes of inflammatory arthritis, tophaceous soft tissue deposits of monosodium urate crystals, uric acid renal calculi and chronic nephropathy. We report the case of a 65-year-old man suffering from tophaceous polyarticular gout and soft-tissue involvement, presenting with ulcerated tophi overlying the left elbow. We also emphasize the disabling effects of the untreated hyperuremic arthropathy.
Case presentation
A 65-year old man with a long-standing history of tophaceous gout and several recurrent episodes of arthritis during the past five years presented with a large, painful, ulcerated tophus located on the left elbow joint to the emergency department. He tried a course of non-steroidal anti-inflammatory drugs (NSAIDs) without improvement.
On physical examination he had a mild fever of 37.8�C. A grayish, voluminous and ulcerated nodule containing chalky material was located on the left elbow. Further examination revealed multiple other tophi overlying the 4th and 5th PIP joints (proximal interphalangeal joint) of his right hand and the first interphalangeal joints of his left hand(Figure 1). Other joints involved were wrists, elbows, ankles, interphalangeal and metatarsophalangeal joints of the feet and heels. Many joints were also deformed. The first metatarsophalangeal joint of his left foot was totally nonfunctional.
Laboratory workup revealed leukocytosis (11.000/mm3), elevated C-reactive protein (60.21 mg/dl) and elevated serum uric acid (11 mg/dl) and normal serum creatinine (0.9mg/dl). Radiographs of the hands showed showing soft tissue swelling and destruction of both wrist, left IP thumb, right 4th and 5th PIP joints, calcified tophi seen in right 2nd MCP joint(meta carpo phalangeal joint)(Figure 2). A culture from the ulcerated tophus was positive for staphylococcus aureus (Methicillin sensitive). Two days after admission, the tophus burst releasing a viscous, chalk-like material. Polarized microscopy confirmed presence of needle shaped monosodium urate crystals (Figure 3).
Antibiotic treatment with IV Ciprofloxacin (1000 mg/day) and intravenous administration of NSAIDs (Diclofenac 100 mg/day) was initiated.
A surgical debridement with lavage of the joint was performed. Debridement was also performed on the minor ulcers. Five days after admission treatment with Febuxostat (80 mg/day) along with Colchicine 0.5mg twice daily was initiated. The patient improved clinically and was discharged two days later. Six months after treatment, he remains symptom free.
Discussion:
Gout is the most common inflammatory arthropathy, reported to affect 2.13% of the population of the United States of America in 2009 [1]. Older age, male sex, postmenopausal state and black race are related to a higher risk for development of the disease [2]. Elevation of uric acid levels above the saturation point for urate crystal formation (6.8 mg/dl) usually results from an impaired renal uric acid excretion and although necessary, it is not sufficient to cause gout. Hyperuricemia and gout can be attributed to uric acid elevating drugs, genetic polymorphisms in genes controlling renal urate transport and predisposing dietary factors, such as consumption of red meat, seafood, alcohol and fructose containing soft beverages [3]. Other conditions associated with the disease include insulin resistance, obesity, hypertension, renal insufficiency, congestive heart failure, and organ transplantation [2].
Over time, poorly controlled gout may progress to a chronic phase, characterized by polyarticular attacks, painful symptoms between acute flares and monosodium urate crystal deposition (tophi) in soft tissues or joints [2]. Tophi are typically found on the helix of the ears, on fingers, toes, wrists and knees, on the olecranon bursae, on the Achilles tendons and also rarely on the sclerae, subconjuctivally, [4] and on the cardiac valves [5]. They can cause pain and dysfunction and are rarely associated with ulcerations [6], bone fractures [7], tendon and ligament rupture [8], carpal tunnel [9] and other nerve compression syndromes [10]. Differential diagnosis for subcutaneous or articular nodules includes septic arthritis, synovial cysts, nodal osteoarthritis, rheumatoid arthritis, sarcoidosis, lymphoma or neoplasms [11]. Synovial fluid or tophus aspiration permits diagnosis through demonstration of negatively birefringent monosodium urate crystals [2].
Treatment options for acute gouty attacks include dietary and lifestyle modifications, NSAIDs, colchicine, oral or topical steroids and corticotropin (ACTH). Interleukin-1 (IL-1) antagonists, such as anakinra, a human recombinant IL-1 receptor antagonist and canakinumab, a monoclonal antibody against IL-1β, have also shown promising results in the treatment of refractory cases or cases intolerant to classical therapy [2]. Even without treatment acute attacks usually resolve spontaneously within seven to 10 days. Normalizing hyperuricemia is of cardinal significance for the control of recurrent attacks and for the regression of tophi. This is achieved with drugs, which either favor uric acid excretion (probenecid), convert uric acid into soluble allantoin (pegloticase), or inhibit uric acid production (allopurinol, febuxostat) [2].
Surgical treatment is seldom required for gout and is usually reserved for cases of recurrent attacks with deformities, severe pain and joint destruction [11]. The main indication for surgery in patients with tophaceous gout is sepsis or infection of ulcerated tophi, followed by mechanical problems, confirmation of diagnosis and pain control [12]. Removal of tophaceous deposits from the hands can be achieved through tenosynovectomy for heavily infiltrated tendons, through a soft-tissue shaving technique for heavy skin infiltration with ulceration and draining fissures [13], or through more complex surgical approaches involving large skin incisions and excision of the tophi [14]. A hydrosurgery system applying a highly pressurized saline stream has also been used with good results for the debridement of tophi [15]. In the early stages, surgical arthroplasty can be carried out, but simple enucleation of the tophi may lead to complications such as skin necrosis, tendon and joint exposures [11]. Amputation is always a valid option for untreatable and infected ulcerations [16].
Conclusion
Secondary infection of tophaceous gout are not uncommon can lead to septicemia. Surgical treatment is required for such cases along with medical therapy.

References:
1.Brook RA, Forsythe A, Smeeding JE, Lawrence Edwards N. Chronic gout: epidemiology, disease progression, treatment and disease burden. Curr Med Res Opin. 2010;26:2813�2821. 2.Neogi T. Clinical practice. Gout. N Engl J Med. 2011;364:443�452.
3.Lee SJ, Terkeltaub RA, Kavanaugh A. Recent developments in diet and gout. Curr Opin Rheumatol. 2006;18:193�198.
4.Sarma P, Das D, Deka P, Deka AC. Subconjunctival urate crystals: a case report. Cornea.2010;29:830�832
5.Iacobellis G. A rare and asymptomatic case of mitral valve tophus associated with severe gouty tophaceous arthritis. J Endocrinol Invest. 2004;27:965�966.
6. Patel GK, Davies WL, Price PP, Harding KG. Ulcerated tophaceous gout. International Wound Journal. 2010;7:423�427.
7.Nguyen C, Ea HK, Palazzo E, Liote F. Tophaceous gout: an unusual cause of multiple fractures. Scand J Rheumatol. 2010;39:93�96.
8.Iwamoto T, Toki H, Ikari K, Yamanaka H, Momohara S. Multiple extensor tendon ruptures caused by tophaceous gout. Mod Rheumatol. 2010;20:210�212.
9.Ali T, Hofford R, Mohammed F, Maharaj D, Sookhoo S, van Velzen D. Tophaceous gout: a case of bilateral carpal tunnel syndrome. West Indian Med J. 1999;48:160�162.
10.Tran A, Prentice D, Chan M. Tophaceous gout of the odontoid process causing glossopharyngeal, vagus, and hypoglossal nerve palsies. Int J Rheum Dis. 2011;14:105�108. 11.Khandpur S, Minz AK, Sharma VK. Chronic tophaceous gout with severe deforming arthritis.Indian J Dermatol Venereol Leprol. 2010;76:69�71.
12.Kumar S, Gow P. A survey of indications, results and complications of surgery for tophaceous gout. N Z Med J. 2002;115:U109.
13. Lee SS, Sun IF, Lu YM, Chang KP, Lai CS, Lin SD. Surgical treatment of the chronic tophaceous deformity in upper extremities - the shaving technique. J Plast Reconstr Aesthet Surg. 2009;62:669�674.
14.Tripoli M, Falcone AR, Mossuto C, Moschella F. Different surgical approaches to treat chronic tophaceous gout in the hand: our experience. Tech Hand Up Extrem Surg. 2010;14:187�190.
15.Lee JH, Park JY, Seo JW, Oh DY, Ahn ST, Rhie JW. Surgical treatment of subcutaneous tophaceous gout. J Plast Reconstr Aesthet Surg. 2010;63:1933�1935.
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16.Ertugrul Sener E, Guzel VB, Takka S. Surgical management of tophaceous gout in the hand.Arch Orthop Trauma Surg. 2000;120:482�483.

What are the Advantages of Off-Pump Coronary Bypass Surgery (OPCAB)?
An alternative to traditional CABG is off-pump or beating heart surgery, where surgeons don't use the heart-lung machine. The procedure is also called OPCAB (Off-Pump Coronary Artery Bypass). The surgeons sew the bypasses onto the heart while it continues beating. Various types of heart stabilizers are used to restrain the heart one section at a time so the surgeon can operate on it. The chest is opened through a midline sternotomy incision. After the target coronary vessel is exposed and stabilized, it is occluded and opened. A bridging plastic tube -- which allows blood flow during suturing -- may be placed. The bypass graft is then sutured to the coronary artery.
The potential benefits/advantages of off-pump surgery may include the following:

Reduced need for blood transfusions
Reduced risk of bleeding, stroke and kidney failure
Potential for reduced psychomotor and cognitive problems
High-risk patients with additional diseases like lung disease, kidney failure and peripheral vascular disease may benefit from this kind of operation