6 15 I am woken up by the mobile ringing by my side.
A tense voice of a male: "Doctor could you please come over....my mom seems to have collapsed"
"Yea, will be there in 15 mins"
"Thanks doctor"
On arrival, the old lady is cold...dead maybe for about an hour. Though the son knows it, he wants to confirm it.
The air around is still and there is a pregnant pause. "Yes, she has passed away", I say with much solemnity. Tears stream down the man's face. He is about 57. A death is a death, old or young though the grief felt when a young soul passes away is incomparable.
"Doctor, can I inform my relatives?"
"Yes, please do"
He calls his brother and he breaks down into a sob. Eeerie moments... heart rending. I stand near the wall waiting for the man to compose himself so that I can fill out the DC (death certificate).
I have this strange habit of not writing a DC in the pen I use to write prescriptions. I ask if any of the relatives of the deceased person has a cheap pen that can be thrown away after writing...if yes..then I chuck it away after writing. Small sentiments. What's life without those?
I hand over the DC and leave the place conveying my condolences. Came home and had a cup of coffee. The day starts on a bad note. There is an Amman Temple near my house but have never visited it in the three months that I shifted here. Went there and spent some time. Pretty peaceful place.
Shortly thereafter another call. This time someone has a swelling of the legs and she has come down from the US. As I finish attending the patient, another call, another panicky male voice: "Sir, my grandmom has wheezing and now she seems to have collapsed....umm... she isnt responding...could you please come over.
There in a jiffy, but by then they have brought the old lady downstairs by the elevator to rush her to the nearest hospital in Adyar...No pulse...Pupils fixed and dilated. 'Everything' was over in a matter of few minutes said the grandson.
"Doctor, is there any point in taking her to the hospital?"
"No, I dont see any."
"Ok sir thanks for coming, we would need the DC...could I collect it in an hour's time?"
"Yea...sure"
The grandson came in another hour and I wrote out a DC for his beloved grandmom. Again I ask him if he has a pen he can afford to throw away. Yes he does.
A lady asked me exactly a month ago when I went through the same ritual of asking for a cheaper pen: "Doctor, why is that you seem to follow such a sentiment, arent doctors beyond all those?"
"No we arent...what makes you think we are any different from you wrt death?"
"Sorry if I sound inquisitive...what do you normally feel when you see death and pain"
"Seeing Death, humbles a person...categorically explains to him the brevity of life and the uselessness of narrow mindedness."
"Guess you are right sir."
So my dear folks...I neednt reiterate that in the short span that we inhabit this planet, lets strive to be kind and good to everyone and make this a better place for us and for generations to come.
Merry Christmas and Happy New Year!
Friday, December 16, 2005
Friday, December 09, 2005
My fav beggars/panhandlers!
Question:
Prove that begging and not prostitution is the oldest profession in the world.
Answer:
Actually the first prostitute tried begging and when that didn’t work or when lusty males leered at her and wanted sex, she gave in, haggled over the price of her body and made easy money. (She looked down upon begging thereafter)
Conclusion:
Isn’t it obvious? So there you go...QED
My area-Velachery-as are other places in Chennai, is full of beggars/panhandlers. I am not here to argue whether one should shell out a coin or not give them any thereby 'discouraging' them to beg. I have my personal favourite beggars. (It is very much the same way you guys have fav actors, politicians and cricketers)
There are 3 notable ones and each has a specific area and they will not be found begging outside of their 'fort' and any other panhandler encroaching into theirs will be prosecuted badly with a flurry of words and sometimes even fisticuffs.
The lady near the FoodWorld Supermarket:
She is about 80 (at least looks like that, I've never ventured asking her age, coz I am a prudent male...never ask femmes their age...ask no question and get no lies) She is just a bundle of bones covered in skin, poor thing. What is worse, she has those horrible truncal tremors...tch tch tch...her body (trunk) keeps shaking so violently and she finds it very difficult to walk. Probably she has Parkinson's. Despite her difficulty she approaches every stranger with a plea for money. There is an eatery below the FoodWorld and when garbage from there is thrown into the nearby dustbin she shuffles towards it and bends into it (almost throwing herself inside) searching for something that could be of use.
You would be wondering how such a shaky woman can even reach out her hand to ask for alms. In Parkinson's typically tremors take place when the limbs are at rest as opposed to when there is movement. (Movement decreases the tremors). I don’t fail to give her a coin or two whenever I go to the supermarket. My thoughts go...: Does she have a son or daughter, maybe her son is a nice man and the daughter-in-law shooed her off...maybe her daughter is a nice lady but her son-in-law doesn’t allow her anywhere near the house. Poor she!
The man near the ATM (I am not telling which ATM for fear of being mugged there by you folks):
This man has Hansen's--med term for leprosy. I always imagine him to be Lazarus. He is quiet, has a contented look about him and doesn’t force peeps to give him money. I think of him as a brilliant chap. Maybe he could've become a software professional and coz of the draconian caste based seat reservation system in TN, he narrowly missed out on getting into an engineering college. (These days in TN it is enough if you have secured a 'pass' in the 12th Board eggzams...some colleges have so many seats that aren’t filled up at all).
But sometimes I think he is really stupid...why would I (or for that matter anyone) go to an ATM? Most likely to withdraw money coz I don’t have a pie on me. And when I come out of the ATM, I am not going to have a pocket full of change coz the machine hands out soiled dirty notes as opposed to spanking crisp ones in the times of yore when ATM's were more of a tourist must-see-place and dear hubby took his wifey and daughter along with him into it and explained with an air of importance on how it functions to his kid and better half while I waited patiently outside getting redder as the seconds went by as slow as Ravi Shastri's batting. (Yea it is a wonder that he hit six sixes in an over)
Well, I try to fish a coin from my trouser pocket and meanwhile our man waits with bated breath to see how much I am going to come up with after fiddling in my trouser pockets for a whole 30 seconds. Alas there is only a 25paise coin and I can sense his frustration. He even curses me under his breath. Meanwhile a svelte femme is getting out of the ATM and our man can get a whiff of the heavenly perfume she is wearing and gallops towards her as if he were going to carry her off a la Prithiviraj Chauhan.
I imagine: How would it be if that bugger-beggar went and planted a kiss on her luscious cheeks
The lady near the Temple:
She isn’t a beggar technically. She sits inside the temple compound and on the pretext of watching over the footwear which the devotees leave behind she 'extends her hands', I repeat, 'extends her hands' while the person comes to retrieve his/her footwear. An unofficial footwear valet you could say!
I happily gave this lady a coin almost daily (coz I visit the Temple everyday, I am a holy fellow you see) till the day I saw a scene. I thought she was a destitute (she looks like a right royal hag) but one day her son came to get the morning 'collections' from her! Mother and son were speaking to each other affectionately and that bugger handed over a tiffin box (with food) for her lunch and left after bidding good bye and best wishes. I asked the hag who he was and that is how I know he is her son.
Back at home I told my mom what had happened. My mom nonchalantly: "Didn’t you know that the old hag is the mother in law of our neighbour's servant lady? She has a daughter who is married to a rich man it seems” "Oh dang! These peeps are well 'settled' eh? Hope she isn't married to a H1B visa holder and on a H4 herself” I thought to myself. But even then I don’t refrain from handing over a coin to her. Maybe she is some Goddess who masquerades as an old lady just to test my charitable sense. I have read so many Amar Chithra Katha comics that say God came in a beggar's avatar to test the devotion and charity of devotees. I wouldn’t want to take a risk, so I continue giving my favs a coin or two whenever I see them (rather whenever they panhandle me). I am a miser. Uff!
Prove that begging and not prostitution is the oldest profession in the world.
Answer:
Actually the first prostitute tried begging and when that didn’t work or when lusty males leered at her and wanted sex, she gave in, haggled over the price of her body and made easy money. (She looked down upon begging thereafter)
Conclusion:
Isn’t it obvious? So there you go...QED
My area-Velachery-as are other places in Chennai, is full of beggars/panhandlers. I am not here to argue whether one should shell out a coin or not give them any thereby 'discouraging' them to beg. I have my personal favourite beggars. (It is very much the same way you guys have fav actors, politicians and cricketers)
There are 3 notable ones and each has a specific area and they will not be found begging outside of their 'fort' and any other panhandler encroaching into theirs will be prosecuted badly with a flurry of words and sometimes even fisticuffs.
The lady near the FoodWorld Supermarket:
She is about 80 (at least looks like that, I've never ventured asking her age, coz I am a prudent male...never ask femmes their age...ask no question and get no lies) She is just a bundle of bones covered in skin, poor thing. What is worse, she has those horrible truncal tremors...tch tch tch...her body (trunk) keeps shaking so violently and she finds it very difficult to walk. Probably she has Parkinson's. Despite her difficulty she approaches every stranger with a plea for money. There is an eatery below the FoodWorld and when garbage from there is thrown into the nearby dustbin she shuffles towards it and bends into it (almost throwing herself inside) searching for something that could be of use.
You would be wondering how such a shaky woman can even reach out her hand to ask for alms. In Parkinson's typically tremors take place when the limbs are at rest as opposed to when there is movement. (Movement decreases the tremors). I don’t fail to give her a coin or two whenever I go to the supermarket. My thoughts go...: Does she have a son or daughter, maybe her son is a nice man and the daughter-in-law shooed her off...maybe her daughter is a nice lady but her son-in-law doesn’t allow her anywhere near the house. Poor she!
The man near the ATM (I am not telling which ATM for fear of being mugged there by you folks):
This man has Hansen's--med term for leprosy. I always imagine him to be Lazarus. He is quiet, has a contented look about him and doesn’t force peeps to give him money. I think of him as a brilliant chap. Maybe he could've become a software professional and coz of the draconian caste based seat reservation system in TN, he narrowly missed out on getting into an engineering college. (These days in TN it is enough if you have secured a 'pass' in the 12th Board eggzams...some colleges have so many seats that aren’t filled up at all).
But sometimes I think he is really stupid...why would I (or for that matter anyone) go to an ATM? Most likely to withdraw money coz I don’t have a pie on me. And when I come out of the ATM, I am not going to have a pocket full of change coz the machine hands out soiled dirty notes as opposed to spanking crisp ones in the times of yore when ATM's were more of a tourist must-see-place and dear hubby took his wifey and daughter along with him into it and explained with an air of importance on how it functions to his kid and better half while I waited patiently outside getting redder as the seconds went by as slow as Ravi Shastri's batting. (Yea it is a wonder that he hit six sixes in an over)
Well, I try to fish a coin from my trouser pocket and meanwhile our man waits with bated breath to see how much I am going to come up with after fiddling in my trouser pockets for a whole 30 seconds. Alas there is only a 25paise coin and I can sense his frustration. He even curses me under his breath. Meanwhile a svelte femme is getting out of the ATM and our man can get a whiff of the heavenly perfume she is wearing and gallops towards her as if he were going to carry her off a la Prithiviraj Chauhan.
I imagine: How would it be if that bugger-beggar went and planted a kiss on her luscious cheeks
The lady near the Temple:
She isn’t a beggar technically. She sits inside the temple compound and on the pretext of watching over the footwear which the devotees leave behind she 'extends her hands', I repeat, 'extends her hands' while the person comes to retrieve his/her footwear. An unofficial footwear valet you could say!
I happily gave this lady a coin almost daily (coz I visit the Temple everyday, I am a holy fellow you see) till the day I saw a scene. I thought she was a destitute (she looks like a right royal hag) but one day her son came to get the morning 'collections' from her! Mother and son were speaking to each other affectionately and that bugger handed over a tiffin box (with food) for her lunch and left after bidding good bye and best wishes. I asked the hag who he was and that is how I know he is her son.
Back at home I told my mom what had happened. My mom nonchalantly: "Didn’t you know that the old hag is the mother in law of our neighbour's servant lady? She has a daughter who is married to a rich man it seems” "Oh dang! These peeps are well 'settled' eh? Hope she isn't married to a H1B visa holder and on a H4 herself” I thought to myself. But even then I don’t refrain from handing over a coin to her. Maybe she is some Goddess who masquerades as an old lady just to test my charitable sense. I have read so many Amar Chithra Katha comics that say God came in a beggar's avatar to test the devotion and charity of devotees. I wouldn’t want to take a risk, so I continue giving my favs a coin or two whenever I see them (rather whenever they panhandle me). I am a miser. Uff!
Monday, December 05, 2005
All you wanted to know about that nagging back pain!
Chronic back pain is a common problem with a large health and social cost. Around a quarter of adults have had back pain in the last month, with one in 40 reporting disabling back or neck pain. Each year around 5% of patients consult their primary care practitioner with back pain, resulting in 137 consultations per 1000 patients. This means a practitioner with 1750 patients will typically see at least one patient with back pain each day.
Facts about back pain:
It's common to see minor abnormalities on x ray films of the lumbar spine. Two randomised studies did not show any benefit in outcome from performing lumbar spine x rays. One found that they have an adverse effect on outcome. They also expose patients to large amounts of radiation.
It's common to see minor abnormalities on magnetic resonance imaging (MRI) scans of the lumbar spine. This is an expensive investigation that's unlikely to improve the patient's outcome. One randomised controlled trial showed that patients who had an x ray had a similar outcome to patients who had a magnetic resonance imaging scan.
Abnormalities are commonly found on magnetic resonance imaging scans. A review of eight studies of magnetic resonance imaging in asymptomatic adults found:
* Bulging discs in 20% to 79%
* Herniated discs in 9% to 76%
* Degenerative discs in 46% to 91%.
Measuring the ESR or plasma viscosity is the best test for excluding malignancy or ankylosing spondylitis. This costs hardly 20rupees!
Evidence suggests that investigating simple back pain is unnecessary. A careful history and examination, if indicated, should exclude any serious cause.
Few treatments have been shown to benefit people with back pain.
Spinal manipulation has not been shown to be effective for chronic low back pain when compared with no treatment. Massage is likely to benefit people with chronic low back pain. But the evidence is weak and based on studies that might have had methodological flaws. There is better evidence for the benefits of exercise classes.
Acupuncture has not been shown to be effective for treating chronic low back pain.
Facet joint injections are likely to be ineffective or harmful.
We also don't know whether the following treatments are effective: electromyographic feedback, epidural steroid injections, lumbar supports, muscle relaxants, physical conditioning programmes, specific exercise regimens such as the McKenzie approach, and transcutaneous electrical nerve stimulation.
Weight loss surprisingly does not reduce back pain but weight gain can aggravate a back ache.
General exercise appears to benefit people with chronic low back pain. There are some data, including cost analysis, supporting the use of an exercise class using cognitive behavioural principles.
Multidisciplinary treatment consisting of intensive physical and psychosocial training by a team often using a group approach, and avoiding passive physiotherapy, reduces pain and improves the day-to-day activity of patients with chronic back pain.
Few people who have been off work with back pain for more than six months ever return to work. Usually patients are worried about returning to work. Returning immediately after an acute back pain episode to full duties might cause their condition to deteriorate in the short term, reducing chances of returning fully to work. A supportive employer can help many people return to work.
Few therapies offered by outpatient physiotherapy departments as a uni-disciplinary treatment are likely to be effective for people with chronic back pain. But it might be worth considering a graded exercise programme, if your local physiotherapy department offers one.
In one study, 32% of patients who presented with back pain reconsulted within three months.21 The same study found that only 21% of those interviewed three months after seeing their GP with back pain were free from symptoms. The authors concluded: "Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences."
Surgical intervention is rarely indicated for chronic simple back pain. Understandably, few orthopaedic surgeons are interested in non-surgical management. Their time is probably better spent delivering treatments proved to be effective.
A systematic review found tricyclic antidepressants, but not SSRIs, to be moderately effective in the treatment of chronic low back pain in patients without depression.
Surprisingly paracetamol eight times a day is very effective in back ache!
Facts about back pain:
It's common to see minor abnormalities on x ray films of the lumbar spine. Two randomised studies did not show any benefit in outcome from performing lumbar spine x rays. One found that they have an adverse effect on outcome. They also expose patients to large amounts of radiation.
It's common to see minor abnormalities on magnetic resonance imaging (MRI) scans of the lumbar spine. This is an expensive investigation that's unlikely to improve the patient's outcome. One randomised controlled trial showed that patients who had an x ray had a similar outcome to patients who had a magnetic resonance imaging scan.
Abnormalities are commonly found on magnetic resonance imaging scans. A review of eight studies of magnetic resonance imaging in asymptomatic adults found:
* Bulging discs in 20% to 79%
* Herniated discs in 9% to 76%
* Degenerative discs in 46% to 91%.
Measuring the ESR or plasma viscosity is the best test for excluding malignancy or ankylosing spondylitis. This costs hardly 20rupees!
Evidence suggests that investigating simple back pain is unnecessary. A careful history and examination, if indicated, should exclude any serious cause.
Few treatments have been shown to benefit people with back pain.
Spinal manipulation has not been shown to be effective for chronic low back pain when compared with no treatment. Massage is likely to benefit people with chronic low back pain. But the evidence is weak and based on studies that might have had methodological flaws. There is better evidence for the benefits of exercise classes.
Acupuncture has not been shown to be effective for treating chronic low back pain.
Facet joint injections are likely to be ineffective or harmful.
We also don't know whether the following treatments are effective: electromyographic feedback, epidural steroid injections, lumbar supports, muscle relaxants, physical conditioning programmes, specific exercise regimens such as the McKenzie approach, and transcutaneous electrical nerve stimulation.
Weight loss surprisingly does not reduce back pain but weight gain can aggravate a back ache.
General exercise appears to benefit people with chronic low back pain. There are some data, including cost analysis, supporting the use of an exercise class using cognitive behavioural principles.
Multidisciplinary treatment consisting of intensive physical and psychosocial training by a team often using a group approach, and avoiding passive physiotherapy, reduces pain and improves the day-to-day activity of patients with chronic back pain.
Few people who have been off work with back pain for more than six months ever return to work. Usually patients are worried about returning to work. Returning immediately after an acute back pain episode to full duties might cause their condition to deteriorate in the short term, reducing chances of returning fully to work. A supportive employer can help many people return to work.
Few therapies offered by outpatient physiotherapy departments as a uni-disciplinary treatment are likely to be effective for people with chronic back pain. But it might be worth considering a graded exercise programme, if your local physiotherapy department offers one.
In one study, 32% of patients who presented with back pain reconsulted within three months.21 The same study found that only 21% of those interviewed three months after seeing their GP with back pain were free from symptoms. The authors concluded: "Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences."
Surgical intervention is rarely indicated for chronic simple back pain. Understandably, few orthopaedic surgeons are interested in non-surgical management. Their time is probably better spent delivering treatments proved to be effective.
A systematic review found tricyclic antidepressants, but not SSRIs, to be moderately effective in the treatment of chronic low back pain in patients without depression.
Surprisingly paracetamol eight times a day is very effective in back ache!
Sunday, December 04, 2005
A gondola ride in Chennai
I do have colourful dreams, sometimes even interactive dreams, but never in my bizarre dreams did I imagine that I would travel by boat inside Chennai city!
Ask me how this happened. I have a call at 9 am in the morning asking me to visit a kid of 7yrs who had a high temperature. I packed my bag and took out my vehicle and on reaching the area I could see water as far as my eyes could. Nearby on a lamp post was tethered a catamaran (boat) that was used by the residents of the area to ferry themselves across. Gosh! A few days back the thoroughfare to the apartment complex was dry and neat. Come the second spell of rains and it turns into a Venice. My area gets to the headlines each time for the wrong reasons when it rains.
I parked my vehicle on a dry spot on the main road and boarded the gondola;)))) This boat isnt rowed but pushed by two people from the behind and pulled by a person from the front. Kindly note, the people who help push the boat arent paid by anyone! They do it as a service and sometimes some Good Samaritan might hand them a ten buck note to meet their coffee/tea/snacks expenditure.
Inside the apartment complex, the water came upto my knees but somehow I managed to wade through the water and get to the flat and examined the kid and wrote out a prescription. The parents were so thankful that I arrived inspite of the inconvenience. A tsunami of satisfaction overcame me!
Ask me how this happened. I have a call at 9 am in the morning asking me to visit a kid of 7yrs who had a high temperature. I packed my bag and took out my vehicle and on reaching the area I could see water as far as my eyes could. Nearby on a lamp post was tethered a catamaran (boat) that was used by the residents of the area to ferry themselves across. Gosh! A few days back the thoroughfare to the apartment complex was dry and neat. Come the second spell of rains and it turns into a Venice. My area gets to the headlines each time for the wrong reasons when it rains.
I parked my vehicle on a dry spot on the main road and boarded the gondola;)))) This boat isnt rowed but pushed by two people from the behind and pulled by a person from the front. Kindly note, the people who help push the boat arent paid by anyone! They do it as a service and sometimes some Good Samaritan might hand them a ten buck note to meet their coffee/tea/snacks expenditure.
Inside the apartment complex, the water came upto my knees but somehow I managed to wade through the water and get to the flat and examined the kid and wrote out a prescription. The parents were so thankful that I arrived inspite of the inconvenience. A tsunami of satisfaction overcame me!
Saturday, December 03, 2005
Chennai jottings...2
The Chennai flower vendor is a usual sight on all street corners in residential areas and more near temples. The vendor is usually an obese/cachectic lady clad in a dirty cotton saree and is especially known for her superior haggling skills. She is helped in her job by her dutiful husband who has to go down on his knees to extract a few bucks out of her to help himself to a 'cutting'* of rum or buy a few beedis.
Come rain or sunshine they can be seen stringing flowers together at their regular spots with an upturned cardboard box that serves as a counter for vending their flowers and one buys a 'muzham' of malli poo/jaadhi/mullai etc over the counter!
A 'muzham' is a measurement of length that is unique to the flower business. It supposedly spans the length from the tip of the right index finger to the cubital fossa (the crease where the arm meets the forearm) of the vendor. Since this varies from person to person and between the sexes, it is usually the femme who measures out the 'muzham' and she sees to it that she bends her palm at the wrist so as to decrease the already miniscule length.
A 'muzham' of malli poo (jasmine) costs anywhere between 3 rupees in the summer to 10 during the rainy season. Ask them why is it costs so much and the ever ready rebuttal w
ould be one of the following:
a) the flowers arent in season no
b) it is raining
c) it is too hot and the flowers get damaged while transportation
d) it is the marriage 'season'
e) it is the festival season
So my dear pals due to the above reasons the quintessential flowers cost a fortune perennially. A usual sight would be thus:
Customeress: "How much do I get for 10 rupees?"
Vendoress(?) nonchalantly: "One and a half muzham"
Customeress as if she has just heard the news that a tsunami has formed in the Indian Ocean and is heading straight towards her house: "What?"
Vendoress: "Yes Ma'am, since it is the festive season, the flowers are in high demand, the going rate at the Koyambedu market is 123456 bucks a kilo."
Customeress: "You people have some lame excuse or the other throughout the year!"
Vendoress: "What to do ma'am, we can give it at subsidised rates only if we can afford it, otherwise we run the risk of a loss. Don't forget ma that I too have three kids to feed"
Customeress: "Ok ok enough of your sad story, give me 2 'muzhams' for 10 bucks.
Vendoress: "No ma, definitely it isnt possible, the rates for the flowers are too high today" (so saying, she measures out the strung flowers on her skinny, short hand)
Customeress: "No, no nothing doing, you haven't taken the right measurement, you have bent your wrist, the flowers are too little, that surely isnt 1 and half muzham"
Vendoress: "No ma, why would I ever cheat, I swear on God that it is the right measurement, see for yourself" (and she runs through the measurement the same as before but a wee bit quicker this time)
Customeress: "For my hand that would be hardly 3/4th of a muzham. Cheri, what else option do I have rather than buying this from you!"
Vendoress: "Inikki adjust pannikko ma, naalaikku rate kammiyaayidum unakku niraya poo tharen." (Kindly adjust today ma'am, tomorrow when the rates go down I shall give you more)
But then...the same thing happens 365 days a year.
There is something to the jasmine flowers that even the ordinary looking Tam girl seems to have a fresh radiance about her once she dons the white flowers on her neatly braided hair. A classical look, a 'homely' look, that right look most Tam males want when they want to take a femme home and tell their Moms: "Ma, this is Nandhini and she is my friend...of late we are contemplating marriage!"
*Cutting: A cutting of any alcoholic drink is 90ml. A 'quarter' pronounced locally as 'kotter' is 180ml, so a cut in 180 is 90. FYI a 'half' is 360 and a 'full' is 720ml.
PS: Actually I wanted to take a pic of the vendoress, but then her possessive husband didnt allow me to and instead wanted his pic taken. Dang! Double dang! ;))))))
Come rain or sunshine they can be seen stringing flowers together at their regular spots with an upturned cardboard box that serves as a counter for vending their flowers and one buys a 'muzham' of malli poo/jaadhi/mullai etc over the counter!
A 'muzham' is a measurement of length that is unique to the flower business. It supposedly spans the length from the tip of the right index finger to the cubital fossa (the crease where the arm meets the forearm) of the vendor. Since this varies from person to person and between the sexes, it is usually the femme who measures out the 'muzham' and she sees to it that she bends her palm at the wrist so as to decrease the already miniscule length.
A 'muzham' of malli poo (jasmine) costs anywhere between 3 rupees in the summer to 10 during the rainy season. Ask them why is it costs so much and the ever ready rebuttal w
ould be one of the following:a) the flowers arent in season no
b) it is raining
c) it is too hot and the flowers get damaged while transportation
d) it is the marriage 'season'
e) it is the festival season
So my dear pals due to the above reasons the quintessential flowers cost a fortune perennially. A usual sight would be thus:
Customeress: "How much do I get for 10 rupees?"
Vendoress(?) nonchalantly: "One and a half muzham"
Customeress as if she has just heard the news that a tsunami has formed in the Indian Ocean and is heading straight towards her house: "What?"
Vendoress: "Yes Ma'am, since it is the festive season, the flowers are in high demand, the going rate at the Koyambedu market is 123456 bucks a kilo."
Customeress: "You people have some lame excuse or the other throughout the year!"
Vendoress: "What to do ma'am, we can give it at subsidised rates only if we can afford it, otherwise we run the risk of a loss. Don't forget ma that I too have three kids to feed"
Customeress: "Ok ok enough of your sad story, give me 2 'muzhams' for 10 bucks.
Vendoress: "No ma, definitely it isnt possible, the rates for the flowers are too high today" (so saying, she measures out the strung flowers on her skinny, short hand)
Customeress: "No, no nothing doing, you haven't taken the right measurement, you have bent your wrist, the flowers are too little, that surely isnt 1 and half muzham"
Vendoress: "No ma, why would I ever cheat, I swear on God that it is the right measurement, see for yourself" (and she runs through the measurement the same as before but a wee bit quicker this time)
Customeress: "For my hand that would be hardly 3/4th of a muzham. Cheri, what else option do I have rather than buying this from you!"
Vendoress: "Inikki adjust pannikko ma, naalaikku rate kammiyaayidum unakku niraya poo tharen." (Kindly adjust today ma'am, tomorrow when the rates go down I shall give you more)
But then...the same thing happens 365 days a year.
There is something to the jasmine flowers that even the ordinary looking Tam girl seems to have a fresh radiance about her once she dons the white flowers on her neatly braided hair. A classical look, a 'homely' look, that right look most Tam males want when they want to take a femme home and tell their Moms: "Ma, this is Nandhini and she is my friend...of late we are contemplating marriage!"
*Cutting: A cutting of any alcoholic drink is 90ml. A 'quarter' pronounced locally as 'kotter' is 180ml, so a cut in 180 is 90. FYI a 'half' is 360 and a 'full' is 720ml.
PS: Actually I wanted to take a pic of the vendoress, but then her possessive husband didnt allow me to and instead wanted his pic taken. Dang! Double dang! ;))))))
Thursday, December 01, 2005
Chennai jottings...
I was sitting at my favourite Chennai Nair Tea Shop when I heard the zaniest conversation in recent times! A man walks in with a bizarre looking hearing aid stuck to his ear with a wire leading to his shirt pocket. On closer scrutiny it is a handsfree set for his mobile. He is speaking into into/to the contraption like there is no tomorrow and motions the 'tea master' to make him a sugarless tea, sits down on a plastic stool and picks up a 'bhaji' that has been made in the Paleontozoic era and kept out in the open to feed the houseflies and also as a receptacle for the dirt, grime and dust produced by the cacophonous Metropolitan Transport Corporation buses plying on roads that have craters similar to the moon.
Man with bizarre handsfree set (MWBHS): "Sir, I forced the girl to come on Tuesday, but she says she has got her exams"
God only knows what the duffer on the other side is telling him...
MWBHS: "No sir, I tried my best to get her over, but she is adamant saying that she has flunked her earlier exams and definitely cannot come this time"
God only knows what the duffer on the other side is telling him...
MWBHS: "Yes sir, she cant afford to do things according to her own luxury, that too after having asked us to go ahead with all the arrangements. Wouldn't we take care of her rain or sunshine, but somehow she seems to have missed the point"
God only knows what the duffer on the other side is telling him...
(Meanwhile, my thought takes a fancy flight and is freewheeling! Jeez these people are doing it in the open now eh? Goddamn, no wonder Chennai is seeing Japanese words like Tsunami in the Tamil papers)
MWBHS: "Sir, I told her father but he says it is none of his business and his daughter is an independent lady and can think for herself. I think I need to talk to her mother about this. How can she do like this, she should have informed us earlier. We have made all the arrangements and now she is backing out at the last minute. Dont worry Sir, I will somehow get her on Tuesday."
(Awww efff, even the parents are cahoots!!! Thirupathi Ezhumalayaaney!!)
God only knows what the duffer on the other side is telling him...
MWBHS: "I have arranged fantastic accomodation too and during this time it is very difficult to get a VIP suite. I have really slogged for it, Sir"
(If only I knew the name of the Hotel and the room number!)
MWBHS: "She badly wanted to go to Thirupathi for the past few years and now when the opportunity is there she cant go it seems. Ok then, what to do, the Lord wants her to come only later, I guess. Sorry for troubling you Sir."
Bloody idiot. He gave me a scare that bugger with the bizarre handsfree set! So Chennai is still safe and innocent?
Man with bizarre handsfree set (MWBHS): "Sir, I forced the girl to come on Tuesday, but she says she has got her exams"
God only knows what the duffer on the other side is telling him...
MWBHS: "No sir, I tried my best to get her over, but she is adamant saying that she has flunked her earlier exams and definitely cannot come this time"
God only knows what the duffer on the other side is telling him...
MWBHS: "Yes sir, she cant afford to do things according to her own luxury, that too after having asked us to go ahead with all the arrangements. Wouldn't we take care of her rain or sunshine, but somehow she seems to have missed the point"
God only knows what the duffer on the other side is telling him...
(Meanwhile, my thought takes a fancy flight and is freewheeling! Jeez these people are doing it in the open now eh? Goddamn, no wonder Chennai is seeing Japanese words like Tsunami in the Tamil papers)
MWBHS: "Sir, I told her father but he says it is none of his business and his daughter is an independent lady and can think for herself. I think I need to talk to her mother about this. How can she do like this, she should have informed us earlier. We have made all the arrangements and now she is backing out at the last minute. Dont worry Sir, I will somehow get her on Tuesday."
(Awww efff, even the parents are cahoots!!! Thirupathi Ezhumalayaaney!!)
God only knows what the duffer on the other side is telling him...
MWBHS: "I have arranged fantastic accomodation too and during this time it is very difficult to get a VIP suite. I have really slogged for it, Sir"
(If only I knew the name of the Hotel and the room number!)
MWBHS: "She badly wanted to go to Thirupathi for the past few years and now when the opportunity is there she cant go it seems. Ok then, what to do, the Lord wants her to come only later, I guess. Sorry for troubling you Sir."
Bloody idiot. He gave me a scare that bugger with the bizarre handsfree set! So Chennai is still safe and innocent?
Tuesday, November 29, 2005
Herbal supplements and surgery
Before you have surgery, tell your doctor about any herbal supplements you're taking. Some common herbal supplements can interfere with the success of your surgery.
You might not think to tell your doctor about the herbal supplements you're taking, such as the echinacea you take to fight off colds or the feverfew you use to prevent your migraines. But what you may not realize is that these and other herbal supplements can affect the success of a surgical procedure, just as conventional medicines can. Tell your doctor about any herbal supplements you're taking well before you have surgery. You may need to stop taking some herbal supplements up to three weeks before surgery to make sure they leave your system completely.
Here's a look at some common herbal supplements and how they can interfere with surgery. Keep in mind that other herbal supplements also may affect your surgery, so be sure to also tell your doctor if you're taking any herbs that aren't on this list.
Danshen
May cause bleeding
Dong quai
May cause bleeding
Echinacea
May interfere with immune functioning, may alter effectiveness of immuno-suppressant drugs given after transplant surgery
Ephedra
May cause abnormal heartbeat, may cause extreme high blood pressure and coma if combined with certain antidepressants and anesthesia
Feverfew
May cause bleeding
Garlic
May cause bleeding, may interfere with normal blood clotting
Ginger
May cause bleeding
Ginkgo
May cause bleeding
Ginseng
May cause bleeding, may cause rapid heartbeat, may cause high blood pressure
Goldenseal
May cause or worsen high blood pressure
Kava
May enhance sedative effects of anesthesia
Licorice (not including licorice candy)
May increase blood pressure
Senna
May cause electrolyte imbalance
St. John's wort
May increase or decrease the effects of some drugs used during and after surgery
Valerian
May interfere with the effects of anesthesia
Source:
Mayoclinic, which sends emails if you subscribe to them: housecall@mayoclinic.com
You might not think to tell your doctor about the herbal supplements you're taking, such as the echinacea you take to fight off colds or the feverfew you use to prevent your migraines. But what you may not realize is that these and other herbal supplements can affect the success of a surgical procedure, just as conventional medicines can. Tell your doctor about any herbal supplements you're taking well before you have surgery. You may need to stop taking some herbal supplements up to three weeks before surgery to make sure they leave your system completely.
Here's a look at some common herbal supplements and how they can interfere with surgery. Keep in mind that other herbal supplements also may affect your surgery, so be sure to also tell your doctor if you're taking any herbs that aren't on this list.
Danshen
May cause bleeding
Dong quai
May cause bleeding
Echinacea
May interfere with immune functioning, may alter effectiveness of immuno-suppressant drugs given after transplant surgery
Ephedra
May cause abnormal heartbeat, may cause extreme high blood pressure and coma if combined with certain antidepressants and anesthesia
Feverfew
May cause bleeding
Garlic
May cause bleeding, may interfere with normal blood clotting
Ginger
May cause bleeding
Ginkgo
May cause bleeding
Ginseng
May cause bleeding, may cause rapid heartbeat, may cause high blood pressure
Goldenseal
May cause or worsen high blood pressure
Kava
May enhance sedative effects of anesthesia
Licorice (not including licorice candy)
May increase blood pressure
Senna
May cause electrolyte imbalance
St. John's wort
May increase or decrease the effects of some drugs used during and after surgery
Valerian
May interfere with the effects of anesthesia
Source:
Mayoclinic, which sends emails if you subscribe to them: housecall@mayoclinic.com
Sunday, November 27, 2005
All because I went for a hair cut!
The Chennai barber has metamorphosed so much that I can hardly recognise him. Gone were the days when there was a rickety old chair in the middle of the salon which had half a door closed with an old fan rotating lazily/screechily above and the barber just went clippety clip for a full 45 minutes. By the time he finished I had a nap and also managed rosy dreams of fair, lipsticked actresses whose semi nude pictures adorned the dirty walls of the barber shop. After 45 mins I gave a 5 rupee professional charge and walked out happily light headed, the weight above my head reduced by almost a kilo!
Nowadays the barber's sports a trendy and cool look replete with a lot of paraphernalia and even a fish tank.
I swear I dont understand what is the fad with aquariums in Chennai that soon the cobbler on the road might be seen having one. Everyone seems to be in a hurry to have their hair cropped or their stubbles worked on that they barge into the place and demand a quick haircut or a shave with a result a long queue of people sit (can one 'sit' in a queue?) impatiently waiting for their turn. I always have this feeling that on the days I go to the barber's the whole town seems to be there.The ever compliant barber gets to work in a jiffy and one can see that he is in a hurry to finish his job rather than caress the lock of hair sending the client into a peaceful trance.
The modern day barber shop is a busy one as opposed to the days of yore when one frequented the barbers just to have a look at the vernacular papers and ogle at the sexy, slim actresses pinned on the walls. It was a place where politics, cinema, and education were discussed at great lengths. The barber kept yakking while the customer went into a hypnotic state. After cutting the hair, the barber donned the role of a masseur : He massaged the head and back. He even assumed the role of a chiropractor or a podiatrist. In fact the first surgeons were barbers. We had a barber in our men's hostel at Stanley Medical College and we cynically called him the 'Stanley Surgeon'.
I just returned from the barber and I should say the experience wasnt too memorable. I closed my eyes and old memories surfaced in my tired mind and I sat oblivious of the barber using a harsh comb and a rough pair of scissors. The days when Devan, my childhood barber came home to cut my unkempt hair on a sunny Saturday afternoon slowly took shape in my mind's eye like a well projected PowerPoint presentation.
Devan was a short and bald man in his fifties with a thin line of hair for a moushtache at the edge of his upper lip. I always wondered who cut his hair or did he do an auto-cut? He did have a salon in the main road at Yercaud, Salem Dt, but visited my house on my father's insistance. We (my brother and I) as kids were very scared of the going to the salon and my Dad thought it was a better idea to ask the barber to come over. Usually it was a Saturday because we had only half a day of school on that day and on Sundays the barber was too busy in his shop that he couldnt make a house-visit.
He came at around 2 pm carrying a black box with all his instruments inside. As soon as I spotted him coming (I usually sat perched on the compound wall near the gate), I would yell: "Appa, barber vandhaachu" (the barber has come). Immediately I would be admonished by Dad: "How many times have I told you to say 'Devan uncle has come? You never listen, useless fellow!" Dad did not like us addressing him as 'barber'. But I always wondered secretly: "How else would anyone call a barber? Dont we call a teacher as teacher and not as Hendricks aunty?" I dont fathom why my father did not want us to address him as 'barber'. Perhaps he thought it was an insult? No work is inferior, isnt it?
Sometimes when the barber came we were so engrossed in our play that it would require our parents to yell at us to go and sit in the chair which had a plank of wood across the arm rests (so that we were at the right height for 'Devan uncle') and get going with the hair cut. One day we didnt turn up even after a few yells from my Dad that he got so angry and even pulled a toy car that I was playing with very harshly and threw it with such force onto the floor that it got smashed to smithereens. I got hurt so badly and I never forgave my father for that.
Ok, I digress. Devan was a very strict man and he wouldnt tolerate any of my pranks. The hardest part of the hair cut was bending my head forward while he cut the hair behind my head. It seemed like a few eons and even if I moved my head a little he shoved it back ruthlessly into position threatening me that he would cut my ears! Devan had an irritating habit of burping and I could almost smell his gastric contents while he burped right behind my ears! Sometimes I thought he would ralph on me. Eeeks.
After I had my barnet cut (usually my bro and I had a fight as to who will get the first haircut and it was me who won) I would lounge around while my brother was having his, irritating him all the while knowing fully that he couldnt do anything to me then (he had the habit of throwing whatever he could find on me).
When Devan finished, my Dad gave him 10 rupees, he received it gratefully and left only to return a month later to burp in my ear.
This evening I missed Devan and even wondered if he was alive. May God bless him wherever he is.
Nowadays the barber's sports a trendy and cool look replete with a lot of paraphernalia and even a fish tank.
I swear I dont understand what is the fad with aquariums in Chennai that soon the cobbler on the road might be seen having one. Everyone seems to be in a hurry to have their hair cropped or their stubbles worked on that they barge into the place and demand a quick haircut or a shave with a result a long queue of people sit (can one 'sit' in a queue?) impatiently waiting for their turn. I always have this feeling that on the days I go to the barber's the whole town seems to be there.The ever compliant barber gets to work in a jiffy and one can see that he is in a hurry to finish his job rather than caress the lock of hair sending the client into a peaceful trance.The modern day barber shop is a busy one as opposed to the days of yore when one frequented the barbers just to have a look at the vernacular papers and ogle at the sexy, slim actresses pinned on the walls. It was a place where politics, cinema, and education were discussed at great lengths. The barber kept yakking while the customer went into a hypnotic state. After cutting the hair, the barber donned the role of a masseur : He massaged the head and back. He even assumed the role of a chiropractor or a podiatrist. In fact the first surgeons were barbers. We had a barber in our men's hostel at Stanley Medical College and we cynically called him the 'Stanley Surgeon'.
I just returned from the barber and I should say the experience wasnt too memorable. I closed my eyes and old memories surfaced in my tired mind and I sat oblivious of the barber using a harsh comb and a rough pair of scissors. The days when Devan, my childhood barber came home to cut my unkempt hair on a sunny Saturday afternoon slowly took shape in my mind's eye like a well projected PowerPoint presentation.
Devan was a short and bald man in his fifties with a thin line of hair for a moushtache at the edge of his upper lip. I always wondered who cut his hair or did he do an auto-cut? He did have a salon in the main road at Yercaud, Salem Dt, but visited my house on my father's insistance. We (my brother and I) as kids were very scared of the going to the salon and my Dad thought it was a better idea to ask the barber to come over. Usually it was a Saturday because we had only half a day of school on that day and on Sundays the barber was too busy in his shop that he couldnt make a house-visit.
He came at around 2 pm carrying a black box with all his instruments inside. As soon as I spotted him coming (I usually sat perched on the compound wall near the gate), I would yell: "Appa, barber vandhaachu" (the barber has come). Immediately I would be admonished by Dad: "How many times have I told you to say 'Devan uncle has come? You never listen, useless fellow!" Dad did not like us addressing him as 'barber'. But I always wondered secretly: "How else would anyone call a barber? Dont we call a teacher as teacher and not as Hendricks aunty?" I dont fathom why my father did not want us to address him as 'barber'. Perhaps he thought it was an insult? No work is inferior, isnt it?
Sometimes when the barber came we were so engrossed in our play that it would require our parents to yell at us to go and sit in the chair which had a plank of wood across the arm rests (so that we were at the right height for 'Devan uncle') and get going with the hair cut. One day we didnt turn up even after a few yells from my Dad that he got so angry and even pulled a toy car that I was playing with very harshly and threw it with such force onto the floor that it got smashed to smithereens. I got hurt so badly and I never forgave my father for that.
Ok, I digress. Devan was a very strict man and he wouldnt tolerate any of my pranks. The hardest part of the hair cut was bending my head forward while he cut the hair behind my head. It seemed like a few eons and even if I moved my head a little he shoved it back ruthlessly into position threatening me that he would cut my ears! Devan had an irritating habit of burping and I could almost smell his gastric contents while he burped right behind my ears! Sometimes I thought he would ralph on me. Eeeks.
After I had my barnet cut (usually my bro and I had a fight as to who will get the first haircut and it was me who won) I would lounge around while my brother was having his, irritating him all the while knowing fully that he couldnt do anything to me then (he had the habit of throwing whatever he could find on me).
When Devan finished, my Dad gave him 10 rupees, he received it gratefully and left only to return a month later to burp in my ear.
This evening I missed Devan and even wondered if he was alive. May God bless him wherever he is.
Saturday, November 26, 2005
Alcohol-Drug Interactions
After having a look at the number of hits to this site and also viewing the referral sites like Google etc, it is very obvious that folks always search for drug interactions and invariably land here or more commonly search for alcohol-drug interactions. To provide peeps with more info I am posting this.
The properties that promote drug interactions:
Chronic alcoholism results in enzyme induction. Acute alcoholic intoxication tends to inhibit drug metabolism (whether the person is an alcoholic or not). Severe alcohol-induced hepatic dysfunction may inhibit ability to metabolize drugs. Disulfiram (Antabuse) like reactions in the presence of certain drugs may occur. Additive CNS (central nervous system) depression with other central nervous depressants may occur.
Clinically documented alcohol-drug interactions:
Acetaminophen:
Increased formation of hepatotoxic acetaminophen metabolites (in chronic alcoholics)
Anticoagulants, oral:
Increased hypoprothrombinaemic effect with acute alcohol intoxication.
Central Nervous System depressants:
Additive or synergistic CNS depression.
Insulin:
Acute alcohol intake may increase hypoglycaemic effect of insulin (especially in fasting patients).
Drugs that produce a disulfiram-like reaction:
The properties that promote drug interactions:
Chronic alcoholism results in enzyme induction. Acute alcoholic intoxication tends to inhibit drug metabolism (whether the person is an alcoholic or not). Severe alcohol-induced hepatic dysfunction may inhibit ability to metabolize drugs. Disulfiram (Antabuse) like reactions in the presence of certain drugs may occur. Additive CNS (central nervous system) depression with other central nervous depressants may occur.
Clinically documented alcohol-drug interactions:
Acetaminophen:
Increased formation of hepatotoxic acetaminophen metabolites (in chronic alcoholics)
Anticoagulants, oral:
Increased hypoprothrombinaemic effect with acute alcohol intoxication.
Central Nervous System depressants:
Additive or synergistic CNS depression.
Insulin:
Acute alcohol intake may increase hypoglycaemic effect of insulin (especially in fasting patients).
Drugs that produce a disulfiram-like reaction:
- Cephalosporins: Disulfiram-like reactions noted with cefamandole, cefaperazone, cefotetan and moxalactam.
- Chloral hydrate: Mechanism not established.
- Disulfiram: Inhibits aldehyde dehydrogenase.
- Metronidazole: Mechanism not established.
- Sulfonylureas: Chlorpropamide is most likely to cause a disulfiram-like reaction; acute alcohol intake may increase hypoglycemic effect (especially in fasting patients)
Thursday, November 24, 2005
The Super 15!
In the good-for-you category of foods, there exists an elite squad of real superstars — foods that go the distance in giving you vitamins, minerals and possible protection from health problems. Pick a few that you like and seek them out at salad bars or slip them into favorite recipes. They keep on giving.
1. Garlic.
One clove may contain more than 15 antioxidants, plus an antibiotic and a bronchial decongestant; may help lower blood pressure, boost immunity, reduce blood clotting, lower bad cholesterol, raise cholesterol and prevent some types of cancer.
Certain compounds clear sinuses; may control high cholesterol and prevent heart attacks and some cancers, including stomach, rectal and colon.
Contains vitamin C, vitamin E, folic acid, protein, calcium and beta-carotene, which may help protect against cancer.
Full of vitamin C, potassium and dietary fiber; also high in pectin, which reduces cholesterol levels and risk of hypertension.
Full of beta-carotene and fiber; may help prevent cancer and reduce risk of heart attack; may also lower cholesterol levels.
Brimming with calcium, protein and riboflavin; can help prevent osteoporosis.
Contain protein, folic acid and fiber; may lower cholesterol and risk of cance
High in fiber, calcium, folic acid and vitamin C, with phytochemicals , that have anticancer properties. Hard for digestion if you have liver disease, makes the liver overwork.
Rich in vitamins C and E, beta-carotene, fiber, potassium and iron; may help prevent cancer.
Boast high amounts of vitamin C; may help protect against cancer; the pectin found in white grapefruit may reduce risk of heart disease.
Contains iron, calcium, magnesium and fiber; the only food to contain genistein, which may inhibit breast cancer by decreasing estrogen levels.
Contain lycopene, which may help fight cancer, plus fiber and vitamin C.
One cup provides 125 percent of the Daily Value for vitamin C and more than 50 percent for vitamin A; melons may protect against cancers of the colon and rectum.
Full of fiber, which may help lower cholesterol, plus iron, copper, folic acid, vitamin E and zinc.
One cup contains more than 20 percent of the Daily Value for magnesium and selenium, plus fiber and antioxidant power; its fiber may help prevent colon cancer and constipation.
Wednesday, November 23, 2005
A house visit, the auto-wallah and the rains
An area called Madipakkam next to Velachery (the area where I stay) in Chennai is a veritable ocean replete with waves whenever it rains for more than a day. One wonders how at all did people have the mind to buy/rent a house/flat in such a low lying area! Come monsoons and normal life is disrupted for more than a week even after it has stopped raining. Even the MTC (govt. bus transport) halts its services to Madipakkam! Imagine.
Ok today I had a phone call from a doctor friend asking me to visit his patient who lives in Madipakkam. I couldnt refuse as the patient was 88yrs old and she was being looked after by her niece and there wasnt any male member in the family to take her to the hospital.
Knowing that the area would be flooded I decided to hire a rick to visit the patient. Mercifully the auto-wallah agreed to ply me to Madipakkam and back(usually even autowallahs refuse to ply to Madipakkam during the rains, if at all they do, the charge would be astronomical, maybe the equivalent of buying an auto and fuelling it for life)
The Good Samaritan auto driver informed me the fare would be 150 bucks. Off I went and the main road to Madipakkam was cut off with water stagnating as far as the eye could see! There were even waves like the ones you see in Hawaii! I could have easily learnt to surf on those waters.
Ok after the auto waded through the waters and went through rickety-rackety roads, we finally reached the house I was to visit.
The poor old lady had high fever, elephantiasis of the legs, inflammatory edema in the legs because of a few furuncles on the legs and diabetic nephropathy.
I gave a shot of paracetamol to reduce the fever and asked for a few investigations. She was sleeping in a very odd position and was about to fall off the bed. Her attendants being ladies and not very strong could not move her into a proper position and so they had barricaded the bed with a few chairs. Along with the help of the auto driver, I managed to pull the patient into a more comfortable position. Ants were streaming along on her limp body. Poor thing, passing urine and motion on the bed and lying in the wetness should have been really uncomfortable and had moved herself to the cot's edge.
Finally while I was about to leave, the lady of the house wanted to know how much she would have to pay the auto driver. Without batting a lid, he charged 250 bucks. The lady was bewildered but eventually gave him the dough. Next she asked me how much my fee was. I said 200 bucks. She was kind of shocked in a pleasant way, and even offered me a 100 extra. Politely I refused and left asking her to take care. As I left she muttered under her breath: Doctor charges 200 and auto driver charges 250!
I don’t know whether it was right on the part of the auto wallah to charge 250, coz the water logging was so very bad, but that’s life. I don’t have a right to suggest to the autowallah to charge less. What if he were to suggest me to charge less? Each one should be responsible for the fee they collect.
You can have a look at the pics that I took from my mobile while traveling by the rick.
Thursday, November 17, 2005
At last!
Finally I seem to have got in touch with my batch mates from Stanley Med College. Chezhian has stumbled on to my site 'accidentally' and Balan feels I have too much time on my hands after reading my blog and wants to know if I am married. Yes Balan, I am married to a beautiful lady who is four years our junior and Praveen after reading the '100 things about me' feels that I have narcisstic tendencies. Well Praveen what else do you expect to read in a '100 things about me' stuff? And that too from an arrogant arsehole like me? ;))))
And guys, whoever is the group manager is a wee bit slow in sending me an invite to join the msn group!
And guys, whoever is the group manager is a wee bit slow in sending me an invite to join the msn group!
Tuesday, November 15, 2005
The Chennai 'Nair Tea Shop'
The ubiquitous Chennai 'Nair Tea Kadai' is an institution of sorts. Dingy, dirty, but catering to the hungry wayfarer and office goer, one can find this shop at every nook and corner in Chennai. I wonder why the Malayali doesnt want to set up shop in Kerala but in ''Singara Chennai". One possible explation would be that since most Mallus are seen everywhere except Kerala, there seems to be a dearth of tea/coffee drinking people in the most literate state in India!!!
Another theory of mine says that the highly literate Mallus are way hygienic than Tamilians and wouldnt want to drink tea in dirty wayside shops. One would be surprised to see software guys from the likes of TCS, Infosys and CTS sitting in these shops with their company badges dangling around their necks and sipping hot chai and biting on a vada or a bajji throwing cleanliness to the winds. Some say that tea tastes better in a glass tumbler!
The 'tea shop' not only vends tea but also an array of fried snacks like vadas, bajji, bondas and the like. Some 'tea shops' even offer curd rice and lemon rice for a quick afternoon lunch. These tea shops seem to be a rendezvous for salesmen, auto-drivers and messages could be passed on to the 'tea-master' to be relayed to other people. How cool and effective is that?
Monday, November 14, 2005
The Glamboyant Masala Dosai
The 'Masala Dosai' is an integral part of Chennai and I can safely say that one misses out on a gastronomic delight if he hasnt savoured this quintessential and most sublime of foods during his/her visit to the city.
To the staunch Tamil it is 'dosai' and when pronounced that way the dish seems very pristine, but to the non Tamil, it is 'dosa', 'dhosa' or even 'dhosha' and this is when it seems the dish loses its 'manna-ish' quality!
On the surface, preparing a dosai seems to be easy, but when one attempts making a crisp one, then everything seems to go awry. The batter has to be just perfect and then the potato masala that goes in the centre while making the dosai should also be of the right consistency and only then can one turn out an authentic Chennai masala dosai.
Masala dosai can never be termed a humble dish, for it has a flavour of flamboyance in it and is a great accompaniment to gin/vermouth. No other South Indian dish goes well with gin. Also fresh filter coffee after a breakfast of masala dosai is nothing short of ambrosia!
Wednesday, October 26, 2005
60 uses of common salt
Although you may not realize it, simple table salt has a great number of uses other than simply seasoning your food. The following list will give you sixty uses of salt, many of which you probably didn't realize:
1. Soak stained hankies in salt water before washing.
2. Sprinkle salt on your shelves to keep ants away.
3. Soak fish in salt water before descaling; the scales will come off easier.
4. Put a few grains of rice in your salt shaker for easier pouring.
5. Add salt to green salads to prevent wilting.
6. Test the freshness of eggs in a cup of salt water; fresh eggs sink; bad ones float.
7. Add a little salt to your boiling water when cooking eggs; a cracked egg will stay in its shell this way.
8. A tiny pinch of salt with egg whites makes them beat up fluffier.
9. Soak wrinkled apples in a mildly salted water solution to perk them up.
10. Rub salt on your pancake griddle and your flapjacks won't stick.
11. Soak toothbrushes in salt water before you first use them; they will last longer.
12. Use salt to clean your discolored coffee pot.
13. Mix salt with turpentine to whiten you bathtub and toilet bowl.
14. Soak your nuts in salt brine overnight and they will crack out of their shells whole. Just tap the end of the shell with a hammer to break it open easily.
15. Boil clothespins in salt water before using them and they will last longer.
16. Clean brass, copper and pewter with paste made of salt and vinegar, thickened with flour
17. Add a little salt to the water your cut flowers will stand in for a longer life.
18. Pour a mound of salt on an ink spot on your carpet; let the salt soak up the stain.
19. Clean you iron by rubbing some salt on the damp cloth on the ironing surface.
20. Adding a little salt to the water when cooking foods in a double boiler will make the food cook faster.
21. Use a mixture of salt and lemon juice to clean piano keys.
22. To fill plaster holes in your walls, use equal parts of salt and starch, with just enough water to make a stiff putty.
23. Rinse a sore eye with a little salt water.
24. Mildly salted water makes an effective mouthwash. Use it hot for a sore throat gargle.
25. Dry salt sprinkled on your toothbrush makes a good tooth polisher.
26. Use salt for killing weeds in your lawn.
27. Eliminate excess suds with a sprinkle of salt.
28. A dash of salt in warm milk makes a more relaxing beverage.
29. Before using new glasses, soak them in warm salty water for awhile.
30. A dash of salt enhances the taste of tea.
31. Salt improves the taste of cooking apples.
32. Soak your clothes line in salt water to prevent your clothes from freezing to the line; likewise, use salt in your final rinse to prevent the clothes from freezing.
33. Rub any wicker furniture you may have with salt water to prevent yellowing.
34. Freshen sponges by soaking them in salt water.
35. Add raw potatoes to stews and soups that are too salty.
36. Soak enamel pans in salt water overnight and boil salt water in them next day to remove burned-on stains.
37. Clean your greens in salt water for easier removal of dirt.
38. Gelatin sets more quickly when a dash of salt is added.
39. Fruits put in mildly salted water after peeling will not discolor.
40. Fabric colors hold fast in salty water wash.
41. Milk stays fresh longer when a little salt is added.
42. Use equal parts of salt and soda for brushing your teeth.
43. Sprinkle salt in your oven before scrubbing clean.
44. Soaked discolored glass in a salt and vinegar solution to remove stains.
45. Clean greasy pans with a paper towel and salt.
46. Salty water boils faster when cooking eggs.
47. Add a pinch of salt to whipping cream to make it whip more quickly.
48. Sprinkle salt in milk-scorched pans to remove odour.
49. A dash of salt improves the taste of coffee.
50. Boil mismatched hose in salty water and they will come out matched.
51. Salt and soda will sweeten the odor of your refrigerator.
52. Cover wine-stained fabric with salt; rinse in cool water later.
53. Remove offensive odors from stove with salt and cinnamon.
54. A pinch of salt improves the flavor of cocoa.
55. To remove grease stains in clothing, mix one part salt to four parts alcohol.
56. Salt and lemon juice removes mildew.
57. Sprinkle salt between sidewalk bricks where you don't want grass growing.
58. Polish your old kerosene lamp with salt for a brighter look.
59. Remove odors from sink drainpipes with a strong, hot solution of salt water.
60. If a pie bubbles over in your oven, put a handful of salt on top of the spilled juice. The mess won't smell and will bake into a dry, light crust which will wipe off easily when the oven has cooled.
1. Soak stained hankies in salt water before washing.
2. Sprinkle salt on your shelves to keep ants away.
3. Soak fish in salt water before descaling; the scales will come off easier.
4. Put a few grains of rice in your salt shaker for easier pouring.
5. Add salt to green salads to prevent wilting.
6. Test the freshness of eggs in a cup of salt water; fresh eggs sink; bad ones float.
7. Add a little salt to your boiling water when cooking eggs; a cracked egg will stay in its shell this way.
8. A tiny pinch of salt with egg whites makes them beat up fluffier.
9. Soak wrinkled apples in a mildly salted water solution to perk them up.
10. Rub salt on your pancake griddle and your flapjacks won't stick.
11. Soak toothbrushes in salt water before you first use them; they will last longer.
12. Use salt to clean your discolored coffee pot.
13. Mix salt with turpentine to whiten you bathtub and toilet bowl.
14. Soak your nuts in salt brine overnight and they will crack out of their shells whole. Just tap the end of the shell with a hammer to break it open easily.
15. Boil clothespins in salt water before using them and they will last longer.
16. Clean brass, copper and pewter with paste made of salt and vinegar, thickened with flour
17. Add a little salt to the water your cut flowers will stand in for a longer life.
18. Pour a mound of salt on an ink spot on your carpet; let the salt soak up the stain.
19. Clean you iron by rubbing some salt on the damp cloth on the ironing surface.
20. Adding a little salt to the water when cooking foods in a double boiler will make the food cook faster.
21. Use a mixture of salt and lemon juice to clean piano keys.
22. To fill plaster holes in your walls, use equal parts of salt and starch, with just enough water to make a stiff putty.
23. Rinse a sore eye with a little salt water.
24. Mildly salted water makes an effective mouthwash. Use it hot for a sore throat gargle.
25. Dry salt sprinkled on your toothbrush makes a good tooth polisher.
26. Use salt for killing weeds in your lawn.
27. Eliminate excess suds with a sprinkle of salt.
28. A dash of salt in warm milk makes a more relaxing beverage.
29. Before using new glasses, soak them in warm salty water for awhile.
30. A dash of salt enhances the taste of tea.
31. Salt improves the taste of cooking apples.
32. Soak your clothes line in salt water to prevent your clothes from freezing to the line; likewise, use salt in your final rinse to prevent the clothes from freezing.
33. Rub any wicker furniture you may have with salt water to prevent yellowing.
34. Freshen sponges by soaking them in salt water.
35. Add raw potatoes to stews and soups that are too salty.
36. Soak enamel pans in salt water overnight and boil salt water in them next day to remove burned-on stains.
37. Clean your greens in salt water for easier removal of dirt.
38. Gelatin sets more quickly when a dash of salt is added.
39. Fruits put in mildly salted water after peeling will not discolor.
40. Fabric colors hold fast in salty water wash.
41. Milk stays fresh longer when a little salt is added.
42. Use equal parts of salt and soda for brushing your teeth.
43. Sprinkle salt in your oven before scrubbing clean.
44. Soaked discolored glass in a salt and vinegar solution to remove stains.
45. Clean greasy pans with a paper towel and salt.
46. Salty water boils faster when cooking eggs.
47. Add a pinch of salt to whipping cream to make it whip more quickly.
48. Sprinkle salt in milk-scorched pans to remove odour.
49. A dash of salt improves the taste of coffee.
50. Boil mismatched hose in salty water and they will come out matched.
51. Salt and soda will sweeten the odor of your refrigerator.
52. Cover wine-stained fabric with salt; rinse in cool water later.
53. Remove offensive odors from stove with salt and cinnamon.
54. A pinch of salt improves the flavor of cocoa.
55. To remove grease stains in clothing, mix one part salt to four parts alcohol.
56. Salt and lemon juice removes mildew.
57. Sprinkle salt between sidewalk bricks where you don't want grass growing.
58. Polish your old kerosene lamp with salt for a brighter look.
59. Remove odors from sink drainpipes with a strong, hot solution of salt water.
60. If a pie bubbles over in your oven, put a handful of salt on top of the spilled juice. The mess won't smell and will bake into a dry, light crust which will wipe off easily when the oven has cooled.
Sunday, October 23, 2005
All Logic Defied!!!
Someone call the shrink, I am going crazy when I think of how girls walk with these;)
Sunday, October 09, 2005
Medicine - Herb/Food Interactions
Many people have the mistaken notion that, being natural, all herbs and foods are safe. This is not so. Very often, herbs and foods may interact with medications you normally take that result in serious side reactions. It is always a good practice to tell your doctor or health practitioners what you are taking so that they can advise you of possible complications, if there is any. You should also keep an eye for unusual symptoms. Very often, this may foretell the symptoms of a drug interaction.
Experts suggest that natural does not mean it is completely safe. Everything you put in your mouth has the potential to interact with something else. The medication that is taken by mouth travels through the digestive system in much the same way as food and herbs taken orally do. So, when a drug is mixed with food or another herb, each can alter the way the body metabolizes the other. Some drugs interfere with the body's ability to absorb nutrients. Similarly, some herbs and foods can lessen or increase the impact of a drug.
Alcohol is a drug that interacts with almost every medication, especially antidepressants and other drugs that affect the brain and nervous system.
Some dietary components increase the risk of side effects. Theophylline, a medication administered to treat asthma, contains xanthines, which are also found in tea, coffee, chocolate, and other sources of caffeine. Consuming large amounts of these substances while taking theophylline increases the risk of drug toxicity.
Certain vitamins and minerals impact on medications too. Large amounts of broccoli, spinach, and other green leafy vegetables high in vitamin K, which promotes the formation of blood clots, can counteract the effects of heparin, warfarin, and other drugs given to prevent clotting.
Dietary fiber also affects drug absorption. Pectin and other soluble fibers slow down the absorption of acetaminophen, a popular painkiller. Bran and other insoluble fibers have a similar effect on digoxin, a major heart medication.
As more and more people discover new herbs, there is more and more potential for the abuse of these herbs and the patients may end up in serious problems. High-risk patients, such as the elderly, patients taking three or more medications for chronic conditions, patients suffering from diabetes, hypertension, depression, high cholesterol or congestive heart failure, should be especially on the lookout for such side reactions.
The following are the examples of known interaction between popular herbs, foods, and prescription and over-the-counter drugs.
Hawthorn, touted as effective in reducing angina attacks by lowering blood pressure and cholesterol levels, should never be taken with Lanoxin (digoxin), the medication prescribed for most for heart ailments. The mix can lower your heart rate too much, causing blood to pool, bringing on possible heart failure.
Ginseng, according to research, can increase blood pressure, making it dangerous for those trying to keep their blood pressure under control. Ginseng, garlic or supplements containing ginger, when taken with the blood-thinning drug, Coumadin, can cause bleeding episodes. Coumadin is a very powerful drug that leaves little room for error, and patients taking it should never take any medication or otherwise before consulting a qualified health professional. In rare cases, ginseng may overstimulate resulting in insomnia. Consuming caffeine with ginseng increases the risk of overstimulation and gastrointestinal upset. Long tern use of ginseng may cause menstrual abnormalities and breast tenderness in some women. Ginseng is not recommended for pregnant or lactating women.
Garlic capsules combined with diabetes medication can cause a dangerous decrease in blood sugars. Some people who are sensitive to garlic may experience heartburn and flatulence. Garlic has anti-clotting properties. You should check with your doctor if you are taking anticoagulant drugs.
Goldenseal is used for coughs, stomach upsets, menstrual problems and even arthritis. However, the plant's active ingredient will raise blood pressure, complicating treatment for those taking antihypertensive medications, especially beta-blockers. For patients taking medication to control diabetes or kidney disease, this herb can cause dangerous electrolyte imbalance. High amount of consumption can lead to gastrointestinal distress and possible nervous system effects. Not recommended for pregnant or lactating women.
Feverfew, believed to be the natural remedy for migraine headaches, should never be taken with Imitrex or other migraine medications. It can result in the patient's heart rate and blood pressure to rise dangerous levels.
Guarana, an alternative remedy being used as a stimulant and diet aid, contains 3 percent to 5 percent more caffeine than a cup of coffee. So, if you are taking any medication that advises you against taking any drink with caffeine, you should avoid taking this stimulant. It may cause insomnia, trembling, anxiety, palpitations, urinary frequency, and hyperactivity. Avoid during pregnancy and lactation period. Long term use of Guarana may lead to decreased fertility, cardiovascular disease, and several forms of cancer.
Kava, a herb that has antianxiety, pain relieving, muscle relaxing and anticonvulsant effects, should not be taken together with substances that also act on the central nervous system, such as alcohol, barbiturates, anti depressants, and antipsychotic drugs.
St. John's Wort is a popular herb used for the treatment of mild depression.
The active ingredient of St. John's Wort is hypericin. Hypericin is believed to exert a similar influence on the brain as the monoamine oxidase (MAO) inhibitors such as the one in major antidepressants. Mixing MAO inhibitors with foods high in tyramine, an amino acid, produces one of the most dramatic and dangerous food-drug interactions. Symptoms, which can occur within minutes of ingesting such foods while taking an MAO inhibitor, include rapid rise in blood pressure, a severe headache, and perhaps collapse and even death. Foods high in tyramine include aged cheese, chicken liver, Chianti (and certain other red wines), yeast extracts, bologna (and other processed meats), dried or pickled fish, legumes, soy sauce, ale, and beer.
Some patients report that Saint Johns Wort caused excessive stimulation and sometimes dizziness, agitation and confusion when taken with other antidepressants or over-the-counter medications like Maximum Strength Dexatrim and Acutrim. It also caused their blood pressure to shoot up.
White Willow, an herb traditionally used for fever, headache, pain, and rheumatic complaints may lead to gastrointestinal irritation, if used for a long time. It exhibits similar reactions as aspirin (aspirin is derived from white willow). Long term use may lead to stomach ulcers.
Drug Interaction and Food
Drug interaction risk isn't limited to herbal supplements. Certain foods can interact with medications.
People taking digoxin should avoid Black licorice (which contains the ingredient glycyrhizin). Together, they can produce irregular heart rhythms and cardiac arrest; licorice and diuretics will produce dangerously low potassium levels, putting a patient at risk for numbing weakness, muscle pain and even paralysis. Licorice can also interact with blood pressure medication or any calcium channel blockers.
Aged cheese (brie, parmesan, cheddar and Roquefort), fava beans, sauerkraut, Italian green beans, some beers, red wine, pepperoni and overly ripe avocados should be avoided by people taking MAO antidepressants. The interaction can cause a potentially fatal rise in blood pressure.
And because Saint Johns Wort contains the same properties as these MAO antidepressants, it stands to reason that people ingesting the herb should avoid these same foods.
Grapefruit juice interacts with calcium channel blockers (including Calan, Procardia, Nifedipine, and Verapamil), cholesterol control medications, some psychiatric medications, estrogen, oral contraceptives and many allergy medications (Seldane, Hismanal). The juice modifies the body's way of metabolizing the medication, affecting the liver's ability to work the drug through a person's system. More Information.
Orange juice shouldn't be consumed with antacids containing aluminum. 'The juice increases the absorption of the aluminum. Orange Juice and milk should be avoided when taking antibiotics. The juice's acidity decreases the effectiveness of antibiotics, as does milk.
Milk also doesn't mix with laxatives containing bisacodyl (Correctol and Dulcolax). You might find the laxative works a little "too well" in the morning.
Large amounts of oatmeal and other high-fiber cereals should not be eaten when taking digoxin. The fiber can interfere with the absorption of the drug, making the act of swallowing the pill a waste of time.
However, don't stop eating your cereal right away, because that could cause digoxin levels in your system to soar to toxic levels. A professional should make the dietary changes after carefully examining the digoxin levels.
Leafy green vegetables, high in vitamin K, should not be taken in great quantities while taking Coumadin. These vegetables could totally negate the affects of the drug and cause blood clotting.
Caffeinated beverages and asthma drugs taken together can cause excessive excitability. Those taking Tagament (Simetidine), quinolone antibiotics (Cipro, Penetrex, Noroxin) and even oral contraceptives should be aware these drugs may cause their cup of coffee to give them more of a Java jolt than they expected.
Grilled meat can lead to problems for those on asthma medications containing theophyllines. The chemical compounds formed when meat is grilled somehow prevent this type of medication from working effectively, increasing the possibility of an unmanageable asthma attack.
Regularly consuming a diet high in fat while taking anti-inflammatory and arthritis medications can cause kidney damage and can leave the patient feeling, drowsy and sedated.
Alcoholic beverages tend to increase the depressive effects of medications such as benzodiazepines, antihistamines, antidepressants, antipsychotics, muscle relaxants, narcotics, or any drug with sedative actions.
It's a good idea to not consume any alcoholic beverages, or at least scale way back, when taking prescription medications. Antioxidant and beta-carotene intensify alcohol's effect on the liver.
Other commonly used over-the-counter medications can cause interaction problems also.
Aspirin can modify the effectiveness of arthritis medications, strong prescription steroids and diuretics. Combining aspirin with diabetic medications can drop blood sugars to dangerous levels. Aspirin can also cause toxicity when taken with glaucoma and anticonvulsant (anti-seizure) drugs and cause bleeding episodes when combined with a blood thinner, like Coumadin.
Acetaminophen can also cause interaction complications when overused. Heavy drinkers who take acetaminophen for hangover relief risk liver damage. Taking high doses of acetaminophen with Coumadin can cause bleeding episodes.
Antacids taken with antibiotics, heart and blood pressure or thyroid medications can decrease drug absorption by up to 90 percent.
Over-the-counter antihistamines - sold under the names Actifed, Theraflu, Dimetapp, Benadryl and Comtrex should be avoided if you are taking antianxiety or antidepressant medications.
Oral contraceptives are less effective when taken with barbiturates, antibiotics, anti-fungal or tuberculosis drugs.
Turnips contain two goitrogenic substances, progoitrin and gluconasturtin, which can interfere with the thyroid gland's ability to make its hormones. Although moderate consumption of goitrogens is not a hazard for healthy people, they can promote development of a goiter (an enlarged thyroid) in persons with thyroid disease.
Tomato contains small quantities of a toxic substance known as solanine that may trigger headaches in susceptible people. They are also a relatively common cause of allergies. An unidentified substance in tomatoes and tomato-based products can cause acid reflux, leading to indigestion and heartburn. Individuals who often have digestive upsets should try eliminating tomatoes for 2 to 3 weeks to see if there is any improvement.
Strawberries, Raspberries, Spinach, and Rhubarb: These contain oxalic acid, which can aggravate kidney and bladder stones in susceptible people, and reduce body's ability to absorb iron and calcium.
Raspberries contain a natural salicylate that can cause an allergic reaction in aspirin sensitive people.
The seeds from fruits such as Apple, apricot, and Quinces contain amygdalin, a compound that turns into Hydrogen Cyanide in the stomach. Eating large amount of seeds can result in cyanide poisoning.
Potatoes: Avoid potatoes with a green tint to the skin, and remove any sprouts; they will taste bitter and may contain solanine, a toxic substance that can cause diarrhea, cramps, and fatigue.
Plums, Peaches, Apricots, and Cherries: These fruits may produce allergic reaction in individuals with confirmed allergies to apricots, almonds, peaches, and cherries. People who are allergic to aspirin may also encounter problems after they have eaten plums or peaches as they contain salicylates. The pits of plums, peaches and apricots contain a compound called amygdalin. When consumed in large amounts, amygdalin breaks down into hydrogen cyanide, a poison.
Horseradish: Very high doses of horseradish can cause vomiting or excessive sweating. Avoid if you have hypothyroidism.
Turmeric: Should be avoided by persons with symptoms from gallstones.
The drug food interaction is summarized below.
Cephalosporins, penicillin
Take on an empty stomach to speed absorption of the drugs.
Erythromycin
Don't take with fruit juice or wine, which decrease the drug's effectiveness.
Sulfa drugs
Increase the risk of Vitamin B-12 deficiency
Tetracycline
Dairy products reduce the drug's effectiveness. Lowers Vitamin C absorption
Dilantin, phenobarbital
Increase the risk of anemia and nerve problems due to deficiency of folalte and other B vitamins.
Fluoxetine
Reduce appetite and can lead to excessive weight loss
Lithium
A low-salt diet increases the risk of lithium toxicity; excessive salt reduces the drug's efficacy
MAO Inhibitors
Foods high in tyramine (aged cheeses, processed meats, legumes, wine, beer, among others) can bring on a hypertensive crisis.
Tricyclics
Many foods, especially legumes, meat, fish, and foods high in Vitamin C, reduce absorption of the drugs.
ACE inhibitors
Take on an empty stomach to improve the absorption of the drugs.
Alpha blockers
Take with liquid or food to avoid excessive drop in blood pressure.
Antiarrhythmic drugs
Avoid caffeine, which increases the risk of irregular heartbeat.
Beta blockers
Take on an empty stomach; food, especially meat, increases the drug's effects and can cause dizziness and low blood pressure.
Digitalis
Avoid taking with milk and high fiber foods, which reduce absorption, increases potassium loss.
Diuretics
Increase the risk of potassium deficiency.
Potassium sparing diuretics
Unless a doctor advises otherwise, don't take diuretics with potassium supplements or salt substitutes, which can cause potassium overload.
Thiazide diuretics
Increase the reaction to MSG.
Pseudoephedrine
Avoid caffeine, which increase feelings of anxiety and nervousness.
Theophylline
Charbroiled foods and high protein diet reduce absorption. Caffeine increases the risk of drug toxicity.
Cholestyramine
Increases the excretion of folate and vitamins A, D, E, and K.
Gemfibrozil
Avoid fatty foods, which decrease the drug's efficacy in lowering cholesterol.
Antacids
Interfere with the absorption of many minerals; for maximum benefit, take medication 1 hour after eating.
Cimetidine, Fanotidine, Sucralfate
Avoid high protein foods, caffeine, and other items that increase stomach acidity.
Oral contraceptives
Salty foods increase fluid retention. Drugs reduce the absorption of folate, vitamin B-6, and other nutrients; increase intake of foods high in these nutrients to avoid deficiencies.
Steroids
Salty foods increase fluid retention. Increase intake of foods high in calcium, vitamin K, potassium, and protein to avoid deficiencies.
Thyroid drugs
Iodine-rich foods lower the drug's efficacy.
Laxative Mineral Oils
Overuse can cause a deficiency of vitamins A, D, E, and K.
Painkillers
Aspirin and stronger non-steroidal anti-inflammatory drugs Always take with food to lower the risk of gastrointestinal irritation; avoid taking with alcohol, which increases the risk of bleeding. Frequent use of these drugs lowers the absorption of folate and vitamin C.
Codeine
Increase fiber and water intake to avoid constipation.
Benzodiazepines
Never take with alcohol. Caffeine increases anxiety and reduce drug's effectiveness.
Experts suggest that natural does not mean it is completely safe. Everything you put in your mouth has the potential to interact with something else. The medication that is taken by mouth travels through the digestive system in much the same way as food and herbs taken orally do. So, when a drug is mixed with food or another herb, each can alter the way the body metabolizes the other. Some drugs interfere with the body's ability to absorb nutrients. Similarly, some herbs and foods can lessen or increase the impact of a drug.
Alcohol is a drug that interacts with almost every medication, especially antidepressants and other drugs that affect the brain and nervous system.
Some dietary components increase the risk of side effects. Theophylline, a medication administered to treat asthma, contains xanthines, which are also found in tea, coffee, chocolate, and other sources of caffeine. Consuming large amounts of these substances while taking theophylline increases the risk of drug toxicity.
Certain vitamins and minerals impact on medications too. Large amounts of broccoli, spinach, and other green leafy vegetables high in vitamin K, which promotes the formation of blood clots, can counteract the effects of heparin, warfarin, and other drugs given to prevent clotting.
Dietary fiber also affects drug absorption. Pectin and other soluble fibers slow down the absorption of acetaminophen, a popular painkiller. Bran and other insoluble fibers have a similar effect on digoxin, a major heart medication.
As more and more people discover new herbs, there is more and more potential for the abuse of these herbs and the patients may end up in serious problems. High-risk patients, such as the elderly, patients taking three or more medications for chronic conditions, patients suffering from diabetes, hypertension, depression, high cholesterol or congestive heart failure, should be especially on the lookout for such side reactions.
The following are the examples of known interaction between popular herbs, foods, and prescription and over-the-counter drugs.
Hawthorn, touted as effective in reducing angina attacks by lowering blood pressure and cholesterol levels, should never be taken with Lanoxin (digoxin), the medication prescribed for most for heart ailments. The mix can lower your heart rate too much, causing blood to pool, bringing on possible heart failure.
Ginseng, according to research, can increase blood pressure, making it dangerous for those trying to keep their blood pressure under control. Ginseng, garlic or supplements containing ginger, when taken with the blood-thinning drug, Coumadin, can cause bleeding episodes. Coumadin is a very powerful drug that leaves little room for error, and patients taking it should never take any medication or otherwise before consulting a qualified health professional. In rare cases, ginseng may overstimulate resulting in insomnia. Consuming caffeine with ginseng increases the risk of overstimulation and gastrointestinal upset. Long tern use of ginseng may cause menstrual abnormalities and breast tenderness in some women. Ginseng is not recommended for pregnant or lactating women.
Garlic capsules combined with diabetes medication can cause a dangerous decrease in blood sugars. Some people who are sensitive to garlic may experience heartburn and flatulence. Garlic has anti-clotting properties. You should check with your doctor if you are taking anticoagulant drugs.
Goldenseal is used for coughs, stomach upsets, menstrual problems and even arthritis. However, the plant's active ingredient will raise blood pressure, complicating treatment for those taking antihypertensive medications, especially beta-blockers. For patients taking medication to control diabetes or kidney disease, this herb can cause dangerous electrolyte imbalance. High amount of consumption can lead to gastrointestinal distress and possible nervous system effects. Not recommended for pregnant or lactating women.
Feverfew, believed to be the natural remedy for migraine headaches, should never be taken with Imitrex or other migraine medications. It can result in the patient's heart rate and blood pressure to rise dangerous levels.
Guarana, an alternative remedy being used as a stimulant and diet aid, contains 3 percent to 5 percent more caffeine than a cup of coffee. So, if you are taking any medication that advises you against taking any drink with caffeine, you should avoid taking this stimulant. It may cause insomnia, trembling, anxiety, palpitations, urinary frequency, and hyperactivity. Avoid during pregnancy and lactation period. Long term use of Guarana may lead to decreased fertility, cardiovascular disease, and several forms of cancer.
Kava, a herb that has antianxiety, pain relieving, muscle relaxing and anticonvulsant effects, should not be taken together with substances that also act on the central nervous system, such as alcohol, barbiturates, anti depressants, and antipsychotic drugs.
St. John's Wort is a popular herb used for the treatment of mild depression.
The active ingredient of St. John's Wort is hypericin. Hypericin is believed to exert a similar influence on the brain as the monoamine oxidase (MAO) inhibitors such as the one in major antidepressants. Mixing MAO inhibitors with foods high in tyramine, an amino acid, produces one of the most dramatic and dangerous food-drug interactions. Symptoms, which can occur within minutes of ingesting such foods while taking an MAO inhibitor, include rapid rise in blood pressure, a severe headache, and perhaps collapse and even death. Foods high in tyramine include aged cheese, chicken liver, Chianti (and certain other red wines), yeast extracts, bologna (and other processed meats), dried or pickled fish, legumes, soy sauce, ale, and beer.
Some patients report that Saint Johns Wort caused excessive stimulation and sometimes dizziness, agitation and confusion when taken with other antidepressants or over-the-counter medications like Maximum Strength Dexatrim and Acutrim. It also caused their blood pressure to shoot up.
White Willow, an herb traditionally used for fever, headache, pain, and rheumatic complaints may lead to gastrointestinal irritation, if used for a long time. It exhibits similar reactions as aspirin (aspirin is derived from white willow). Long term use may lead to stomach ulcers.
Drug Interaction and Food
Drug interaction risk isn't limited to herbal supplements. Certain foods can interact with medications.
People taking digoxin should avoid Black licorice (which contains the ingredient glycyrhizin). Together, they can produce irregular heart rhythms and cardiac arrest; licorice and diuretics will produce dangerously low potassium levels, putting a patient at risk for numbing weakness, muscle pain and even paralysis. Licorice can also interact with blood pressure medication or any calcium channel blockers.
Aged cheese (brie, parmesan, cheddar and Roquefort), fava beans, sauerkraut, Italian green beans, some beers, red wine, pepperoni and overly ripe avocados should be avoided by people taking MAO antidepressants. The interaction can cause a potentially fatal rise in blood pressure.
And because Saint Johns Wort contains the same properties as these MAO antidepressants, it stands to reason that people ingesting the herb should avoid these same foods.
Grapefruit juice interacts with calcium channel blockers (including Calan, Procardia, Nifedipine, and Verapamil), cholesterol control medications, some psychiatric medications, estrogen, oral contraceptives and many allergy medications (Seldane, Hismanal). The juice modifies the body's way of metabolizing the medication, affecting the liver's ability to work the drug through a person's system. More Information.
Orange juice shouldn't be consumed with antacids containing aluminum. 'The juice increases the absorption of the aluminum. Orange Juice and milk should be avoided when taking antibiotics. The juice's acidity decreases the effectiveness of antibiotics, as does milk.
Milk also doesn't mix with laxatives containing bisacodyl (Correctol and Dulcolax). You might find the laxative works a little "too well" in the morning.
Large amounts of oatmeal and other high-fiber cereals should not be eaten when taking digoxin. The fiber can interfere with the absorption of the drug, making the act of swallowing the pill a waste of time.
However, don't stop eating your cereal right away, because that could cause digoxin levels in your system to soar to toxic levels. A professional should make the dietary changes after carefully examining the digoxin levels.
Leafy green vegetables, high in vitamin K, should not be taken in great quantities while taking Coumadin. These vegetables could totally negate the affects of the drug and cause blood clotting.
Caffeinated beverages and asthma drugs taken together can cause excessive excitability. Those taking Tagament (Simetidine), quinolone antibiotics (Cipro, Penetrex, Noroxin) and even oral contraceptives should be aware these drugs may cause their cup of coffee to give them more of a Java jolt than they expected.
Grilled meat can lead to problems for those on asthma medications containing theophyllines. The chemical compounds formed when meat is grilled somehow prevent this type of medication from working effectively, increasing the possibility of an unmanageable asthma attack.
Regularly consuming a diet high in fat while taking anti-inflammatory and arthritis medications can cause kidney damage and can leave the patient feeling, drowsy and sedated.
Alcoholic beverages tend to increase the depressive effects of medications such as benzodiazepines, antihistamines, antidepressants, antipsychotics, muscle relaxants, narcotics, or any drug with sedative actions.
It's a good idea to not consume any alcoholic beverages, or at least scale way back, when taking prescription medications. Antioxidant and beta-carotene intensify alcohol's effect on the liver.
Other commonly used over-the-counter medications can cause interaction problems also.
Aspirin can modify the effectiveness of arthritis medications, strong prescription steroids and diuretics. Combining aspirin with diabetic medications can drop blood sugars to dangerous levels. Aspirin can also cause toxicity when taken with glaucoma and anticonvulsant (anti-seizure) drugs and cause bleeding episodes when combined with a blood thinner, like Coumadin.
Acetaminophen can also cause interaction complications when overused. Heavy drinkers who take acetaminophen for hangover relief risk liver damage. Taking high doses of acetaminophen with Coumadin can cause bleeding episodes.
Antacids taken with antibiotics, heart and blood pressure or thyroid medications can decrease drug absorption by up to 90 percent.
Over-the-counter antihistamines - sold under the names Actifed, Theraflu, Dimetapp, Benadryl and Comtrex should be avoided if you are taking antianxiety or antidepressant medications.
Oral contraceptives are less effective when taken with barbiturates, antibiotics, anti-fungal or tuberculosis drugs.
Turnips contain two goitrogenic substances, progoitrin and gluconasturtin, which can interfere with the thyroid gland's ability to make its hormones. Although moderate consumption of goitrogens is not a hazard for healthy people, they can promote development of a goiter (an enlarged thyroid) in persons with thyroid disease.
Tomato contains small quantities of a toxic substance known as solanine that may trigger headaches in susceptible people. They are also a relatively common cause of allergies. An unidentified substance in tomatoes and tomato-based products can cause acid reflux, leading to indigestion and heartburn. Individuals who often have digestive upsets should try eliminating tomatoes for 2 to 3 weeks to see if there is any improvement.
Strawberries, Raspberries, Spinach, and Rhubarb: These contain oxalic acid, which can aggravate kidney and bladder stones in susceptible people, and reduce body's ability to absorb iron and calcium.
Raspberries contain a natural salicylate that can cause an allergic reaction in aspirin sensitive people.
The seeds from fruits such as Apple, apricot, and Quinces contain amygdalin, a compound that turns into Hydrogen Cyanide in the stomach. Eating large amount of seeds can result in cyanide poisoning.
Potatoes: Avoid potatoes with a green tint to the skin, and remove any sprouts; they will taste bitter and may contain solanine, a toxic substance that can cause diarrhea, cramps, and fatigue.
Plums, Peaches, Apricots, and Cherries: These fruits may produce allergic reaction in individuals with confirmed allergies to apricots, almonds, peaches, and cherries. People who are allergic to aspirin may also encounter problems after they have eaten plums or peaches as they contain salicylates. The pits of plums, peaches and apricots contain a compound called amygdalin. When consumed in large amounts, amygdalin breaks down into hydrogen cyanide, a poison.
Horseradish: Very high doses of horseradish can cause vomiting or excessive sweating. Avoid if you have hypothyroidism.
Turmeric: Should be avoided by persons with symptoms from gallstones.
The drug food interaction is summarized below.
Cephalosporins, penicillin
Take on an empty stomach to speed absorption of the drugs.
Erythromycin
Don't take with fruit juice or wine, which decrease the drug's effectiveness.
Sulfa drugs
Increase the risk of Vitamin B-12 deficiency
Tetracycline
Dairy products reduce the drug's effectiveness. Lowers Vitamin C absorption
Dilantin, phenobarbital
Increase the risk of anemia and nerve problems due to deficiency of folalte and other B vitamins.
Fluoxetine
Reduce appetite and can lead to excessive weight loss
Lithium
A low-salt diet increases the risk of lithium toxicity; excessive salt reduces the drug's efficacy
MAO Inhibitors
Foods high in tyramine (aged cheeses, processed meats, legumes, wine, beer, among others) can bring on a hypertensive crisis.
Tricyclics
Many foods, especially legumes, meat, fish, and foods high in Vitamin C, reduce absorption of the drugs.
ACE inhibitors
Take on an empty stomach to improve the absorption of the drugs.
Alpha blockers
Take with liquid or food to avoid excessive drop in blood pressure.
Antiarrhythmic drugs
Avoid caffeine, which increases the risk of irregular heartbeat.
Beta blockers
Take on an empty stomach; food, especially meat, increases the drug's effects and can cause dizziness and low blood pressure.
Digitalis
Avoid taking with milk and high fiber foods, which reduce absorption, increases potassium loss.
Diuretics
Increase the risk of potassium deficiency.
Potassium sparing diuretics
Unless a doctor advises otherwise, don't take diuretics with potassium supplements or salt substitutes, which can cause potassium overload.
Thiazide diuretics
Increase the reaction to MSG.
Pseudoephedrine
Avoid caffeine, which increase feelings of anxiety and nervousness.
Theophylline
Charbroiled foods and high protein diet reduce absorption. Caffeine increases the risk of drug toxicity.
Cholestyramine
Increases the excretion of folate and vitamins A, D, E, and K.
Gemfibrozil
Avoid fatty foods, which decrease the drug's efficacy in lowering cholesterol.
Antacids
Interfere with the absorption of many minerals; for maximum benefit, take medication 1 hour after eating.
Cimetidine, Fanotidine, Sucralfate
Avoid high protein foods, caffeine, and other items that increase stomach acidity.
Oral contraceptives
Salty foods increase fluid retention. Drugs reduce the absorption of folate, vitamin B-6, and other nutrients; increase intake of foods high in these nutrients to avoid deficiencies.
Steroids
Salty foods increase fluid retention. Increase intake of foods high in calcium, vitamin K, potassium, and protein to avoid deficiencies.
Thyroid drugs
Iodine-rich foods lower the drug's efficacy.
Laxative Mineral Oils
Overuse can cause a deficiency of vitamins A, D, E, and K.
Painkillers
Aspirin and stronger non-steroidal anti-inflammatory drugs Always take with food to lower the risk of gastrointestinal irritation; avoid taking with alcohol, which increases the risk of bleeding. Frequent use of these drugs lowers the absorption of folate and vitamin C.
Codeine
Increase fiber and water intake to avoid constipation.
Benzodiazepines
Never take with alcohol. Caffeine increases anxiety and reduce drug's effectiveness.
Medicines and Food
Almost every patient and some doctors have this doubt: When should a particular medicine be taken? Before, With or After Food. This blog attempts to clear the fog.
Food can affect some medicines. Therefore often your medicine label may note "take with food", "take on an empty stomach" or "take half an hour before food". For many medicines that you take every day it is best to take them at the same time in relation to food every day.
Common instructions about medicines and foods and usual explanations are as follows:
Take with food
In most cases the medicine can be taken during the meal or immediately after the meal. There may be two reasons for this instruction, either the medicine can cause a stomach upset if you take it without food (e.g. doxycycline, Augmentin), or food will make the medicine be absorbed better into the body (e.g. griseofulvin)
Take after food
This may be for the same reasons as take with food. In the case of Gaviscon, it is used after food so that it works better to stop the food coming up from the stomach into the oesophagus (gullet).
Take on an empty stomach
In most cases the medicine should be taken at least two hours after the last time you ate and at least one hour before you are going to eat again. Examples include flucloxacillin, and antibiotic that doesn't work nearly as well if you have it with food, and etidronate.
For some medicines even the smallest amount of food in the stomach greatly reduces the amount of medicine that passes into the bloodstream. A group of medicines called bisphosphonates, used to treat conditions such as osteoporosis, are a particular problem. They include: alendronate, clodronate, etidronate and risedronate.
For medicines that must be taken on an empty stomach so that they pass into the bloodstream properly, you should choose times of the day that are convenient to you. Before breakfast is ideal for once daily medicines, but other good times include mid-morning, mid-afternoon and last thing at night. Bisphosphonate medicines (see above) should not be taken at bedtime.
This instruction is because the medicine is not absorbed as well by the body if you have much food in your stomach. In some cases the medicine may bind with something in the food. In other cases there is a special coating (enteric coating) on the tablet that does not dissolve until it gets into the intestine, so if you take the medicine with a big meal it can take many hours to start working (e.g. anti-inflammatories with an enteric coating).
Medicines generally work faster if taken on an empty stomach, so some pain relievers may be recommended to be taken before food.
Do not take grapefruit or grapefruit juice while taking medicine. In the last couple of years grapefruit have been found to alter the levels of some medicines in the body. In some cases the amount of the medicine in the blood can be increased by as much as 16 times the usual amount. So, if this instruction is on the label of your medicine you are best to avoid grapefruit and grapefruit juice completely.
Enzymes in the wall of the gut change some medicines on the way through into the bloodstream, making them less active. Grapefruit juice blocks these enzymes so medicines that would normally be changed instead arrive intact in the bloodstream in greater amounts than expected.
Avoid certain foods with certain medicines
Monoamine oxidase inhibitors such as tranylcypromine (Parnate) or phenelzine (Nardil) have special instructions with respect to foods. Many foods need to be avoided including cheese, sour cream, yeast and meat extracts, liver, sherry, beer (even non-alcoholic), red wine, avocados, chocolate, soy beans, broad bean pods, meals prepared with tenderisers, pickled fish, canned figs. Your pharmacist or doctor will be able to give you a more complete list.
Do not take antacids that contain magnesium or aluminum (e.g., Gelusil), the ulcer medicine sucralfate (Sucrafil), or vitamin or mineral supplements that contain iron or zinc for a minimum of 2 hours before or 2 hours after a dose of medicine. Taking antacids, sucralfate, or vitamin or mineral supplements too close to a dose of medicine can greatly decrease the effects of the medicine.
Common medicines taken with food
Common medicines taken on an empty stomach
Examples of medicines that don't mix well with grapefruit juice
Food can affect some medicines. Therefore often your medicine label may note "take with food", "take on an empty stomach" or "take half an hour before food". For many medicines that you take every day it is best to take them at the same time in relation to food every day.
Common instructions about medicines and foods and usual explanations are as follows:
Take with food
In most cases the medicine can be taken during the meal or immediately after the meal. There may be two reasons for this instruction, either the medicine can cause a stomach upset if you take it without food (e.g. doxycycline, Augmentin), or food will make the medicine be absorbed better into the body (e.g. griseofulvin)
Take after food
This may be for the same reasons as take with food. In the case of Gaviscon, it is used after food so that it works better to stop the food coming up from the stomach into the oesophagus (gullet).
Take on an empty stomach
In most cases the medicine should be taken at least two hours after the last time you ate and at least one hour before you are going to eat again. Examples include flucloxacillin, and antibiotic that doesn't work nearly as well if you have it with food, and etidronate.
For some medicines even the smallest amount of food in the stomach greatly reduces the amount of medicine that passes into the bloodstream. A group of medicines called bisphosphonates, used to treat conditions such as osteoporosis, are a particular problem. They include: alendronate, clodronate, etidronate and risedronate.
For medicines that must be taken on an empty stomach so that they pass into the bloodstream properly, you should choose times of the day that are convenient to you. Before breakfast is ideal for once daily medicines, but other good times include mid-morning, mid-afternoon and last thing at night. Bisphosphonate medicines (see above) should not be taken at bedtime.
This instruction is because the medicine is not absorbed as well by the body if you have much food in your stomach. In some cases the medicine may bind with something in the food. In other cases there is a special coating (enteric coating) on the tablet that does not dissolve until it gets into the intestine, so if you take the medicine with a big meal it can take many hours to start working (e.g. anti-inflammatories with an enteric coating).
Medicines generally work faster if taken on an empty stomach, so some pain relievers may be recommended to be taken before food.
Do not take grapefruit or grapefruit juice while taking medicine. In the last couple of years grapefruit have been found to alter the levels of some medicines in the body. In some cases the amount of the medicine in the blood can be increased by as much as 16 times the usual amount. So, if this instruction is on the label of your medicine you are best to avoid grapefruit and grapefruit juice completely.
Enzymes in the wall of the gut change some medicines on the way through into the bloodstream, making them less active. Grapefruit juice blocks these enzymes so medicines that would normally be changed instead arrive intact in the bloodstream in greater amounts than expected.
Avoid certain foods with certain medicines
Monoamine oxidase inhibitors such as tranylcypromine (Parnate) or phenelzine (Nardil) have special instructions with respect to foods. Many foods need to be avoided including cheese, sour cream, yeast and meat extracts, liver, sherry, beer (even non-alcoholic), red wine, avocados, chocolate, soy beans, broad bean pods, meals prepared with tenderisers, pickled fish, canned figs. Your pharmacist or doctor will be able to give you a more complete list.
Do not take antacids that contain magnesium or aluminum (e.g., Gelusil), the ulcer medicine sucralfate (Sucrafil), or vitamin or mineral supplements that contain iron or zinc for a minimum of 2 hours before or 2 hours after a dose of medicine. Taking antacids, sucralfate, or vitamin or mineral supplements too close to a dose of medicine can greatly decrease the effects of the medicine.
Common medicines taken with food
- Anti-diabetics such as glibenclamide and metformin
- Anti-inflammatories or NSAIDs (e.g. Voltaren, Naprosyn), unless enteric coated, or a quick effect is required.
- Steroids e.g. prednisone, prednisolone, hydrocortisone
- Adalat (nifedipine)
- Augmentin (amoxicillin + clavulanic acid)
- Aspirin in high doses
- Daonil (glibenclamide)
- Diamicron (gliclazide)
- Epilim (sodium valproate)
- EES (erythromycin ethyl succinate)
- Fergon (iron)
- Ferrogradumet (iron)
- Flagyl (metronidazole)
- Glucophage (metformin)
- Griseofulvin
- Lanoxin (digoxin)
- Lithicarb (lithium)
- Megostat (megestrol)
- Minidiab (glipizide)
- Mino-tabs (minocycline)
- Naprosyn (naproxen)
- Nifuran (nitrofurantoin)
- Nolvadex (tamoxifen)
- Nuelin (theophylline)
- Priadel (lithium)
- Roaccutane (isotretinoin)
- Salazopyrin (sulphasalazine)
- Slow K (potassium)
- Sporanox (itraconazole)
- Theo-dur (theophylline)
- Vermox (mebendazole)
- Vibra-tabs (doxycycline)
- Voltaren (diclofenac)
- Zinc
- Zyloprim (allopurinol)
Common medicines taken on an empty stomach
- Flucloxacillin
- Penicillamine
- Levothyroxine (thyroxine)
- Penicillin v phenoxymethylpenicillin)
- Oxytetracycline
- Bidanzen (serratio-peptidase)
- Capoten (captopril)
- Didronel (etidronate)
- ERA (erythromycin stearate)
- ERYC (erythromycin base)
- Floxapen (flucloxacillin)
- Norflox (norfloxacin)
- Omez (omeperazole)
- Rifampicin
- Selectol (celiprolol)
- Sucralfate
- Mebeverine
- Sodium cromoglicate
Examples of medicines that don't mix well with grapefruit juice
- Halcion (triazolam)
- Isoptin (verapamil)
- Plendil (felodipine)
- Prepulsid (cisapride)
- Zocor (simvastatin)
Thursday, September 29, 2005
Facts about Restless Legs Syndrome (RLS)
What Is Restless Legs Syndrome?
Restless legs syndrome (RLS) is a sleep disorder in which a person experiences unpleasant sensations in the legs described as creeping, crawling, tingling, pulling, or painful. These sensations usually occur in the calf area but may be felt anywhere from the thigh to the ankle. One or both legs may be affected; for some people, the sensations are also felt in the arms. These sensations occur when the person with RLS lies down or sits for prolonged periods of time, such as at a desk, riding in a car, or watching a movie. People with RLS describe an irresistible urge to move the legs when the sensations occur. Usually, moving the legs, walking, rubbing or massaging the legs, or doing knee bends can bring relief, at least briefly.
RLS symptoms worsen during periods of relaxation and decreased activity. RLS symptoms also tend to follow a set daily cycle, with the evening and night hours being more troublesome for RLS sufferers than the morning hours. People with RLS may find it difficult to relax and fall asleep because of their strong urge to walk or do other activities to relieve the sensations in their legs. Persons with RLS often sleep best toward the end of the night or during the morning hours. Because of less sleep at night, people with RLS may feel sleepy during the day on an occasional or regular basis. The severity of symptoms varies from night to night and over the years as well. For some individuals, there may be periods when RLS does not cause problems, but the symptoms usually return. Other people may experience severe symptoms daily.
Many people with RLS also have a related sleep disorder called periodic limb movements in sleep (PLMS). PLMS is characterized by involuntary jerking or bending leg movements during sleep that typically occur every 10 to 60 seconds. Some people may experience hundreds of such movements per night, which can wake them, disturb their sleep, and awaken bed partners. People who have RLS and PLMS have trouble both falling asleep and staying asleep and may experience extreme sleepiness during the day. As a result of problems both in sleeping and while awake, people with RLS may have difficulties with their job, social life, and recreational activities.
Some common symptoms of RLS include:
Other possible characteristics include:
What Causes It?
Although the cause is unknown in most cases, certain factors may be associated with RLS:
RLS occurs in both sexes. Symptoms can begin any time, but are usually more common and more severe among older people. Young people who experience symptoms of RLS are sometimes thought to have "growing pains" or may be considered "hyperactive" because they cannot easily sit still in school.
How Is It Diagnosed?
There is no laboratory test that can make a diagnosis of RLS and, when someone with RLS goes to see a doctor, there is usually nothing abnormal the doctor can see or detect on examination. Diagnosis therefore depends on what a person describes to the doctor. The history usually includes a description of the typical leg sensations that lead to an urge to move the legs or walk. These sensations are noted to worsen when the legs are at rest, for example, when sitting or lying down and during the evening and night. The person with RLS may complain about trouble sleeping or daytime sleepiness. In some cases, the bed partner will complain about the person's leg movements and jerking during the night.
To help make a diagnosis, the doctor may ask about all current and past medical problems, family history, and current medications. A complete physical and neurological exam may help identify other conditions that may be associated with RLS, such as nerve damage (neuropathy or a pinched nerve) or abnormalities in the blood vessels. Basic laboratory tests may be done to assess general health and to rule out anemia. Further studies depend on initial findings. In some cases, a doctor may suggest an overnight sleep study to determine whether PLMS or other sleep problems are present. In most people with RLS, no new medical problem will be discovered during the physical exam or on any tests, except the sleep study, which will detect PLMS if present.
How Is It Treated?
In mild cases of RLS, some people find that activities such as taking a hot bath, massaging the legs, using a heating pad or ice pack, exercising, and eliminating caffeine help alleviate symptoms. In more severe cases, medications are prescribed to control symptoms. Unfortunately, no one drug is effective for everyone with RLS. Individuals respond differently to medications based on the severity of symptoms, other medical conditions, and other medications being taken. A medication that is initially found to be effective may lose its effectiveness with nightly use; thus, it may be necessary to alternate between different categories of medication in order to keep symptoms under control.
Although many different drugs may help RLS, those most commonly used are found in the following three categories:
Although there is some potential for benzodiazepines and opioids to become habit forming, this usually does not occur with the dosages given to most RLS patients.
A nondrug approach called transcutaneous electric nerve stimulation may improve symptoms in some RLS sufferers who also have PLMS. The electrical stimulation is applied to an area of the legs or feet, usually before bedtime, for 15 to 30 minutes. This approach has been shown to be helpful in reducing nighttime leg jerking.
Due to recent advances, doctors today have a variety of means for treating RLS. However, no perfect treatment exists and there is much more to be learned about the treatments that currently seem to be successful.
Restless legs syndrome (RLS) is a sleep disorder in which a person experiences unpleasant sensations in the legs described as creeping, crawling, tingling, pulling, or painful. These sensations usually occur in the calf area but may be felt anywhere from the thigh to the ankle. One or both legs may be affected; for some people, the sensations are also felt in the arms. These sensations occur when the person with RLS lies down or sits for prolonged periods of time, such as at a desk, riding in a car, or watching a movie. People with RLS describe an irresistible urge to move the legs when the sensations occur. Usually, moving the legs, walking, rubbing or massaging the legs, or doing knee bends can bring relief, at least briefly.
RLS symptoms worsen during periods of relaxation and decreased activity. RLS symptoms also tend to follow a set daily cycle, with the evening and night hours being more troublesome for RLS sufferers than the morning hours. People with RLS may find it difficult to relax and fall asleep because of their strong urge to walk or do other activities to relieve the sensations in their legs. Persons with RLS often sleep best toward the end of the night or during the morning hours. Because of less sleep at night, people with RLS may feel sleepy during the day on an occasional or regular basis. The severity of symptoms varies from night to night and over the years as well. For some individuals, there may be periods when RLS does not cause problems, but the symptoms usually return. Other people may experience severe symptoms daily.
Many people with RLS also have a related sleep disorder called periodic limb movements in sleep (PLMS). PLMS is characterized by involuntary jerking or bending leg movements during sleep that typically occur every 10 to 60 seconds. Some people may experience hundreds of such movements per night, which can wake them, disturb their sleep, and awaken bed partners. People who have RLS and PLMS have trouble both falling asleep and staying asleep and may experience extreme sleepiness during the day. As a result of problems both in sleeping and while awake, people with RLS may have difficulties with their job, social life, and recreational activities.
Some common symptoms of RLS include:
- Unpleasant sensations in the legs (sometimes the arms as well), often described as creeping, crawling, tingling, pulling, or painful;
- Leg sensations are relieved by walking, stretching, knee bends, massage, or hot or cold baths;
- Leg discomfort occurs when lying down or sitting for prolonged periods of time;
- The symptoms are worse in the evening and during the night.
Other possible characteristics include:
- Involuntary leg (and occasionally arm) movements while asleep;
- Difficulty falling asleep or staying asleep;
- Sleepiness or fatigue during the daytime;
- Cause of the leg discomfort not detected by medical tests;
- Family members with similar symptoms.
What Causes It?
Although the cause is unknown in most cases, certain factors may be associated with RLS:
- Family history. RLS is known to run in some families--parents may pass the condition on to their children.
- Pregnancy. Some women experience RLS during pregnancy, especially in the last months. The symptoms usually disappear after delivery.
- Low iron levels or anemia. Persons with these conditions may be prone to developing RLS. The symptoms may improve once the iron level or anemia is corrected.
- Chronic diseases. Kidney failure quite often leads to RLS. Other chronic diseases such as diabetes, rheumatoid arthritis, and peripheral neuropathy may also be associated with RLS.
- Caffeine intake. Decreasing caffeine consumption may improve symptoms.
RLS occurs in both sexes. Symptoms can begin any time, but are usually more common and more severe among older people. Young people who experience symptoms of RLS are sometimes thought to have "growing pains" or may be considered "hyperactive" because they cannot easily sit still in school.
How Is It Diagnosed?
There is no laboratory test that can make a diagnosis of RLS and, when someone with RLS goes to see a doctor, there is usually nothing abnormal the doctor can see or detect on examination. Diagnosis therefore depends on what a person describes to the doctor. The history usually includes a description of the typical leg sensations that lead to an urge to move the legs or walk. These sensations are noted to worsen when the legs are at rest, for example, when sitting or lying down and during the evening and night. The person with RLS may complain about trouble sleeping or daytime sleepiness. In some cases, the bed partner will complain about the person's leg movements and jerking during the night.
To help make a diagnosis, the doctor may ask about all current and past medical problems, family history, and current medications. A complete physical and neurological exam may help identify other conditions that may be associated with RLS, such as nerve damage (neuropathy or a pinched nerve) or abnormalities in the blood vessels. Basic laboratory tests may be done to assess general health and to rule out anemia. Further studies depend on initial findings. In some cases, a doctor may suggest an overnight sleep study to determine whether PLMS or other sleep problems are present. In most people with RLS, no new medical problem will be discovered during the physical exam or on any tests, except the sleep study, which will detect PLMS if present.
How Is It Treated?
In mild cases of RLS, some people find that activities such as taking a hot bath, massaging the legs, using a heating pad or ice pack, exercising, and eliminating caffeine help alleviate symptoms. In more severe cases, medications are prescribed to control symptoms. Unfortunately, no one drug is effective for everyone with RLS. Individuals respond differently to medications based on the severity of symptoms, other medical conditions, and other medications being taken. A medication that is initially found to be effective may lose its effectiveness with nightly use; thus, it may be necessary to alternate between different categories of medication in order to keep symptoms under control.
Although many different drugs may help RLS, those most commonly used are found in the following three categories:
- Benzodiazepines are central nervous system depressants that do not fully suppress RLS sensations or leg movements, but allow patients to obtain more sleep despite these problems. Some drugs in this group may result in daytime drowsiness. Benzodiazepines should not be used by people with sleep apnoea.
- Dopaminergic agents are drugs used to treat Parkinson's disease and are also effective for many people with RLS and PLMS. These medications have been shown to reduce RLS symptoms and nighttime leg movements.
- Opioids are pain-killing and relaxing drugs that can suppress RLS and PLMS in some people. These medications can sometimes help people with severe, unrelenting symptoms.
Although there is some potential for benzodiazepines and opioids to become habit forming, this usually does not occur with the dosages given to most RLS patients.
A nondrug approach called transcutaneous electric nerve stimulation may improve symptoms in some RLS sufferers who also have PLMS. The electrical stimulation is applied to an area of the legs or feet, usually before bedtime, for 15 to 30 minutes. This approach has been shown to be helpful in reducing nighttime leg jerking.
Due to recent advances, doctors today have a variety of means for treating RLS. However, no perfect treatment exists and there is much more to be learned about the treatments that currently seem to be successful.
Wednesday, September 28, 2005
The Great Indian IT boom!
This would give you an inkling of what people mean when they say IT is the in thing. If you are wondering what is that structure, it is 'supposed' to be a mobile ironing vehicle which has been parked for eons against the compound wall of a house. Does the landlord have his clothes ironed for free? ;)
Monday, September 26, 2005
Sunday outing!
It was the Baptism of Paul Rosario son of one of my close family friends. I would be understating if I said 'family friends', actually they are more than friends but family. The Holy Mass was at 11 am at the Fatima Church in East Tambaram. Mass was conducted by Rev. Fr. Peter, who is the maternal uncle of Vimal Raj, father of baptism-boy.Quite a few family members had attended the Mass and the delectable lunch which was served afterwards. Attending functions has not been my forte, but these days I seem to have changed my views on attending social/religious events. Ofcourse they help to bond with family and friends apart from giving us a break from the normal routine. A time to share experiences and views.
Hepatitis C: Prevalence, complications, management
Hepatitis C virus (HCV) infection is the most common blood-borne infection worldwide and an important health care problem (National Center for Health Statistics, 1996; National Institutes of Health, 1997), as it represents the leading indication for liver transplantation. Hepatitis C virus (HCV) is the major cause of transfusion non-A, non-B hepatitis and continues to be a major cause of human liver disease throughout the world. Approximately 20-30% of patients with chronic hepatitis C develop cirrhosis (Hoofnagle, 1997). The course of hepatitis C is variable among individuals, but it eventually can lead to chronic hepatitis, decompensated cirrhosis, and hepatocellular carcinoma.
The prevalence of HCV around the world ranges from 0.4 to 2%. Hepatitis C is gradually being recognised as a major health problem even in developing countries. Among Indian blood donors, the seroprevalence varies from 0.48% in Vellore, TN to 1.85% in New Delhi. Although it is not well established, hepatitis-C infections do not easily take place through the sexual route and is therefore regarded as a problem confined largely to drug injectors.
Researchers in India have identified, for the first time, two patients with chronic liver disease - a 46-year-old man and a 52-year-old woman, both from eastern India - who were found to be infected with hepatitis C virus genotype 6 strains. These strains have been previously reported only from Hong Kong and Southeast Asia.
Magnitude of hepatitis C virus infection in India: Prevalence in healthy blood donors, acute and chronic liver diseases. Link
Several advances in the management of chronic HCV infection have occurred in the last decade. More recent research has propelled a shift from interferon alfa monotherapy to combination therapy with pegylated interferon (peginterferon) and ribavirin as the standard treatment for chronic hepatitis C. Numerous clinical studies and review articles have been published in the recent literature, the aim of which is to investigate the efficacy of peginterferon versus standard interferon as monotherapy and combination therapy with ribavirin. Clearly defining the terminology of the treatment endpoints to better understand the clinical findings in these studies is important. An earlier review article used the following definitions:
* End-of-treatment response occurs on the basis of having no detectable HCV RNA (virologic response) at the end of the treatment.
* Sustained response occurs based on reference range ALT levels and no detectable HCV RNA at the end of the treatment and throughout the observation period after stopping the therapy. Sustained virologic response (SVR) is defined as the absence of detectable HCV RNA 24 weeks after cessation of therapy.
* Nonresponse to treatment is when ALT levels remain abnormal at all time points evaluated during the study period or ALT levels become elevated (or HCV RNA appears) after having been in the reference range (or having no detectable HCV RNA) on treatment.
* A histologic response is defined as a reduction in the Knodell score of 2 or more points compared to the baseline (Lindsay, 1997).
Future targets of therapy
Combining peginterferons with ribavirin considerably improves efficacy but at the expense of poor tolerability attributable to ribavirin, and a significant proportion of patients in these trials did not respond to treatment. Given the significant adverse effects attributed to interferon-ribavirin therapy, patients need to be screened carefully to assess their candidacy for this therapy. Future therapeutic developments may include 1 or more of the following approaches: understanding the HCV genomic organization, elucidating the viral life cycle and HCV replication strategy, and understanding the immune mechanisms required for viral propagation or infectivity (Sookoian, 2003). Therapies under development and evaluation for patients with hepatitis C include adjunctive use of the antiviral agent amantadine and the immunomodulatory agent thymalfasin as well as novel small molecules, which include the ribavirin analogs, viramidine and levovirin, and BILN 2061, an inhibitor of HCV serine protease (Foster, 2004).
The prevalence of HCV around the world ranges from 0.4 to 2%. Hepatitis C is gradually being recognised as a major health problem even in developing countries. Among Indian blood donors, the seroprevalence varies from 0.48% in Vellore, TN to 1.85% in New Delhi. Although it is not well established, hepatitis-C infections do not easily take place through the sexual route and is therefore regarded as a problem confined largely to drug injectors.
Researchers in India have identified, for the first time, two patients with chronic liver disease - a 46-year-old man and a 52-year-old woman, both from eastern India - who were found to be infected with hepatitis C virus genotype 6 strains. These strains have been previously reported only from Hong Kong and Southeast Asia.
Magnitude of hepatitis C virus infection in India: Prevalence in healthy blood donors, acute and chronic liver diseases. Link
Several advances in the management of chronic HCV infection have occurred in the last decade. More recent research has propelled a shift from interferon alfa monotherapy to combination therapy with pegylated interferon (peginterferon) and ribavirin as the standard treatment for chronic hepatitis C. Numerous clinical studies and review articles have been published in the recent literature, the aim of which is to investigate the efficacy of peginterferon versus standard interferon as monotherapy and combination therapy with ribavirin. Clearly defining the terminology of the treatment endpoints to better understand the clinical findings in these studies is important. An earlier review article used the following definitions:
* End-of-treatment response occurs on the basis of having no detectable HCV RNA (virologic response) at the end of the treatment.
* Sustained response occurs based on reference range ALT levels and no detectable HCV RNA at the end of the treatment and throughout the observation period after stopping the therapy. Sustained virologic response (SVR) is defined as the absence of detectable HCV RNA 24 weeks after cessation of therapy.
* Nonresponse to treatment is when ALT levels remain abnormal at all time points evaluated during the study period or ALT levels become elevated (or HCV RNA appears) after having been in the reference range (or having no detectable HCV RNA) on treatment.
* A histologic response is defined as a reduction in the Knodell score of 2 or more points compared to the baseline (Lindsay, 1997).
Future targets of therapy
Combining peginterferons with ribavirin considerably improves efficacy but at the expense of poor tolerability attributable to ribavirin, and a significant proportion of patients in these trials did not respond to treatment. Given the significant adverse effects attributed to interferon-ribavirin therapy, patients need to be screened carefully to assess their candidacy for this therapy. Future therapeutic developments may include 1 or more of the following approaches: understanding the HCV genomic organization, elucidating the viral life cycle and HCV replication strategy, and understanding the immune mechanisms required for viral propagation or infectivity (Sookoian, 2003). Therapies under development and evaluation for patients with hepatitis C include adjunctive use of the antiviral agent amantadine and the immunomodulatory agent thymalfasin as well as novel small molecules, which include the ribavirin analogs, viramidine and levovirin, and BILN 2061, an inhibitor of HCV serine protease (Foster, 2004).
Lipoprotein(a) and cardiovascular disease
Lipoprotein(a) (Lp[a]) is an atherogenic lipoprotein that consists of LDL-C (ie, cholesterol, phospholipids, and apolipoprotein B-100) linked covalently by a disulfide bond to apolipoprotein(a). Apolipoprotein(a) is homologous to plasminogen, a proenzyme promoting clot lysis. Unlike plasminogen, apolipoprotein(a) promotes thrombosis by competitive inhibition of plasminogen. Lp(a) binds to endothelial cells, monocytes, and macrophages. It is believed to provide the link between thrombosis and atherosclerosis.
The level of Lp(a) is unrelated to the level of other lipoproteins or apolipoproteins. Lp(a) levels are genetically determined. The actual level is a function of synthesis in the liver rather than of degradation or catabolism. Lp(a) levels are decreased in chronic liver disease and increased in end-stage renal disease, hypothyroidism, and acromegaly. Both testosterone and estrogen decrease Lp(a) levels. Furthermore, Lp(a) is an acute-phase reactant, increasing after an acute event.
Population studies have shown a skewed distribution among white and Asian populations. African Americans have a normal distribution of Lp(a) levels; however, plasma levels are 2-4 times higher than in whites. Lp(a) does not appear to convey the same risk of coronary artery disease (CAD) as among whites. Increased levels of Lp(a) have been associated with increased risk of CAD among South Asians.
Risks of Lp(a)
The literature on the risk of Lp(a) is not always concordant. However, a meta-analysis of 27 prospective studies with a mean follow-up period of 10 years showed that patients with Lp(a) levels in the upper tertile had a 70% increased risk of coronary heart disease (CHD).
Using a nested case-control design, the Lipid Research Clinics Coronary Primary Prevention Trial reported that an elevated Lp(a) level was an independent risk factor for CHD during a follow-up period of 7-10 years. In contrast, in the Physicians’ Health Study, using a nested case-control design, Lp(a) levels did not predict future myocardial infarction after 60 months.
The Framingham Heart Study reported an 11.4% prevalence of Lp(a) levels greater than 30 mg/dL in the cohort population. Lp(a) was an independent risk factor for CHD events among men aged 55 years or younger. The attributable risk of 9.3% was similar to a total cholesterol level of 240 mg/dL or higher (10.3%) or an HDL-C level of less than 35 mg/dL (10.3%).
In a Swedish study of 1216 patients with established coronary disease, an Lp(a) level of 30 mg/dL or greater was present in 30% of the population and found to be an independent predictor of death over a mean follow-up period of 6.7 years. Other predictors of death included a high fibrinogen level, a low antithrombin III level, depressed left ventricular function, and a high coronary obstruction score.
To assess the predictive role of Lp(a) in the Cardiovascular Health Study, 3972 ambulatory men and women aged 65 years or older who were free of cardiovascular disease were monitored for 7.4 years. For men only, elevated levels of Lp(a) were associated with a 2.92 times increased risk of stroke, a 2.09 times increased risk of death due to vascular diseases, and a 1.60 times increased risk of all-cause mortality.
Children who have an Lp(a) level of 30 mg/dL or greater are more likely to have a parental history of heart attack or angina before age 50 years.
The Familial Atherosclerosis Treatment Study examined 146 men aged 62 years or younger with known CAD and apolipoprotein B levels of 125 mg/dL or higher. Baseline coronary disease severity, its progression, and events over a 2.5-year period were best correlated with Lp(a) levels. However, once LDL-C levels were lowered, Lp(a) was not as predictive for atherogenic outcomes.
In the Prospective Cardiovascular Münster Study, men with Lp(a) levels of 20 mg/dL or greater were shown to have 2.7 times more cardiovascular events over a 10-year period compared to men with lower levels. The risk was magnified in concert with other risk factors, including a high LDL-C, low HDL-C, and hypertension.
Elevated levels of Lp(a) are associated with other risks as well:
* Saphenous vein graft stenosis after coronary bypass surgery is related to Lp(a). With a level of 31.6 mg/dL, 92% of patients developed vein graft stenosis.
* An elevated Lp(a) level has been shown to be a risk factor for venous thromboembolism.
* An interaction between elevated levels of Lp(a) and factor V Leiden, protein C deficiency, antithrombin deficiency, and hyperhomocystinemia seems to exist.
* Lp(a) levels of greater than 30 mg/dL are associated with an increased risk of atherosclerotic cardiovascular disease.
Clinical guidelines
Rather than being viewed as a major risk factor, Lp(a) is considered an “emerging” risk factor for cardiovascular disease by the Adult Treatment Panel (ATP) III; thus, routine measurement is not advocated. The ATP III recognized that a high Lp(a) level could count as a second risk factor, justifying a lower goal for LDL-C levels, although that was considered a controversial approach.
Recommendations for assessment of Lp(a)
Measurement of Lp(a) levels should be reserved for persons with a strong family history of premature CAD and those with genetic causes of hypercholesterolemia. Consider measuring levels in patients with a normal lipid profile and established CAD.
Lp(a) is not stable at room temperature; thus, an analysis should be immediately performed or centrifuged and frozen for later determination. Measurement of Lp(a) is performed using immunologic methods, and assays for measurement of Lp(a) levels are variable. Since accurate methodology is not available in most clinical chemistry laboratories, samples must generally be sent to special laboratories.
In general, dietary interventions and exercise are ineffective in reducing Lp(a) levels. However, increased fish, almond, and red wine consumption appears to be modestly effective. Statins have been reported to have variable effects on Lp(a). Nicotinic acid in doses of 3-4 g daily can also lower Lp(a) levels as much as 30%. However, whether niacin reduces the associated risks is unknown. Both tamoxifen and estrogen lower Lp(a) levels. LDL apheresis is considered the most effective means to lower Lp(a) levels as much as 50%.
The level of Lp(a) is unrelated to the level of other lipoproteins or apolipoproteins. Lp(a) levels are genetically determined. The actual level is a function of synthesis in the liver rather than of degradation or catabolism. Lp(a) levels are decreased in chronic liver disease and increased in end-stage renal disease, hypothyroidism, and acromegaly. Both testosterone and estrogen decrease Lp(a) levels. Furthermore, Lp(a) is an acute-phase reactant, increasing after an acute event.
Population studies have shown a skewed distribution among white and Asian populations. African Americans have a normal distribution of Lp(a) levels; however, plasma levels are 2-4 times higher than in whites. Lp(a) does not appear to convey the same risk of coronary artery disease (CAD) as among whites. Increased levels of Lp(a) have been associated with increased risk of CAD among South Asians.
Risks of Lp(a)
The literature on the risk of Lp(a) is not always concordant. However, a meta-analysis of 27 prospective studies with a mean follow-up period of 10 years showed that patients with Lp(a) levels in the upper tertile had a 70% increased risk of coronary heart disease (CHD).
Using a nested case-control design, the Lipid Research Clinics Coronary Primary Prevention Trial reported that an elevated Lp(a) level was an independent risk factor for CHD during a follow-up period of 7-10 years. In contrast, in the Physicians’ Health Study, using a nested case-control design, Lp(a) levels did not predict future myocardial infarction after 60 months.
The Framingham Heart Study reported an 11.4% prevalence of Lp(a) levels greater than 30 mg/dL in the cohort population. Lp(a) was an independent risk factor for CHD events among men aged 55 years or younger. The attributable risk of 9.3% was similar to a total cholesterol level of 240 mg/dL or higher (10.3%) or an HDL-C level of less than 35 mg/dL (10.3%).
In a Swedish study of 1216 patients with established coronary disease, an Lp(a) level of 30 mg/dL or greater was present in 30% of the population and found to be an independent predictor of death over a mean follow-up period of 6.7 years. Other predictors of death included a high fibrinogen level, a low antithrombin III level, depressed left ventricular function, and a high coronary obstruction score.
To assess the predictive role of Lp(a) in the Cardiovascular Health Study, 3972 ambulatory men and women aged 65 years or older who were free of cardiovascular disease were monitored for 7.4 years. For men only, elevated levels of Lp(a) were associated with a 2.92 times increased risk of stroke, a 2.09 times increased risk of death due to vascular diseases, and a 1.60 times increased risk of all-cause mortality.
Children who have an Lp(a) level of 30 mg/dL or greater are more likely to have a parental history of heart attack or angina before age 50 years.
The Familial Atherosclerosis Treatment Study examined 146 men aged 62 years or younger with known CAD and apolipoprotein B levels of 125 mg/dL or higher. Baseline coronary disease severity, its progression, and events over a 2.5-year period were best correlated with Lp(a) levels. However, once LDL-C levels were lowered, Lp(a) was not as predictive for atherogenic outcomes.
In the Prospective Cardiovascular Münster Study, men with Lp(a) levels of 20 mg/dL or greater were shown to have 2.7 times more cardiovascular events over a 10-year period compared to men with lower levels. The risk was magnified in concert with other risk factors, including a high LDL-C, low HDL-C, and hypertension.
Elevated levels of Lp(a) are associated with other risks as well:
* Saphenous vein graft stenosis after coronary bypass surgery is related to Lp(a). With a level of 31.6 mg/dL, 92% of patients developed vein graft stenosis.
* An elevated Lp(a) level has been shown to be a risk factor for venous thromboembolism.
* An interaction between elevated levels of Lp(a) and factor V Leiden, protein C deficiency, antithrombin deficiency, and hyperhomocystinemia seems to exist.
* Lp(a) levels of greater than 30 mg/dL are associated with an increased risk of atherosclerotic cardiovascular disease.
Clinical guidelines
Rather than being viewed as a major risk factor, Lp(a) is considered an “emerging” risk factor for cardiovascular disease by the Adult Treatment Panel (ATP) III; thus, routine measurement is not advocated. The ATP III recognized that a high Lp(a) level could count as a second risk factor, justifying a lower goal for LDL-C levels, although that was considered a controversial approach.
Recommendations for assessment of Lp(a)
Measurement of Lp(a) levels should be reserved for persons with a strong family history of premature CAD and those with genetic causes of hypercholesterolemia. Consider measuring levels in patients with a normal lipid profile and established CAD.
Lp(a) is not stable at room temperature; thus, an analysis should be immediately performed or centrifuged and frozen for later determination. Measurement of Lp(a) is performed using immunologic methods, and assays for measurement of Lp(a) levels are variable. Since accurate methodology is not available in most clinical chemistry laboratories, samples must generally be sent to special laboratories.
In general, dietary interventions and exercise are ineffective in reducing Lp(a) levels. However, increased fish, almond, and red wine consumption appears to be modestly effective. Statins have been reported to have variable effects on Lp(a). Nicotinic acid in doses of 3-4 g daily can also lower Lp(a) levels as much as 30%. However, whether niacin reduces the associated risks is unknown. Both tamoxifen and estrogen lower Lp(a) levels. LDL apheresis is considered the most effective means to lower Lp(a) levels as much as 50%.
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