Penicillin

The Penicillium mold (fungus) was accidentally discovered by Alexander Fleming in his laboratory in 1928. The fungus produced pencillin which blocked the growth of Staphylococcus (a bacteria). Penicillium is important for the production of penicillin, an antibiotic.

Penicillin took a long time to come on the market. It was made available by the end of the Second World War (1945), and helped to save soldiers on the battle field from influenza (flu), who would otherwise die. Thus, penicillin was hailed as a saviour of the soldiers involved in the great war. More soldiers were returning after the war due to penicillin. Even postal boxes had penicillin posters draped them, with the words, 'Penicillin cures gonorrhea in 4 hours'.

While the initial green fungus (Penicillium notatum) was grown in petri dishes, the fungus grows well on orange skin. It also grows well on orange skin kept in the fridge and on stale bread. However, higher yields of penicillin comes from Penicillium chrysogenum grown on the flesh of cantaloupe (a fruit like a melon, with orange flesh).

Penicillin allergy is uncommon but people who have severe allergy to penicillin have severe itch after trying oral penicillin or died after being injected with penicillin. Doctors will always ask parents or patients before prescribing or administering penicillin. You should know whether you are allergic to penicillin or otherwise.

Commercial penicillin is produced by fermentation, which is done in batches using cultured media from microbial sources (not animal sources). Corn steep liquor is mixed with glucose (as carbon source) and first sterilised in tanks. The fungus is added to the fermentation tanks and produces penicillin as a natural secondary product (metabolite). The fungus is then separated from the penicillin (in the fermentation broth). The penicillin is then purified for use as medicine. The fungus is recycled to produce another batch of penicillin.

There was one poster which said, 'Try Penicillin. Made from mold, you can get this drug from your doctor or prepare it yourself'. It is alright to try and see Penicillium growth on orange skin and/or bread at home. However, care has to be taken not to contaminate other food kept at home or stored in the fridge. Care has also got to be taken not to breathe in the spores released from the fungus. If you can smell the fungus, the spores are already inside you! Keep your distance or use a face mask. Take pictures and destroy the fungus by burning it outside your home. Take precaution when you use fire.

External links:
https://botit.botany.wisc.edu/toms_fungi/nov2003.html
https://labmonk.com/fermentation-process-of-antibiotics
https://www.nlm.nih.gov/exhibition/fromdnatobeer/exhibition-interactive/illustrations/penicillin-alternative.html
https://www.slideshare.net/seetaram443/penicillins-53561419
https://www.slideshare.net/banuman35/penicillins-by-dr-panchumarthy-ravisankar-mpharm-phd

CKD Stage 3 and Ketosteril

Chronic Kidney Disease (CKD) Stage 3 is a renal condition with symptoms or asymptomatic, depending on severity.

1. reduced clearance of urea and creatinine from blood into urine. 
2. Blood urea and creatinine exceed normal levels. 
3. Urine output can be none, little (oliguria) or normal. 
4. The patient has uremia with nausea. 
5. The patient may feel lousy at times, 
6. tired at times, 
7. loss of appetite at times, and 
8. fatigued at times. 
9. Depression may begin to seep in as the patient learns of his/her worsening condition, while doctors try to figure out the best treatment regime for the patient's failing kidney(s) or renal function/system.

Protein intake becomes important in CKD. Controlling protein intake in the diet is not so easy to do. It is easier said than done in the home setting. A protein restricted diet (40 g protein/day) contains protein the size of a match-box. That is not much for a 70 kg patient. The patient will start feeling hungry very easily.

There are options which researchers have worked on.

1. Low protein intake
2. Restricted animal protein
3. Vegetarian protein
4. Vegetarianism

To reduce dietary protein intake and yet maintain amino acid metabolism, a ketoanalogue can be used.

1. Ketosteril is a ketoanalogue of creatinine. 
2. Ketosteril will reduce blood creatinine levels and save the kidney(s), giving the kidney(s) time to recover. However, CKD can still progress, but slower.
3. Ketosteril is prescribed for pre-dialysis stable CKD patients. 
4. It is prescribed for CKD Stage 5. 
5. However, it can be prescribed for stable CKD Stage 2 and Stage 3.

Use of Ketosteril comes with its dangers. There are safety guidelines for using Ketosteril. Some doctors will prescribe 2 tablets 3x a day. Without a doctor's prescription, patients may take more tablets per day. Refer to pharmacy.

Government hospitals and university hospitals do not supply Ketosteril FOC. Patients have to purchase Ketosteril on their own, from pharmacies. The cost varies widely, from RM250 to RM280 per 100 tablets.

External links

"Ketosteril® - Fresenius Kabi India." Fresenius-kabi.com. N. p., 2019. Web. 4 Mar. 2019.

Tzekov VD, et al. (2000). Low protein diet and ketosteril in predialysis patients with renal failure. Folia Med (Plovdiv). 2000;42(2):34-7. PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 March 2019, from https://www.ncbi.nlm.nih.gov/pubmed/11217281

J, B. (1984). Discovery and rediscovery of low protein diet. Clin Nephrol. 1984 Jan;21(1):29-35. PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 4 March 2019, from https://www.ncbi.nlm.nih.gov/pubmed/636806

Gluba-Brzózka, Anna, Beata Franczyk, and Jacek Rysz. "Vegetarian Diet In Chronic Kidney Disease—A Friend Or Foe." Nutrients 9.4 (2017): 374. Web. 4 Mar. 2019.

CT Urography

Each normal ureter is 25 cm long.

In hydronephrosis of the kidneys and ureters, there is inflammation of both kidneys and ureters. Inflammation of the kidneys may appear similar. However, the ureters maybe asymmetrically affected.

Two separate soft tissue masses can surround the ureters at two different locations along each ureter. The right soft tissue mass can surround the distal part of the ureter (about 4 cm). The left soft tissue mass can surround the proximal part of the ureter (about 4 cm).

The soft tissue mass may continue to grow and compress on the ureters and stop urine flow into the urinary bladder, leading to little or no urine. The patient may not suffer any pain (asymptomatic) in the beginning . However, later on, the patient may suffer great pain as renal conditions worsen.

There are 2 investigations to be done: CT Urography, and biopsy.

CT Urography is for evaluation of the ureters. The radiologist and urologist will investigate to find out the underlying cause(s):

1. Congenital abnormalities
2. Filling defects
3. Dilatation
4. Narrowing
5. Deviations in the course of urine flow and output

Biopsy is to investigate what the soft tissue mass is. Biopsy may show malignant (cancerous) growth. It maybe limited or have spread. The cytologist in Pathology will inform. Fine Needle Aspiration Biopsy (FNAB) involves aspirating a small volume of biopsy sample via a small keyhole made in the abdomen. Any biopsy is painful and will need anaesthesia.

Treatment is by surgical removal of the soft tissue masses surrounding the ureters.

The entire uterus may have to be removed too.

Radiotherapy, chemotherapy etc may be needed.


External links:

CT Urography for evaluation of the ureter
https://pubs.rsna.org/doi/full/10.1148/rg.2015140209

Retroperitoneal sarcoma of the ureters
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049017/pdf/cro-0007-0301.pdf

Soft tissue sarcomas of the kidneys
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387353/pdf/rt-2015-1-5635.pdf

Fibrosarcoma
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5732833/pdf/oncotarget-08-104638.pdf

Malignant soft tissue tumors
https://www.cedars-sinai.edu/Patients/Health-Conditions/Soft-Tissue-Tumors---Malignant.aspx

Urothelial Tumors of the Renal Pelvis and Ureters: Problem, Epidemiology, Etiology
https://emedicine.medscape.com/article/452449-overview#a5
https://emedicine.medscape.com/article/452449-overview#a7

Ureteral neoplasms
https://pubs.rsna.org/doi/pdf/10.1148/radiographics.10.2.2183298

Leiomyosarcoma of the distal ureter
https://www.um.edu.mt/umms/mmj/PDF/547.pdf

Kidney tumor > Renal pelvic tumors > Urothelial carcinoma of renal pelvis
http://www.pathologyoutlines.com/topic/kidneytumormalignanturothelialcarcinoma.html

Transitional cell carcinoma (TCC)
https://radiopaedia.org/articles/transitional-cell-carcinoma-ureter?lang=us

Infection and Antibiotics: Tazocin

I studied detailed bacterial structure in my fourth year of the undergraduate program It was thought by Dr Mina Hector, under Biochemistry. There were only two students. We read page by page. I still have my textbook.

Many soldiers and victims died as a result of infection and antibiotic was not yet discovered in the First World War (WW1). 

Penicillin was accidentally discovered by a Scottish bacteriologist, Alexander Fleming, on 28 September 1928 at the St Mary's Hospital in London, England. He returned from vacation and noticed a green mold, Penicillium notatum, from orange peel had contaminated his petri dishes of Staphylococcus. 

Penicillin was made available when the Second World War (WW2) almost came to a close. It helped to save many lives. Sir Alexander Fleming was bestowed the Nobel Prize in Physiology or Medicine in 1945. His laboratory is being preserved. 

The discovery of Penicillin triggered the Antibiotic Era. Many other antibiotics were then isolated, studied and produced in various laboratories by many nations.

Tazocin is an antibiotic manufactured and marketed by Pfizer, UK and a few other companies in the 1990s. Its active ingredients are sodium piperacillin and sodium tazobactam.

Tazocin is used for treating infections and septicaemia in the intensive care unit (ICU) and hospital wards. It works well for both Gram positive (Gram +) and Gram negative (Gram -) bacterial infections. Pseudomonas aeruginosa is Gram -.

Pseudomonas lung infection has a characteristics odour and productive cough, initially brown sputum and subsequently thick white sputum.  Sputum culture & sensitivity (C&S) will provide Pseudomonas aeruginosa isolate.

Sputum C&S

Tazocin is used for treating patients with severe Pseudomonas lung infection, with complicated renal infection.  Tazocin is administered intravenously (i.v.).

There are 2 types of vial packing:
Each vial of Tazocin 2 g / 0.25 g contains 5.67 mmol (130 mg) of sodium.
Each vial of Tazocin 4 g / 0.5 g contains 11.35 mmol (261 mg) of sodium.

The usual dose is 4 g piperacillin / 0.5 g tazobactam given every 8 hours (8 hourly).
For nosocomial pneumonia and bacterial infections, the recommended dose is 4 g piperacillin / 0.5 g tazobactam administered every 6 hours (6 hourly).

For renal patients, creatinine is determined and creatinine clearance calculated. Tazocin dose is reduced and administered 6 hourly. Tazocin (6 hourly is given i.v. within 30 minutes) for 5 days in renal impairment (obstructive uropathy).

Combined use of piperacillin/tazobactam and vancomycin may be associated with an increased incidence of acute kidney injury (AKI).

Intravenous Tazocin (2 g / 0.25 g) in saline 

External links

https://www.medicines.org.uk/emc/product/1267/smpc

https://www.medicines.org.uk/emc/files/pil.1267.pdf

National Center for Biotechnology Information. PubChem Compound Database; CID=23695841, https://pubchem.ncbi.nlm.nih.gov/compound/23695841 (accessed Feb. 9, 2019).

https://www.ncbi.nlm.nih.gov/pubmed/9017778

https://www.netdoctor.co.uk/medicines/infection/a7622/tazocin-piperacillin-and-tazobactam/

https://www.mims.com/malaysia/company/info/pfizer

Bronchopneumonia

Air travel is more affordable today compared to the 1950s and 1960s. As more people travel, they can carry bacteria, fungi and viruses from one place to another, infecting almost everyone on their travel route. Longer flights (5 hours to 15 or 18 hours) will mean passengers will be in contact with carriers and breathing stale contaminated cabin air.

Aircrafts had the habit of spraying the entire cabin upon flight landing, leaving passengers on board to breathe whatever insecticide and bacteriocide they wish to spray cabin air with. Passengers have no choice accept to breath whatever it is they are spraying. It feels humiliating having arrived at a port of call and being sprayed upon without knowing what is being sprayed.

A more intriguing thing is why aren't sick passengers removed to sick bay at the port of arrival? Why are sick passengers allowed to travel which coughing terribly on board and in that way, contaminate everyone and especially susceptible passengers who are otherwise healthy?

Forehead touchless thermometers are available today. Even this is not used to detect sick travellers who are spreading air-borne infection in-flight, and on long flights.

Chest infection may take some time to develop. Travellers appear healthy and happy for 2 weeks at their destination, but soon develop some of the worst chest infections in human air travel. Some have have died, and some have survived the ordeal of such a horrible air-borne traveller's disease.

There are many unanswered questions about air-borne diseases contracted by travellers. Who will take the challenge to stop air-borne travel infections from spreading? Who will pay for hospitalisation and medicine costs? Who will attend to the patients' recuperation, which is long and painful? Some hospitals will advise travellers to return to their original country and seek treatment at home. Some travellers fall ill and have no time to return home, and end up in hospital of a foreign country, with huge unpaid bills. Many cases involved student travels to visit friends, family travels to visit students at overseas institutions, and other reasons for travelling.

Insurance schemes and plans are available, but many do not honour their T&C. As such, students, family members and travellers are stuck with not knowing what to do. It is very frightening not knowing how to proceed when being overseas and facing a life/death health problem.

Not everyone has good immunity against all chest infections. Some do, most don't. There are vaccines which can assist if taken at the correct time before a trip. They do help to allay severe infections. Despite taking such steps, some will still fall victim to a new infection which can be fatal within a short time if no emergency treatment is given.

Bronchopneumonia is one of the worst of chest infections which can be picked up by air-travel. Others are tuberculosis (TB) and the flu (H1N1, SARS).

Airport securities and health authorities are only interested to curb H1N1 and SARS, even though they should look into bronchopneumonia and TB among all travellers.


External links

What is bronchopneumonia
https://www.medicalnewstoday.com/articles/323167.php

Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173892/pdf/crj-21-4-239.pdf

Hematoma from phlebotomy

Some people have small visible veins from which the nurse can obtain a blood specimen. Sometimes elderly patients have collapsed veins, making blood sampling difficult. In both cases, blood sampling is painful, even when using a fine gauge butterfly needle.

Sometimes many scars from old pricks can be seen on the arm. This should make the nurse aware of previous difficulties with blood sampling.

Even when the nurse tries to find the best blood vessel to prick, she may not be able to locate a good visible sufficiently big blood vessel to prick, and thus a small blood vessel has to be pricked to obtain a blood specimen. This can result in a painful pricking and possible hematoma.

This superficial hematoma is a visible blue-black patch beneath a fair skin complexion. It is not instantly visible, but becomes visible an hour or two after pricking or blood sampling. It is itchy and painful, even a day after blood taking. It still prevails and becomes less painful with time.

Clearance of the blue-black patch will take some time, as the macrophages clear cell and blood debris under the skin. It will clear entirely and the pain will disappear without treatment.

However, if the blue-black patch is very painful, bulging and expanding, then it is better to return to hospital and seek treatment.

External links

https://www.labce.com/spg549505_hematoma.aspx

https://library.med.utah.edu/WebPath/TUTORIAL/PHLEB/PHLEB.html

https://www.rxlist.com/hematoma/drugs-condition.htm

https://static1.squarespace.com/static/594ab51229687f2da30c9f34/t/5b55eb3903ce640becb0c22e/1532357437581/PHLEBOTOMY+BOOK.PDF