CT coronary Calcium score Test:

Coronary calcium scans use a special X-ray test called computed tomography (CT) to check for the buildup of calcium in plaque on the walls of the arteries of the heart (coronary arteries). Because calcifications are an early sign of CHD, a coronary calcium scan can show whether you're at risk for a heart attack or other heart problems before other signs and symptoms occur. Coronary calcium scans are also called cardiac calcium scoring.

Calcimax K2 in patients with high CT coronary calcium score

Beyond its role in blood clotting, recent research has revealed that vitamin K also plays a vital role in maintaining healthy bones and arteries by keeping calcium in the bones and out of the arteries.

• Insufficient vitamin K2 leads to decreased bone mineral density, a key factor in osteoporosis, and an excess of calcium in the arterial wall, which increases the risk of heart disease.
• Studies have also shown that even modest amounts of vitamin K2 fight heart disease by controlling calcium-regulating proteins in vascular tissue, which keeps calcium out of the arteries and prevents the formation of dangerous calcified plaques.

Vitamin K2 Protects Against Coronary Heart Disease

• Normal deposition of calcium occurs in two organs: bone and teeth. Abnormal deposition of calcium in the body occurs in three places: the inner lining of the arteries (the intima) where athero-sclerotic plaque accrues; the muscle layer of arteries (“medial calcification”); and heart valves. Vitamin K2 appears to be the form of vitamin K that contributes to controlling all of these phenomena.
• Higher intakes of vitamin K2 also corresponded to less calcium deposition in the aorta (an indirect measure of atherosclerosis), whereas participants who ingested less K2 were more likely to show moderate or severe calcification. The lowest risk of heart attack and aortic calcification was seen in participants who included more than 32.7 mcg a day of vitamin K2 in their diet.

1.      RED VEGETABLES: Tomatoes, peppers and beets conain the antioxidant lycopene. Lycopene also acts as a natural sun block, protecting the skin from damage while increasing collagen levels.

2.      DARK GREEN VEGETABLES: Rich in vitamin C, dark green vegetables like spinach and kale can rev up collagen production.

3.      BERRIES: Blackberries and raspberries scavenge free radicals while simultaneously increasing collagen levels.

4.      ORANGE VEGETABLES & Fruits: Vegetables that are orange in color, like carrots and sweet potatoes, are rich in vitamin A, and fruits like oranges, pumpkin, peaches, papayas which restores and regenerates damaged collagen.

5.      Foods that are rich in sulphur are also important in collagen production. Some examples of sulphur rich foods are green and black olives, fresh cucumbers, Garlic, onion, egg and celery stalks.

6.      Omega fatty acids found in fish such as salmon and tuna are also excellent because they create the ideal environment for collagen production. If you’re a vegetarian, you can still get the same fatty acids from nuts such as cashews and almonds as well as avocados.

Type 1: In type 1diabetes (formerly called insulin-dependent diabetes or juvenile-onset diabetes); more than 90% of the insulin-producing cells of the pancreas are permanently destroyed. The pancreas, therefore, produces little or no insulin. Only about 10% of all people with diabetes have type 1 disease. Most people who have type 1 diabetes develop the disease before age 30.

Scientists believe that an environmental factor—possibly a viral infection or a nutritional factor in childhood or early adulthood—causes the immune system to destroy the insulin-producing cells of the pancreas. A genetic predisposition may make some people more susceptible to the environmental factor.

Type 2: In type 2 diabetes (formerly called non-insulin-dependent diabetes or adult-onset diabetes), the pancreas continues to produce insulin, sometimes even at higher-than-normal levels. However, the body develops resistance to the effects of insulin, so there is not enough insulin to meet the body's needs.

Type 2 diabetes was once rare in children and adolescents but has recently become more common. However, it usually begins in people older than 30 and becomes progressively more common with age. About 15% of people older than 70 have type 2 diabetes. Type 2 diabetes also tends to run in families.

Obesity is the chief risk factor for developing type 2 diabetes, and 80 to 90% of people with this disorder are overweight or obese. Because obesity causes insulin resistance, obese people need very large amounts of insulin to maintain normal blood sugar levels.

• Elderly and debilitated patients are more prone to bleeding complications while taking this drug.
• Advise patient to report signs/symptoms of hemorrhage, skin and tissue necrosis, and hepatitis.
• Instruct patient to avoid situations/activities in which cuts, bruising, or injury is likely to occur. Patient should brush teeth with a soft bristle toothbrush. You may bleed and bruise more easily while you are using this medicine. Stay away from rough sports or other situations where you could be bruised, cut, or injured. Brush and floss your teeth gently. Be careful when using sharp objects, including razors and fingernail clippers. Avoid picking your nose. If you need to blow your nose, blow it gently.
• Patient should not drink alcohol while taking this drug.
• Advise patient there are multiple significant drug-drug interactions for this drug. Consult healthcare professional prior to new drug use (including over-the-counter and herbal drugs).
• Instruct patient to avoid cranberry juice or cranberry products.
• Patient should consume approximately the same amount of vitamin K daily. Advise patient against drastic changes in diet such as eating large amounts of foods high in vitamin K (asparagus, broccoli, cabbage, brussels sprouts, spinach).
• Patient should call healthcare professional if intravenous dose is missed, as drug should be given on a regular schedule. (injection) for IV use only; not recommended for IM administration. Administer as slow bolus injection over 1 to 2 minutes into peripheral vein, use reconstituted solution within 4 hr; do not refrigerate; discard unused solution 

§         There are many other medicines that you should not use while you are using warfarin. These include many herbs, supplements, and over-the-counter medicines, including NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin, ibuprofen, naproxen. Check the labels of all medicines to be sure they do not contain NSAIDs.

• Using this medicine while you are pregnant can harm your unborn baby. Use an effective form of birth control to keep from getting pregnant. If you think you have become pregnant while using the medicine, tell your doctor right away.
• Make sure your doctor knows if you are breastfeeding, or if you have kidney disease, liver disease, congestive heart failure, high blood pressure, diabetes, any type of infection, or bleeding problems. Tell your doctor if you have had recent surgery or injury, protein C deficiency, or a history of problems caused by heparin.
• You must have a blood test such as PT/INR to make sure this medicine is working and is not causing problems. Your doctor will tell you how often you need to have the test done. It is very important that your doctor checks your progress at regular visits. Keep all appointments.
• Diet and other medicines can affect the PT/INR level. Do not start or stop other medicine or change your diet without telling your doctor first.
• Tell your doctor right away if you get hurt or start to have diarrhea, fever, or any signs of infection.
• Carry an ID card or wear a medical alert bracelet to let emergency caregivers know that you use warfarin.
• This medicine may cause skin or tissue damage (gangrene). Call your doctor right away if you have pain, color change, or temperature change in any part of your body. Call your doctor right away if you have a pain in your toes and they look purple or dark. This problem must be treated right away to avoid permanent damage.
• Make sure any doctor or dentist who treats you knows that you are using this medicine. Your doctor might tell you to change the dose or stop using this medicine for a short time. Do not change anything unless your doctor tells you to.
• Keep a list of your medicines with you at all times.

Possible Side Effects While Using This Medicine:
Call your doctor right away if you notice any of these side effects:

1.      Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing

2.      Bleeding from your gums or nose, bruising easily, or coughing up blood

3.      Blistering, soreness, or redness of the skin

4.      Chest pain, trouble breathing

5.      Decrease in how much or how often you urinate

6.      Dizziness, fainting, or lightheadedness

7.      Heavy menstrual bleeding, or bleeding from cuts or wounds that does not stop

8.      Numbness, tingling, or weakness anywhere in your body\

9.      Pain, color change, or temperature change in any area of your body

10.  Painful, prolonged erection of your penis

11.  Purple discoloration of your toes or the soles of your feet, or new pain in a leg, foot, or your toes

12.  Red or dark brown urine, or red or black stools

13.  Swelling in your hands, ankles, or feet

14.  Unusual bleeding, bruising, or weakness

15.  Vomiting blood or material that looks like coffee grounds

16.  Yellow skin or eyes

Vitamin K₁(phylloquinone) is dietary vitamin K. Dietary fat enhances its absorption. Infant formulas contain supplemental vitamin K.

Vitamin K₂refers to a group of compounds (menaquinones) synthesized by bacteria in the intestinal tract; the amount synthesized does not satisfy the vitamin K requirement.

Vitamin K₁ is Fat Soluble Vitamin K and Menadione is Vitamin K₃ a water soluble analogue of Vitamin K.

National List of Essential Medicines of India 2011 lists only Phytomenadione and has deleted Menadione  Sodium Bisulphite.

Phytonadione (Phytomenadione) may be used to treat hypoprothrombinemia, particularly that caused by the anticoagulants derived from coumarin or indanedione. Menadione sodium bisufite is not effective against these antagonists because its conversion to menaquinone – 4 is very inefficient.

Whenever possible, phytonadione should be given po or sc. The usual adult dose is 5 to 20 mg. (Rarely, even when phytonadione is correctly diluted and given slowly, IV replacement can result in anaphylaxis or anaphylactoid reactions.) INR usually decreases within 6 to 12 h. The dose may be repeated in 6 to 8 h if INR has not decreased satisfactorily. Phytonadione 2.5 to 10 mg po is indicated for nonemergency correction of a prolonged INR in patients taking anticoagulants. Correction usually occurs within 6 to 8 h. When only partial correction of INR is desirable (eg, when INR should remain slightly elevated because of a prosthetic heart valve), lower doses (eg, 1 to 2.5 mg) of phytonadione can be given.

In infants, bleeding due to deficiency can be corrected by giving phytonadione 1 mg sc or IM once. The dose is repeated if INR remains elevated. Higher doses may be necessary if the mother has been taking oral anticoagulants.

VITAMIN K TOXICITY

Vitamin K1 (phylloquinone) is not toxic when consumed orally, even in large amounts. However, menadione (a synthetic, water-soluble vitamin K precursor) can cause toxicity and should not be used to treat vitamin K deficiency. Because Phytomenadione is fat soluble, patients with fat malabsorption, especially in biliary obstruction or hepatic disease, may become deficient. Menadione is a water soluble synthetic Vitamin k derivate that can be given orally to prevemt Vit K deficiency only in patients with Malabsorption Syndromes.

Rheumatoid arthritis (RA) and Planning a Pregnancy:

Pregnancy alters the immune state, possibly contributing to a change in the course of rheumatoid arthritis (RA).  In the past there were concerns that RA might affect the ability to conceive, but if the disease is well controlled, most women with RA can have an enjoyable and successful pregnancy. For decades, the improving effects of pregnancy on the disease activity in women with RA have been observed. Symptoms of RA often improve in pregnant patients, frequently resulting in a reduced need for medication, but may flare up after delivery.

The risk of fetal loss or genetic abnormalities for women with RA is not significantly greater than for any other pregnant women.

Important Points While Planning a Pregnancy:

1.      Planning ahead is important and you should discuss your plans as early as possible with your rheumatologist, since some of the drugs used to treat RA can be maintained while trying to conceive but several should be avoided as they are known to affect fertility

2.      Also some drugs may have to be stopped several months before trying to conceive to ensure they are eliminated from the body

3.      All women should undergo pre – conception counseling before conception for their specific risk, depending on their rheumatic condition and the medications they are taking.

4.      It is essential to discuss your medications with both your Rheumatologist and Gynecologist

5.      Each woman’s rheumatic disease should be well under control for a period of at least 3-6 months before attempting pregnancy. As long as your medicines are not harmful to the fetus, you should remain on your medicines to prevent risk of a disease flare.

6.      All women who are pregnant or planning a baby should take folic acid supplements to decrease the risk of spina bifida and this can be especially important if you have been treated with drugs such as methotrexate.

RA during pregnancy

Many changes to the immune system occur normally during pregnancy. These changes enable a fetus to grow and develop. Up to 75% of women find that the pain and swelling associated with RA is much improved during pregnancy, usually in the second trimester (14-27 weeks) and this is probably due to the normal hormonal changes in pregnancy. This temporary remission normally continues throughout the course of the pregnancy. During the later stages of pregnancy, swelling, backaches and tiredness are common for many women regardless of their RA status.

It is sometimes difficult to distinguish between the common discomforts of pregnancy and the symptoms of RA. Pregnancy discomforts that are similar to those of RA include the following:

• Fatigue
• Swelling of the hands, feet, or ankles
• Joint pain, especially in the low back
• Shortness of breath
• Numbness or pain in one or both hands (caused by carpal tunnel syndrome of pregnancy)

Pregnancy outcome: Most reports show that there is no increase in stillbirth or miscarriage in women who have RA. However, some medications, may increase the risk of having a smaller than normal infant (Low birth weight) and may increase the risk of premature rupture of the membranes.

Reference:

1.      http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/pregnancy.asp

2.      http://www.uptodate.com/contents/rheumatoid-arthritis-and-pregnancy-beyond-the-basics

3.      http://emedicine.medscape.com/article/335186-overview#showall

1.      Since purine chemicals are converted by the body into uric acid, purine-rich foods are avoided. Examples of foods rich in purines include shellfish and organ meats such as liver, brains, kidneys, and sweetbreads. Researchers have reported, in general, that meat or seafood consumption increases the risk of gout attacks, while dairy food consumption seemed to reduce the risk.

2.      Total alcohol intake was strongly associated with an increased risk of gout (beer and liquor were particularly strong factors).

3.      Fructose from the corn syrup in soft drinks also increases the risk of gout. Fructose is the only carbohydrate that increases uric acid levels

4.      Weight reduction can be helpful in lowering the risk of recurrent attacks of gout. This is best accomplished by reducing dietary fat and calorie intake, combined with a regular aerobic exercise program.

5.      Drink plenty of fluids to help flush uric acid from your body. Aim for 8 to 16 glasses a day. 

6.      Saturated fat lowers the body's ability to eliminate uric acid. Choosing plant-based protein, such as beans and legumes, and low-fat or fat-free dairy products will help you cut down the amount of saturated fat in your diet. High-fat meals also contribute to obesity, which is linked to gout.

The most common side effects are diarrhea, nausea, vomiting, constipation, rash and headaches. Dizziness, nervousness, abnormal heartbeat, muscle pain, weakness, leg cramps and water retention rarely occur.

Long-term ( 1 to 3 years) treatment with pantoprazole may also make it harder for your body to absorb vitamin B-12, resulting in a deficiency of this vitamin.

High doses and long-term use (1 year or longer) may increase the risk of osteoporosis-related fractures of the hip, wrist, or spine.