Arsenic and permissible limits

By Dr Deepu

Arsenic is a semi-metal element in the periodic table. It is odorless and tasteless. It enters drinking water supplies from natural deposits in the earth or from agricultural and industrial practices. 
Non-cancer effects can include thickening and discoloration of the skin, stomach pain, nausea, vomiting; diarrhea; numbness in hands and feet; partial paralysis; and blindness. Arsenic has been linked to cancer of the bladder, lungs, skin, kidney, nasal passages, liver, and prostate.
EPA has set the arsenic standard for drinking water at .010 parts per million (10 parts per billion) to protect consumers served by public water systems from the effects of long-term, chronic exposure to arsenic.  Water systems must comply with this standard by January 23, 2006, providing additional protection to an estimated 13 million Americans.
EPA proposed arsenic regulations to revise the existing NPDWR on June 22, 2000 (65 FR 38888), which proposed a Maximum Contaminant Level (MCL) of 0.005 mg/L (5 μg/L). The October 2000 appropriations bill for EPA amended the SDWA, directing EPA to promulgate a final arsenic standard no later than June 22, 2001. The Final Rule, published on January 22, 2001, established the MCL at 0.01 mg/L (10 μg/L) (40 CFR 141.62(b)(16)). The Rule was to become effective on March 23, 2001, 60 days after publication. The Rule established that the 0.01 mg/L (10 μg/L) MCL becomes enforceable on January 23, 2006, and that the clarifications to compliance and new source contaminants monitoring regulations become enforceable on January 22, 2004 (40 CFR 141.6(j) & (k)).
Because of the importance of the Arsenic Rule and the national debate surrounding it related to science and costs, EPA's Administrator publicly announced on March 20, 2001, that the Agency  would take additional steps to reassess the scientific and cost issues associated with this Rule. EPA requested that the National Academy of Sciences (NAS) convene a panel of scientific experts to review the Agency's interpretation and application of arsenic research, worked with its National Drinking Water Advisory Council (NDWAC) to review the assumptions and methodologies underlying the Agency's estimate of arsenic compliance costs, and asked its Science Advisory Board (SAB) to look at the benefits associated with the Rule. On October 31, 2001, the EPA Administrator announced that the 10 ppb (0.010 mg/L) standard for arsenic would remain stating that, "the 10 ppb protects public health based on the best available science and ensures that the cost of the standard is achievable."

On January 22, 2001 EPA adopted a new standard for arsenic in drinking water at 10 parts per billion (ppb), replacing the old standard of 50 ppb.  The rule became effective on February 22, 2002.  The date by which systems must comply with the new 10 ppb standard is January 23, 2006.

Study: Arsenic Exposure In Womb Linked To Increased Respiratory Infections For Newborns

By Dr Deepu









HealthDay (11/23) reports that a new study published in the journal Environmental Health Perspectives suggests that children exposed to high levels of arsenic in the womb face an increased risk for infections and respiratory symptoms in the first year of their life. Researchers measured levels of arsenic in 412 pregnant women in New Hampshire whose homes and private wells, and they found “infants exposed to arsenic in the womb had more infections that led to a doctor visit or treatment with prescription medications.” senior author Margaret Karagas, chair of epidemiology at Dartmouth College’s School of Medicine, said in a college news release: “These results suggest that arsenic exposure may increase the risk and severity of certain types of infections.”

Read about ARSENIC and its permissible limits

FDA Approves Lung Cancer Drug

By Dr Deepu


The Wall Street Journal (11/25, B6, Steele, Subscription Publication) reports that the Food and Drug Administration announced Tuesday that it had approved Eli Lilly’s lung cancer drug, Portrazza (necitumumab). Portrazza, in combination with two forms of chemotherapy, treats patients who have advanced squamous non-small cell lung cancer and have not already received another treatment for their advanced lung cancer.
        The Indianapolis Star (11/25, Swiatek) reports that the drug “is the first biologic approved to treat patients with metastatic squamous non-small-cell lung cancer.” Although Eli Lilly did not release a price for the drug, the company “said it plans to offer a discount program to offer income-eligible patients a way to receive Portrazza for a copay of no more than $25 a dose.” 
Indicated for first-line treatment of metastatic squamous NSCLC in combination with gemcitabine and cisplatin
800 mg IV infused over 1 hr on days 1 and 8 of each 3-week cycle prior to gemcitabine and cisplatin infusion
Continue therapy until disease progression or unacceptable toxicity.
Mechanism of Action
Epidermal growth factor receptor (EGFR) inhibitor; monoclonal antibody that binds to the human EFGR and blocks interaction between EGFR and its ligands
Expression and activation of EGFR has been correlated with malignant progression, induction of angiogenesis, and inhibition of apoptosis
Pharmacokinetics
Time to steady state: ~100 days
Total systemic clearance at steady-state: 14.1 mL/hr
Vd: 7 L
Half-life: ~14 days
Adverse effects
Infusion-related reactions
  1. Grade 1: Reduce the infusion rate by 50%
  2. Grade 2: Stop the infusion until signs and symptoms have resolved to grade 0 or 1; resume infusion at 50% reduced rate for all subsequent infusions
  3. Grade 3 or 4 IRR: Permanently discontinue


Dermatologic toxicity
·         Grade 3 rash or acneiform rash: Withhold until symptoms resolve to grade ≤2, then resume infusion at reduced dose of 400 mg for at least 1 treatment cycle; if symptoms do not worsen, may increase dose to 600 mg and 800 mg in subsequent cycles
·         Permanently discontinue if
    1. Grade 3 rash or acneiform rash do not resolve to grade ≤2 within 6 wk
    2. Reactions worsen or become intolerable at a dose of 400 mg
    3. Patient experiences grade 3 skin induration/fibrosis
    4. Grade 4 dermatologic toxicity

Limitations of use: Not indicated for treatment of nonsquamous NSCLC
Hypomagnesemia (83%)
Hypocalcemia (45%)
Rash (44%)
Hypocalcemia (albumin corrected) (36%)
Hypophosphatemia (31%)
Vomiting (29%)
Hypokalemia (28%)
Hypomagnesemia, grade 3-4 (20%)
Diarrhea (16%)
Dermatitis acneiform (15%)
Weight decreased (13%)
Stomatitis (11%)
Headache (11%)
1-10%
Hemoptysis (10%)
Venous thromboembolic events (9%)
Acne (9%)
Hypophosphatemia, grade 3-4 (8%)
Paronychia (7%)
Conjunctivitis (7%)
Pruritus (7%)
Dry skin (7%)
Hypocalcemia, grade 3-4 (6%)
Hypokalemia, grade 3-4 (5%)
Skin fissures (5%)
Pulmonary embolism (5%)
Venous thromboembolic events, grade 3-4 (5%)
Hypocalcemia (albumin corrected), grade 3-4 (4%)
Vomiting, grade 3-4 (3%)
Diarrhea, grade 3-4 (2%)

Global Plan to End TB to Save Over 10 Million Lives

By Dr Deepu

The world is losing its battle with tuberculosis, which is now the biggest infectious killer globally, causing 1.5 million deaths every year, according to the new GlobalPlan to End TB 2016-2020, which was released Nov. 20 by the Stop TB Partnership. The plan’s targets, called 90-(90)-90, are aiming for 90 percent rates in the three areas of: TB diagnosis, care for vulnerable populations, and treatment. New tools are needed for successful implementation, and the Global Plan calls for an additional $9 billion to create a vaccine, rapid diagnostic tests, and drug regimens (including for drug-resistant TB). The plan will be shared with high-level politicians from around the world at the 46th Union World Conference on Lung Health in Cape Town, South Africa, in December.

Top FDA Official Says Regulators Should Consider Potential Benefits Of E-Cigarettes

By Dr Deepu


The Congressional Quarterly (10/22, Siddons, Subscription Publication) reports that Mitch Zeller, head of the Food and Drug Administration’s Center for Tobacco Products, said Wednesday that regulators have to consider the possible health benefits for smokers who transition to e-cigarettes. “If there is an opportunity to shift those unable or unwilling to quit from the most harmful form of nicotine delivery, to the least harmful form,” Zeller said, “then I think that we as regulators have an opportunity to explore what those options are. “

Fauci Optimistic About The Development Of A Universal Flu Vaccine Within Next 5 To 10 Years

By Dr Deepu


In a 1,500-word article, NBC News (10/20) reports on its website on this year’s flu vaccine, the market environment, and the push for vaccination. The piece also reports on the “holy grail for flu: A universal vaccine,” which is currently being pursued at the National Institutes of Health. National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci “said he’s optimistic a universal vaccine is five to 10 years away.” In an interview, Fauci said, “I think that we are making extraordinary progress and we can sort of see that light at the end of the tunnel.” He added, “If we can successfully induce a response against that stem part of that protein, we’re going to be very close to developing a universal flu vaccine.” In the meantime, public health researchers “emphasized the best thing the public can do to avoid spread of the flu is to wash hands, cover coughs and sneezes…and get vaccinated.”

Sleep Apnea May Be More Dangerous For Women Than For Men

By Dr Deepu


The New York Times (10/20, D6, Bakalar) “Well” blog reports that research published in Circulation suggests that “sleep apnea may be even more dangerous for women than for men.” Investigators found that “obstructive sleep apnea was independently associated with increased troponin T, heart failure and death in women, but not in men.” The researchers also found that “in women, but not men, sleep apnea was associated with an enlarged heart, another risk factor for cardiovascular disease.”

Normal Vocal Cords

By Dr Deepu


CDC: Teen Smoking Rates Declining, Marijuana Use On The Rise

By Dr Deepu


HealthDay (10/16, Reinberg) reports that according to today’s MMWR, the CDC says that smoking among teenagers has dropped 64 percent in recent years, but marijuana use has more than doubled. Investigators “tracked teen smoking rates from 1997 to 2013.” The researchers found that “overall, the number of teens who smoked cigarettes or cigars dropped from 20.5 percent to slightly more than 7 percent, while marijuana use went from 4 percent to 10 percent.”

EV-D68 No More Deadly Than Common Cold Germs, Study Finds

By Dr Deepu


HealthDay (10/16, Thompson) reports that a new study conducted at McMaster University in Ontario, Canada suggests that enterovirus D68, which made headlines in 2014 after sickening children across North America, is “no more deadly than other common cold germs.” For the study, the researchers compared “87 kids treated for EV-D68 at McMaster Children’s Hospital with 87 kids who caught a rhinovirus or some other enterovirus at the same time.” The findings were published in the Canadian Medical Association Journal. Medscape (10/16) also covers the story.

Sleep Apnea May Increase A Woman’s Risk For Heart Problems

By Dr Deepu


HealthDay (10/15, Preidt) reports that research indicated that “sleep apnea can boost a woman’s risk for heart problems and even death, but there was no such effect for men.” The study also indicated that, “compared to women without sleep apnea, women with the disorder had higher blood levels of troponin, a chemical signal of early heart damage.” The study was published in Circulation.

Kartageners Syndrome

By Dr Deepu
See the question
The answer is b."Kartagener syndrome"

Kartagener syndrome is the inheritable disorder of dextrocardia, chronic sinusitis (with the formation of nasal polyps), and bronchiectasis. Patients may also present with situs inversus.The disorder is due to a defect that causes the cilia within the respiratory tract epithelium to become immotile. Cilia of the sperm are also affected

Chest Challenge MCQ - Give your diagnosis

By Dr Deepu
A teenage boy presents with a history of chronic sinusitis and frequent pneumonias. On physical examination, the patient has normal vital signs and is afebrile. He has mild frontal and maxillary sinus tenderness with palpation. Transillumination of the sinuses is normal. Heart sounds are best heard on the right side of the chest. The boy is coughing copious amounts of yellowish sputum. The chest X ray is shown.
Which of the following is the most likely diagnosis?
a.Cystic fibrosis
b.Kartagener syndrome
c.Pulmonary dysplasia
d.Tuberculosis

e.Pulmonary hypertension