This reality remains a severely underpublicized facet of American life as the steady increase in the aged population continues. Additionally, the increased work and family commitments of relatives combined with the rising cost of medical coverage engenders the need for careful planning by both seniors and family alike. As preventive measures remain the most effective response to the increase in home-based danger, the following list identifies four sensible steps critical to the safeguard of senior safety.

Identify hazards 

Inventory the layout of the home or residence to determine the acute hazards. Some hazards include furniture, household appliances and stairs. Additionally, inspect the condition of any indoor wiring and ensure that heating devices remain properly regulated and in good working order.

Develop a schedule 

Concerned family members and relatives should develop a schedule designed to both capture the activity of the senior and evaluate the health and welfare of the relative. The schedule should account for the use of call-ins or in-person visits while creating a stable chain of support and concern. Additionally, aspects of the schedule coincide with time period related to the use of over-the-counter and physician-prescribed medication.

Hire an assistant 

Hire a licensed professional caregiver to provide routine medical care along with companionship and emergency response. Though the use of licensed individuals ensures professional assistance, family members and relatives remain a reliable resource for this activity. Consult with the senior prior to hiring the aide while creating a written agreement outlining responsibilities while indentifying critical concerns and protocols.

Purchase a medical alert device 

The use of the 911 emergency response system remains critical in provide acute care for home-based seniors. As mentioned above, in-home safety begins with the inspection and use of critical equipment. In additional to the validation of a serviceable home-based landline, the use of medical alert technology augments emergency response efforts. These small, inexpensive devices provide an immediate connection with emergency services in the event of a fall or cardiac emergency. The technology efficiently establishes contact with local medical authorities while conserving valuable time and effort.

As with any plan or preparation contingencies exist. While this remains an established fact, proper preparation combined with effective communication lends much in the way of the safeguard of seniors and the prevention of ailment or injury.

Guest Article by JenniferSmith
Email address: jennaleesmith1@gmail.com 

There are a couple factors that lend credibility to such a connection. First, studies have shown that Vitamin D carries some beneficial immune system impacts that, in turn, may make that system less likely to attack nerve cells. Secondly, the data tells us that MS rates are far higher in regions of the world distant from the equator. While this is truer in the Northern Hemisphere than in the Southern Hemisphere, the fact remains that a correlation exists between sunlight exposure and MS contraction. Since most people get a majority of their Vitamin D from the sun, there may very well be a direct connection between the supplement and the disease.

But researchers have yet to determine exactly what that connection is or how it works. Furthermore, while numerous studies stress the link between MS prevention and high Vitamin D doses, just as many others call it into question and dispute the strength of the relationship. Clearly, it is up to research leaders in the scientific world such as Marc Sprenger of the ECC and Brian Cass – Huntingdon Life Sciences – to continue investigating the issue.

In the meantime, what should doctors tell their patients? Since it takes a large amount of Vitamin D to approach levels of toxicity, there is little harm in advising MS patients to take the supplement on a daily basis – especially if they live in a low-sunlight region. Similarly, since MS is caused by both genetic and environmental factors, any patient who has family members afflicted with the disease may also be well-served to take Vitamin D as a preventative measure. But patients with no signs of MS in their bodies or their genetic histories should be given no reason to overreact on the Vitamin D front. Their chance of contracting MS is very low, and a daily supplement is going to have almost no effect on that probability.

Guest Article by JenniferSmith
Email address: jennaleesmith1@gmail.com 

Tuberculosis

When we were studying Bachelors in the Medical college, initially we were pretty scared of the infections, primarily Tuberculosis. We have seen many of our seniors and friends down with Tuberculosis. The severe most is when TB reaches the Meninges, we have seen it cause blindness and permanent disability . The highest risk people are Ophthalmologist while performing Fundoscopy, Physicians, Pediatricians and nursing staff and attendants who are involved in the patient care. Tuberculosis is not a stigma, but a well known fact and a Fear to all the health workers, as we ourselves are human beings as well. ( Traffic Police who test alcohol by smelling breath- How much risk do they carry ?)

Hepatitis B, C and HIV

Needle pricks, cuts, injury during blood sampling, exposure the blood when not wearing gloves, accidental splashing of blood into the eyes… and we don’t always know the  Serological Status of the patient. Hep B and C are more likely to be transmitted than HIV. But whichever one you get them, you know the consequences. There are many health workers who have under intense stress after needle pricks and exposure to blood, many had to take Prophylaxis and Immunoglobulins ( Very expensive) and some have even been infected. Surgeons, OT nurses, Cleaning attendants are the most exposed people.

Meningococcemia

The dreaded organism Meningococci which causes Menigococcemia and Meningitis, is not rarely encountered specially at ER. It is a severe disease that is transmitted very quickly and is more severe in children. We as health professionals often take Prophylactic antibiotics – Ciprofloxacin, Rifampicin etc and even advise all the close contacts to do the same.

Influenza

The Avian Flu, The Swine Flu, all that is seen in the TV, Internet are some of the disease we have to face. We are exposed to such diseases even unknowingly and the sad thing is that even when we know the disease for certain, we lack adequate equipments to protect ourselves. Those masks and gloves don’t help.

Chicken Pox

When acquired by an adult, results could be devastating. It is highly communicable and with 95% secondary attack rate threatens the ones who had never had it before. Disseminated Varicella, Hemorrhagic varicella, Chicken pox etc are dreaded complications including encephalitis.

Besides these infectious diseases, 

Radiation Hazard that arise from X-Ray radiations, Fluroscopy etc are often unaccounted but on long run prove to have adverse affect on the health professionals.

While Administering anti-neoplastic agents like Cyclophosphamide , health worker are exposed to its ill-effects of not well-protected clothing are available.

And many more..

So, being in Health care sector requires a lot of sacrifice . The  other thing bad about it is, this thing always goes unnoticed and we are never credited for it.

Magnitude of Problem-

Clinical and subclinical VAD are problems in at least 75 countries.
Clinical VAD occurs mainly in countries in Southeast Asia and sub-Saharan Africa.  Severe VAD – refugee settlements and in displaced populations
Improving the vitamin A status of children with deficiencies (aged 6-59 mo) can reduce measles and diarrhea mortality rates by 50% and 33%, respectively, and can decrease risk rates from all causes of mortality by 23%.

Developing countries –
Estimated 250 million children are at risk for vitamin deficiency syndromes.
Up to 10 million malnourished children, develop xerophthalmia and have an increased risk of complications and death from measles.
Each year, 250,000-500,000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight.
WHO Fact sheet

Dietary Source
Animal foods-

• Liver, Eggs, Butter, Cheese
• Whole milk, Fish and Meat.
• Fish Liver Oil – richest source.

Plant Foods- Provitamins

• Green leafy vegetable- spinach and amaranth
• Green and yellow fruits and vegetables- Papaya, mango,pumpkin and roots like carrots

Fortified foods-
▫Vanaspati, Margarine, Milk
1 Retinol Equivalent = 1 μg Retinol = 6 μg beta-carotene = 12 μg of other carotene
1 IU= 0.3 μg of Retinol.

Metabolism
Absorption ,Bioavailability and Transport
 70-90% percent of vitamin A from the diet is absorbed in
the intestine.
 Retinol-binding protein (RBP) is the specific carrier used
to transport all-trans retinol in the plasma.
 The all-trans isoform accounts for more than 90% of all
plasma vitamin A .
 Retinol + RBP= holo-RBP.
 Holo-RBP + Transthyretin (TTR- prealbumin)- not filtered
by the glomerulus, but instead freely circulates
throughout the plasma

Storage
50 to 85% of the total body retinol are stored in the liver in hepatic stellate (star-shaped) cells along with droplets of lipid.
Over 90% – stored in the form of retinyl esters + FAOnce hepatic stellate cells are saturated with all the retinol -hypervitaminosis can result.

beta-carotene, can be stored in adipose cells of fat depots throughout the body .

Excretion –
Via- kidneys mainly via renal catabolism and glomerular filtration .
Renal disease
elevated serum levels of RBP and retinol
must be more aware of vitamin A toxicity.

Roles of Vitamin A-

1. Vitamin A is essential to vision -production of retinal pigments for vision in dim light
2. Role in gene expression and transcription, that regulates cell growth and differentiation.( Acts like Steroid Hormone)
3. Retinoic acid is especially important in heart, eye, lung and ear development .
4. The development of gap junctions between cells is also affected by retinoic acid. Regulation- Leucopynes
5. Key role in glycoprotein synthesis ( Retinyl Phosphate) ,mucopolysaccharides and Transferrin
6. Reproductive processes (spermatogenesis) &, bone development, along with maintenance, and immune system function are dependent upon different isoforms of vitamin A.
7. Integrity of glandular & epithelial tissue which line Intestinal, respiratory & urinary tract, skin & eyes. testicular & vaginal epithelium.
8. 8. Vitamin A also has antioxidant properties. ↓ incidence of lung, breast, oral, esophageal, & bladder cancers.

The RDAs of vitamin A for various age groups are as follows:
Infants aged 1 year or younger – 375 mcg
Children aged 1-3 years – 400 mcg
Children aged 4-6 years – 500 mcg
Children aged 7-10 years – 700 mcg
All males older than 10 years – 1000 mcg
All females older than 10 years – 800 mcg

Risk Factors for Vitamin A  deficiency-

Intake Diarrhea, worms (ascaris) & other intestinal disorders impair vit A absorption
Measles, respiratory tract infection & other febrile illness ↑metabolic demands.
Protein Energy Malnutrition (PEM), Zinc & Iron deficiency impairs utilization & transport of Vit A.
toddlers and preschool children living below the poverty line.

Subclinical forms of VAD

Without any symptoms
Higher risk of developing respiratory and diarrheal infections
The growth rate is decreased, and bone development is slowed.
The patient may also report increased fatigue, as a manifestation of VAD anemia.

Occular Sign: WHO classification of Xeropthalmia

Primary signs:
X1A Conjunctival xerosis
X1B Bitot,s spots
X2 Corneal xerosis
X3A Corneal ulceration (1/3rd)

Secondary Signs:
XN Night blindness
XF Fundal changes
XS Corneal scarring

Extra-ocular manifestations:

Phrynoderma: scaly & toad like skin- Follicular hyperkeratosis
Renal & vesical calculi.
Atrophy of germinal epithelium interfere reproductive functions
Dry skin, Dry hair, Pruritus, Broken fingernails
Excessive deposition of periosteal bone secondary to reduced osteoclastic activity
Anemia
Keratinization of mucous membrane
Impairment of the humoral and cell-mediated immune system.

PREVENTION-

• Improvement of diet :
• adequate & regular intake of foods rich in vitamin A and Food Fortification.
• ↓contributory factors eg. PEM, diarrhea, respiratory infection & measles.
• Regular Vit A supplementation: Vit A can be stored in body for 6-9 months administer a single massive dose of 2 lakh IU vit A orally every 6 months to (preschool children/ 1-5 yrs) ½ the dose to (6 months to 1 yr) of age.
• In measles, severe PEM 2 doses oral for 2 consecutive days. Persistent diarrhea or prolonged febrile condition: one dose in each episode (least 1 month interval)
• During pregnancy (not >300 mug retinol/day): ↓ maternal morbidity & ↓ perinatal mortality.
• High dose at Post partum period: ↓ mortality in 1st 4 months of life.
• Consumption of Vitamin A rich food
• Kitchen garden: to grow vit A rich foods.

3 doses at 0, 1 & 30 days
50,000 for < 6 months, 1 lac 6-12 months & 2 lac unit in children >1 yr
Same dose repeat next day & repeat at 4 wks

Local t/t of eye:

1. Antibiotic drops/ ointment X 3 day,
2. atropine drops X 1 day,
3. padding for corneal ulcer.

Vitamin A toxicity

Continous Intake of 15 X RDA

Acute/ pseudotumor cerebri (Intra Cranial Pressure ↑ICP):
headache, vomiting, dizziness, ↑ant. fontanel, papilledema.

Chronic intoxication causes:
nausea, vomiting, anorexia & sleep disorders
skin desquamation → Dermatitis
Enlargement of Liver and Spleen, hypolastic anemia
benign intracranial hypertension
Bone pain, Diarrhea

Teratogenic to fetus:
craniofacial malformation in fetus of mothers on oral retinoid for acne.

Investigations for VAD-

1. A serum retinol study- costly but direct measure using high-performance liquid chromatography. < 0.7 mg/L in children-fluorometry, spectrophotometry
2. A serum RBP study -easier to perform ,less expensive , RBP is a protein and can be detected by an immunologic assay.
3. A zinc level is useful because zinc deficiency interferes with RBP production.
4. An iron panel is useful because iron deficiency can affect the metabolism of vitamin A.
5. Albumin levels are indirect measures of vitamin A levels.
6. An electrolyte evaluation and liver function studies should be performed to evaluate for nutritional status.
7. Imaging Studies -In children, radiographic films of the long bones may be useful when an evaluation is being made for bone growth and for excessive deposition of periosteal bone.

Procedures
Dark-adaptation threshold should be tested.

Recommendations-

1. The American Academy of Pediatrics has recommended vitamin A supplementation for infants aged 6-24 months who are hospitalized with measles and for all hospitalized children older than 6 months.
2. The WHO – UNICEF joint statements recommends -vitamin A be administered to all children, especially those younger than 2 years, who are diagnosed with measles.
3. A Cochrane Database of Systematic Reviews article concluded that daily treatment with 200,000 IU of vitamin A for at least 2 days reduces mortality rates in Measles children less than 2 yrs.
4. A more recent Cochrane Database of Systematic Reviews article, including 43 randomized trials representing 215,633 children, provides strong support for the importance of vitamin A supplementation in preventing childhood mortality.
5. A single dose of vitamin A improves haemoglobin concentration, retinol status and phagocytic function of neutrophils in preschool children.
6. A substantial reduction (40 percent) in pregnancy- related mortality was observed among the women who received vitamin A or beta-carotene supplements on a weekly basis before, during, and after pregnancy (West et al, 1999)

Vitamin A and its derivatives being used in

• Acne
• Psoriasis
• Treatment of Corneal Ulcer
• Role of Vitamin A as anti-oxidant is being studied.
• Studies going on to see if Vitamin A is solution to cancer- specially Breast, lung and Prostate Cancers.