Drug eluted stent and percutaneous coronary intervention by :LAW JIA JUIN (with references)

   
     Angioplasty is the technique of mechanically widening a narrowed or obstructed blood vessel, the latter typically being a result of atherosclerosis. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500 times normal blood pressure (6 to 20 atmospheres). The balloon crushes the fatty deposits, opening up the blood vessel for improved flow, and the balloon is then deflated and withdrawn. In surgery is known as percutaneous coronary intervention (PCI).It is one therapeutic procedure used to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart disease.(besides Coronary Artery Bypass Graffing CABG) These stenotic segments are due to the build up of cholesterol-laden plaques that form due to atherosclerosis. PCI is usually performed by an interventional cardiologist, though was developed and originally performed by interventional radiologists. Besides the balloon ,in PCI a scaffold known as stent is also used to support the vessel for opening and reduce the risk of reobstruction and reblockage .However the incidence of restenosis and rebuild of cholesterol deposit on the same site of surgery supporting by stent are reported very frequently even though the patient is follow up with oral medication after the surgery.
 
     The good news is there is a new stent known as drug eluding stent is believed to reduce the risk of restenosis. Drug eluting stent (DES) is a peripheral or coronary stent (a scaffold) placed into narrowed, diseased peripheral or coronary arteries that slowly releases a drug to block cell proliferation. This prevents fibrosis that, together with clots (thrombus), could otherwise block the stented artery, a process called restenosis. The drugs coated can be thrombolytic agents or anticlotting drugs. The stent is usually placed within the peripheral or coronary artery by an Interventional cardiologist or Interventional Radiologist during an angioplasty procedure.



REFERENCES: http://en.wikipedia.org/wiki/Drug-eluting_stent

coffee ,heart disease, high blood pressure, and type 2 diabetes mellitus written by LAW JIA JUIN

   
     Many of us were wondering whether can coffee be involved in the diet Of a cardiac disease sufferer or a hypertensive patient. In this article I am going to discussed on the relationshijp between coffee ,heart disease ,high blood pressure and also type 2 diabetes mellitus. There is no evidence saying that coffee is a risk factor for coronary heart disease. In fact coffee have the effects against coronary heart disease. A study published in international journal of cardiologist in 2009 coffee said that coffee can reduce the risk of coronary heart disease in women (just like red wine,they cause vasodilation and prevent the blockage of coronary vessels, but it is less effective than red wine).A study also proves that caffeine ingested in the form of coffee have little effect on the increase of blood pressure (due to dilution effect and also pharmacokinetic factors,the increase in heart rate is less as compare to when consuming the caffeine directly) so hypertensive patient can drink a moderate amount of coffee without having to worry too much provided they didn't abuse it. Excessive consumption of coffee eg more than 8 cups per day can increase body metabolism rate (catabolism of glucose and anabolism of cholestreol...) and so the cholesterol level in our body increases too, thus rising the risk of coronary heart disease.

     
     Obesity can lead to type two diabetes mellitus in which the pancrease still producing insulin for the conversion of unconsumed glucose into glycogen and lipid for storage, but what happens is the body becomes resisted towards insulin .For an obese patient the glycogen and lipid is too much, the storge is too huge, so as a natural tendency the body will try and prevent the conversion of more glucose into glycogen by insulin, thus the blood glucose level rises. According to American journal clinical nutrition 2006 ,long term use of appropriate amount of coffee can result in weight loss when more fat and glycogen is catabolized due to the higher metabolism rate resulted from caffeine. In addition to that, more glucose is oxidized ,so patient blood glucose level is now been reduced. Besides that, after the weigh loss resulting from the rapid catabolism of glycogen and fat, there is now more space for the storage and conversion of glucose into glycogen by insulin. Thus the medical condition of type 2 diabetes mellitus patient can be improved .

How old are you? By -Law JIA JUIN

   
     "Age is a question of mind over matter.  If you don't mind, it doesn't matter."Said Leroy "Satchel" Paige. When someone ask for your age, then you can actually answer them with your official age(putative age), chronological age, Chinese age or even biological age.
     Official age is the age recorded or documented in the birth certificate. But it must not be the real age of a person, since in the olden day some parents may not be able to register their childs as soon as they were born, especially those living in rural area and were isolated from big city in which the registration department located. So another term known as chronological age is used. Chronological age is the age counted from the day in which the baby was first born. For some Chinese they are actually using their own system -the Chinese age. This is because we Chinese take into account the time the baby is gestating in mother's womb.
     There is another type of age I introducing here, the biological age. Perhaps this is the most important age of all when it comes to medical treatment, especially surgery and cancerous treatment. Our biological age can tell us how fit and healthy we are ,and how nice our bodies' organs can function, without considering how long ago we were born. This biological age can actually be measured and estimated by biological age analyser //machine.
     So next time if some one ask you how old are you, do remember to reinsure which age they are referring to. And if someone say that your biological age looked younger than your actual age ,they simply mean you are young and healthy, and don't forget to thanks them for their compliments. Take care of your body since young to delay the progress of your biological age!

Spine cancer -by :LAW JIA JUIN

   
     Nervous system is made up of central nervous system and peripheral nervous system. Spinal cord and brain together make up the vital central nervous system. Spinal cord is protected by spine/ vertebraes ,vertebraes are bones with lumen which made up the spinal column and bear the spinal nerves.
     Spine is such a crucial and important organ for spinal cord protection, but it is easily targeted by metastasised cancers, which spread from primary cancerous organ or site,this condition is known as secondary spine cancer. In facts cancers can actually establish from vertebrates themselves ,and this kind of spine cancer is known as primary spine cancer in which the cancers develop in the spine but not spread from other site. This primary spine cancer can be further classified into benign spine cancer and metastasised spine cancer. Benign cancer means the cancer is localized on a specific area of spine but not spreading, but it can metastasise in the later stage, in which lump of cancers dislodge from the cancerous spine area and spreading to other part of spine or even other systems and organs via lymphatic and circulatory systems. If the spine become cancerous or invaded by cancerous cells from other cancerous organs, the rapid growing cancerous cells will compete with the normal functioning spine cells for nutrients, oxygen, and space. Eventually, the spinal bones will be destroyed and the spinal column become unstable ,this will cause enormous pain, and worse come to worst the patient can become paralysis ,sensory failure and lost of bower and bladder control. In some cases ,the spinal bone will collapse and the cancer mass will collapse the spinal cord and spinal nerves. The patient quality of life will definitely be affected even in the early stage of spine cancer, this is due to the unbearable pain and the patient won't be able to stand up, walk, and even lay down comfortably, the backbone just simply cannot bear the weigh of patient and also the posture of patients.
     The aim of treatments involve pain management, removal of cancerous mass, and maintaineance of spinal bones. Vertebeoplasty or kyphoplasty is once of the effective treatment, cement is injected into the destroyed vertebrae through small needles ,X ray is used as guidance for the insertion of needle. This cement work to reinforce the destroyed bones and to relieve the pain sensation experienced by patient thus improving patoent life. If patient suffers from paralysis due to the compression on spinal cord, then surgery is needed to remove the cancerous mass which compress the spinal cord before carrying out cement injection. Secondly , metal implantation is another method. Titanium is usually chosen since it is strong, flexible, light, non rusty and corrosive, despite that it is expensive. Titanium is implanted to stabilize the spinal column and prevent further rupture of it. Cement injection and metal implantation can be carried out via open surgery and also minimal invasive spine surgery, in which small incision is carried out using special instrument. After the surgery ,short course of chemotherapy and radiotherapy are required. Together with pharmacological treatments, and other non-pharmacological treatments patient life can be improved.

SEIZURE-by LAW JIA JUIN

Background story: 
My brother was driving me home after our gathering, somehow our topic of conversation came to a scene in a drama -THE WALKING DEAD SEASON 2. .Both of us had been crazy of this english drama for more than one month.

"Why is it Carl jerking and shivering on the bed of Hershell after been shot by gun and what is the medical condition known as?" my bro asked. :)

"The condition is known as seizure " I managed to answer the name of CARL'S condition. But I was still not sure with the causes of seizure. But one thing for sure was seizure can be related to nervous system , eg the BRAIN

"what is it caused by? is it due to shock?" he kept asking.
"shot ,ya agree with you" i replied.
"Bro, not shot ...but shock..." he corrected me. I THINK I REALLY NEED A HEARING AID TO HELP ME LOL
"oh i see...i think it may be due to..." i stopped half way. Because inside my heart i was not sure with the causes of it, how can the brain and spinal cord be damaged while Carl was been shot on his abdominal part??
"har...due to what...??" he asked for complete sentence.
"due to.....hmm..i am not sure bro ....sorry man...i am not good in pretending, i would rather say i donnt know if i am not sure...." i said ,hoping he wonnt keep asking the same question to me. I really unsure with the causes of seizure and i donnt like to bluff especially in front of my best friend.
I was once been taught that seizure can be due to brain damage ;and the common sense is the damage might be due to 
a)) direct brain damage like shot // hit at head or infection by bacterial 
b))and indirect brain damage due to shortage of oxygen
I was suspecting infection in the brain due to the invasion of bacterial  from the air-exposed wound of Carl abdomen. Deep inside my heart i was confused ,
at one hand i was thinking of brain infection and on the other hand i was thinking of blood brain barrier. 

How can a bacterial and viruses be able to enter the brain when the brain is still protecting by the strong tight blood brain barrier! Remark: blood brain barrier is a special layer of tissue around the brain with tight junction which seperate the brain with the blood vessel and act as a filter to prevent the enter of bacteria and viruses. It is strong enough to prevent brain infection unless there is a wound on head but remember? Carl is not shot at head!

So i decided not to say this out as an explanation. 
Then i was thinking whether seizure can be caused by indirect damage exp: due to brain hypoxia (lacking of oxygen supply to brain)
But i can briefly still remember that Carl was given blood tranfusion from Rick (Group A; RH+ve).


"Is it due to shock?" my friend interrupted my thinking
"u heard of shock? shock is like someone who lost his limb due to serious injury ..." He explained to me.
WOW MY FRIEND KNOW QUITE ALOT. THIS SHOWN THAT HE READ AND HEARD QUITE ALOT TOO...
"ya i learnt about shock...but there are quite a number of shock bro.." i replied.
Shock can be classified into 3 types:

1. hypovolaemic shock eg blood lost OR fluid lost as stated above
2. cardiogenic shock eg heart problem.
3. distributive shock(can be further divided into septic shock, anaphylactic shock and neurologic shock)

***TO READ MORE ABOUT HYPOVOLAEMIC SHOCK AND MANAGEMENT PLZ READ MY PREVIOUS ARTICLE
Direct damage due infection is unvalid due to the healthy undamaged blood brain barrier , the reason of hypovolaemic shock cannt be established too due to the frequent blood tranfusion from Rick to Carl
"bye bye, see u bro...good night' my last sentence to my bro, when his car reached in front of my house.
I had reached my home but question from my friend still hovering inside my brain....
Then ,i tried to linked wound infection with shock suggested by my friend. BINGO! Infection of the wound had caused the blood vessels of  carl to be dilated and expanded, this is like the case of hypersensitivity *** To READ MORE ON HYPERSENSITIVITY ON MY BLOG PLZ FOLLOW THIS LINK http://jiajuin0409.blogspot.com/2011/12/allergic-reaction-by-law-jia-juin.html
This also tell us that the volume and lumen of blood vessels increased due to vasodilation BUT the volume of blood fluid inside the vessel remained constant, thinking the blood vessel as a hose or pipe, blood as water and heart as the power pump for water, the common sense here is when the pipe dilated while volume of water remained ,the pressure inside the hose or pipe must had been decreased, this is why carl blood pressure decreased ,blood cannt be able to reach his brain and the brain must be suffering from serious hypoxia due to oxygen shortage, as a normal response the brain will order the heart to contract and release faster so that the blood can be deliver faster and efficiently to the brain, in order to compensate the need of oxygen supply,  This is why although carl blood pressure dropped greatly, his heart still pumping fast and hard (this situation is known as tachycardia) .The frequent nerve impulses from the brain to make the contraction and relaxation of myogenic cardiac muscle also resulting in the seizure of other body muscles. This type of shock is known as anaphylactic shock, and the management is as below:
1.Fluid resuscitation or infusion  ***TO READ MORE ABOUT FLUID RESUSCITATION  PLZ follow this link http://jiajuin0409.blogspot.com/2011/12/fluid-resuscitation-and-hypovolemic.html
2.mediacation:
a))adrenaline
b))antihistamine
c))glucorcorticoid
d))B agonist

3.oxygen supply (that is why the doct needed ventilator )

But one thing i am still not sure is how can a patient suffering from brain hypoxia due to anaphylactic shock be able to wake up , talk and flash back on the beautiful deer, 

this shown that he is still under conscious and be able to use his higher brain fuction like memory and speech this *doesnt support anaphylactic shock and hypoxia very much T.T*, since most of the time a patient with brain damage due to the lackage of oxygen supplied from shock will remain blur ,speechless, numb and worse remained unconcious!

3 Dimensional printer !

In this modern day, everything had been computerized, a computer can practically reduce our workload. By keying in the values and descriptions a computer can easily help us to imagine out the design of a specific model, and with the help of a cheap printer a 2 dimensional sketch can be produced out for further evaluations.

But things keep changing better and moving forward. I am here to introduce you guys to an even more advance printer ,a 3D printer! This plastic extrusion printer was designed by MarkerBot Industries and is known as CupCake CNC 3D printer .It was sold with an affordable price.

This printer comes in a kit that we can assemble ourselves. This 3D printer can practically mould out any object you saw or touched in your daily life. Some apple's fans can even use it for the design of their own I-phone carrying case, or even a cup or plate lol.

Most parts and moulder of the CupCake CNC can be made by the machine itself. If the times come when demand has outstripped its production capabilities, the costumer can actually make a call to the company to ask them for the production of extra parts in order to pick up the slack.

Fungal infection ,Antifungals agents and antibacterial agent eg:curam-LAW JIA JUIN

BY LAW JIA JUIN

A Statement from author:Today I am going to make my article into points form, because I heard from some readers that my previous articles are too long and hard to be understood. And I myself also find out that reading an article of few hundreds word can be very tired.

B Background: My uncle had asked me what antifungal to be applied for fungal infection.

C Types of microorganism:

•         Fungi/fungus

•         Archae

•          Bacteria

•          Algae

•         Protozoa

•          Viruses

•          Prions

D So…what is fungus and what properties it has?

1.      A fungus is a group of eukaryotic organisms which involves microorganisms such as yeasts and molds ,as well as larger microorganism like mushroom.  <Read also extra info for comparison between prokaryotic organism and eukaryotic organism>

2.      Fungus is neither a plant nor an animal,

3.      It can be unicellular or multicellular,

4.      Its’ cell wall is further enhanced by chitin which doesn’t present in bacterial.

5.      It does not have chlorophyll and so is photosynthesis independent.  <Read also extra info for explanation on the consequences of photosynthesis independent>

6.      Fungi usually feed on dead organisms.

7.      Fungi can be classified based on their site of origins, structure, and type of spores produced. <Read also extra info for explanation on classification of fungi>

8.      Despite we hate fungi due to the annoying symptoms resulted from fungal infection,  they do have important contribution to human life. .  <Read also extra info for the contribution of fungi towards human life.>

9.      Squalene/ sterol found on cell membrane is known as ergosterol, wherease those found in human and animal are known as cholesterol.  <Read also extra info for explanation on the synthesis of ergosterol>

10.  Cell wall of fungus is made up of cellulose, and cell wall of prokaryotic bacterial is made up of peptidoglycan. .  <Read also extra info for explanation on  peptidoglycan>

extra info –by LAW JIA JUIN

1.      comparison between prokaryotic organism and eukaryotic organism:

5.Consequences of photosynthesis independent:

since fungus is photosynthesis independent ,it can occupy dark area and thus:L

a.       invade interior part of body

b.      grow in all direction

These make fungal infection more difficult to be treated.

8. contribution of fungi towards human life:

a. mushrooms serve as food.

b. Fungi can produce antibacterial agents eg:

i) cephalosporium gives cephalothin

 ii)penicillin notatum gives benzyl penicillin.

  iii)Fusidium coccimeum gives fusidic acid

    iv) P.Griseofulvum gives Griseofulvin

7. explanation on classification of fungi.

• Based on the site of origin

• Soil- Geophilic

• Animals- Zoophilic

• Human skin- antrhopophilic

• Based on the structure

• Unicellular- Yeasts- Candida albicans

• Multicellular- Moulds- Penicillium notatum

•Based on types of spore production

• Basidiomycetes- Basidiospores

• Ascomycetes- Ascospores

9. Explanation on the production of ergosterol:

      squalene oxide à cyclosterol

Cyclosterol à sitosterol (in plant only)

OR

Cyclosterol à ianosterol then

Ianosterolà cholesterol in animal

For fungi: Ianosterol (from cyclosterol) à ergosterol

11.explanation on  peptidoglycan:

Peptidoglycan is:

-          polymer of sugars (a glycan)

-          cross-linked by short chains of amino acids (peptide)

-          bacterial peptidoglycans contain N-acetylmuramic acid (component of murein) and N-acetylglucoasamide, bacterial murein is a unique type of peptidoglycan

See photos below:

Why is fungal infection more difficult to be treated than bacterial infection??

BCZ:

-     Fungi have rigid cell wall with chitin coated on it.

-     Cell membrane of fungi are stronger due to the present of ergosterols which contribute to the fluidity and strength of their cell membrane, thus more difficult to be penetrated by antimicrobial and tougher to be destroyed by body enzyme.

-     Mix infection (fungal infection together with bacterial infection) can be resulted, this is because fungi always invade region difficult to be penetrated by antimicrobial agents and also region which do not get enough blood supply. Lacking of blood supply mean blood cells example: white blood cells and antibiotics which fight against bacterial had failed to reach that region .Thus region of fungal infection is usually region which is prone to bacterial infection esp: anaerobic bacterial bcz less blood supply means less oxygen supply as well. Therefore usually antifungal must be used together with antibacterial for effective treatment. Treatment become even harder when the patient is immune compromised example those HIV patients or those who had taken corticosteroid for long period of time.

E.Type of fungal infection.

5 types of fungal infections:

-     Superficial infection -skin hair nail

-     Subcutaneous(upper layer of skin dermis) infection

-     Cutaneous(inner layer of skin dermis) infection

-     Systemic-fever and hypotension (caused by systemic vasodilation resulted from acute            inflammatory response, read also my previous post title: Allergic reaction and inflammatory responses by LAW JIA JUIN link: http://jiajuin0409.blogspot.com/2011/12/allergic-reaction-by-law-jia-juin.html )

-    Opportunistic infection- example HIV and TB patients.

See photos below:

F Antifungal agents/ drugs:

Classified into 6 main classes:

 1.Polyenes eg :amphotericin, nystation

·         Mechanisms of action: selectively bind to ergosterol in fungal cell membrane altering membrane fluidity and producing pores and osmotic cell death. Some people may asked since these antifungals act on sterol wouldn’t it harm human body or cell membrane as well? The answer is no, there are safe when applied to human and animals because they didn’t have much effect on human sterol (cholesterol on human cell membrane ) instead they bind specifically to fungals’ sterol which is known as ergosterol.

2.Azoles class (mostly used) eg: ketoazole, miconazole….

·         Mechanisms of action: Selectively block ergosterol synthesis (not cholesterol synthesis) by inhibiting demethylation of ianosterol. Mamalian or host P450 enzyme less affected.

3.5-flucytosine

·         Mechanisms of action: Converted by fungal cytosine deaminase into 5-fluorouracil; inhibits DNA synthesis. Mamalian cells lack cytosine deaminase so less affected by this drug.

4.Griseofulvin

·         Mechanisms of action: Inhibit fungal growth by binding to microtubules, disrupting mitotic spindles. Mamalian microtubules less affected, so does not harm human being.

5.Echinocandins eg caspofungin, micafungin, anidulofungin

·         Mechanisms of action:  Inhibits fungal Beta glucan(cell wall) synthesis, disrupting cell wall integrity. Mamalian//human host cells have no cell wall thus is not affected.

6.Allylamines eg terbinafine

•              Mechanism of action: selectively blocks ergosterol synthesis by inhibiting squalen e epoxidase(for the synthesis of ergosterol precursor, squalene oxide) . Mamalian host cells do not need this enzyme for squalene oxide production ,thus remained unaffected . < read the “Explanation on the production of ergosterol” under extra info above>

Antifungals for Superficial (Topical) mycosis:

1. Clotrimazole: usually used to treat oral, skin and vaginal fungal infection

2.Econazole: mostly applied for fungal infection on skin fold area and anus

3. Griseofulvin: used mainly for serious untreated topical infection, parenteral//injection via IV is banned since toxic. Can be fungicidal or fungistatic

4.Miconazole: effective against dermatophytes infection on skin

5.Nystatin: usually used for the treatment of tinea pedis// fungal foot infection

6.Amphotericin B: mainly used in IV treatment of fatal systemic infection, inner skin infection and throat (oropharyngeal) infection ,effective for the treatment of various fungal infections specially as

empiric therapy in immunocompromised patients.Work as both fungistatic and fungicidal at different concentrations. Although it gives broad and empiric therapy, it is only used for acute infection in hospital setting, this is due to risk and adverse effect of it, for example the problem resulted from infusion and its’nephrotoxic property.

7.Ketoconazole and others: slow acting and requires long treatment

durations. So less effective against acute infections. usually used for atopic and dermis infection

1,2,4,7 are classified under the class of azole//imidazole

So aution should be taken when these agents are

concurrently administered with:

·          Benzodiazepines, Phenytoin, Carbamazepine

·          HMG-CoA reductase inhibitors

·         Cyclosporine, Tacrolimus and Sirolimus,

·         Methylprednisolone

·          Dihydropyridine calcium channel blockers Verapamil and

·         Diltiazem

·         Sulfonylureas

·         Rifampin, Rifabutin, Vincristine, Docetaxel,

The choice of drug dependent on the type of fungus and the site of infection

Antifungals for systemic mycosis:

_ Amphotericin B: mainly for inner skin infection and throat (oropharyngeal) infection

_ Imidazoles (Fluconazole, Itraconazole, Ketoconazole, Voriconazole, Miconazole)

_ Flucytosine: for treatment of urinary bladder fungal infection

_ Griseofulvin: used mainly for serious untreated topical infection

_ Nystatin: usually used for the treatment of tinea pedis// fungal foot infection

_ Terbinafine:

The choice of drug dependent on the type of fungus and the site of infection

If the antifungal doesn’t work then a stronger or different one must be considered (also consider mix thearapy with antibacterial )because fungus can develop its’ resistance towards drug just like bacterial, for example fungus can change the structure of ergosterol produced or alter the synthetic pathway, so that antifungal can no longer target at them, fungus is as smart as bacterial, it is the race between human and  bacterial LOL.

So as a conclusion I will suggest my uncle to take a drug with the regimen of suitable antifungal and anti-inflammatory agent(treat symptoms of him) eg betamethasone + itraconazone (broad spectrum but less adverse effect than amphotericin B), and also I will advise him to take good care of personal hygience. Also I will advise him not to take antacid or H2 blocker if itraconazone is to be dispensed in oral form instead of cream form. In fact in the market there is already a cream formulation with the combination of betamethasone and antifungal(The choice of antifungal is dependent on the type of fungus and the site of infection) for treatment of topical fungal infection

G.Background 2: My uncle also told me that he was dispensed with antibiotics known as curam.

#Antibiotics are classified into 5 main types based on their target of action on bacterial call:

1.Cell wall synthesis inhibitor types (which can be further classified into Beta lactams group .Under this beta lactam group ,the antibacterial can still be classified into penicillin subgroup, cephalosporin subgroup, carbapenems subgroup. Other cell wall synthesis inhibitor include cycloserine, vamcomycin and bacitracin)

2.Protein synthesis inhibitor (not to be discussed in this article)

3.DNA inhibitor (not to be discussed in this article)

4.folic acid inhibitor  (not to be discussed in this article)

Cell membrane inhibitor (not to be discussed in this article)

Curam is actually a combination amoxycilin (a broad spectrum antibiotic)and clavulanic acid which is an beta lactamase inhibitor. Amoxycilin is relatively safe antibacterial to be used.

+Amoxycilin is situated under:

Antibiotics à Cell wall synthesis inhibitor typesà Beta lactams group(meaning to say that this antibiotic has a special beta lactam ring as its’ functional antifungal unit)àpenicilin subgroupàsecond generation with extended spectrum (gram positive and negative cocci + gram +ve gram –ve bacilli)

?Why is clavulanic acid added into this antibiotics?

This is to fight against the penicillin resisted bacterial. This resisted bacterial had developed a resistance towards beta lactam antibiotic by degrading penicilin antibiotics ,this is done by Beta lactamase enzyme produced by this evolved bacterial. So with the presence of clavulanic acid beta lactamase enzyme produced by this smart bacterial can be inactivated.

+Others ways in which bacterial can evolve and become resisted towards antibiotics (other than beta lactam types):

1With the presence of an alternative enzyme to cheat antibiotic
2Mutation in the target
3Modification of the target
4 Reduced uptake of the antibiotic 5Active efflux of the antibiotic

+Side effect of penicillin type antibiotic eg: hypersensitivity and diarhoea but not 100% will happen