HIV - Management update



NACO follows WHO recommendation to start ART irrespective of cd4 count, clinical stage,age or population ..

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HbA1c : interpretation and common errors


HbA1c measures glycation of hemoglobin and considered equivalent to mean blood glucose over period of 8 to 12 weeks.
It depends on :
  1. Red cell turnover
  2. HbA1c in reticulocytes
  3. Rate of glycation which depends on age of RBCs

Any factor which cause reduced life span of RBCs  may give erroneously low hba1c and vice versa .


Conditions causing high HbA1c
  1. Iron deficiency anemia
  2. Pernicious anemia
  3. Drugs - statins,Aspirin in high doses
  4. Hyperbilirubinemia
  5. Renal failure
  6. Few Hemoglobinopathies
  7. Splenectomy

Conditions causing low HbA1c
  1. Hemolytic anemia
  2. Renal failure
  3. Hemoglobinopathies
  4. Splenomegaly
  5. Drugs - hydroxyurea, Administration of iron and b12, Vitamin c & e ~ antioxidants, TMP-SMX, antiretroviral
  6. Alcoholism
  7. Chronic liver disease
  8. Hypertriglyceridemia

Alternatives for glycated hemoglobin HbA1c are
glycated albumin, fructosamine, or serum albumin-adjusted fructosamine.

Studies done on HbA1c
  1. NHANES Study
  2. DETECT 2
  3. ADAG STUDY
  4. DCCT
  5. UKPDS

The A1C test should be performed using a method that is certified by the NGSP (www.ngsp.org)

Criteria for Diabetes
A1C ≥6.5%(48mmol/mol).The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*
Criteria for Pre Diabetes (ADA 2017)
A1C=  5.7 - 6.4% (39 - 47 mmol/mol)


Reference

  1. American Diabetes Association Standards of Medical Care in Diabetes 2017
  2. Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes  Mellitus    Abbreviated Report of a WHO Consultation - 2011

A2 milk, desi cows and Jallikattu - Need to unlearn what's wrong been taught over years.

Recent debate on the ban of Jallikattu which will decimate India’s indigenous cattle breed (https://thewire.in/19157/banning-jallikattu-will-decimate-indias-indigenous-cattle-breeds/) brought my attention over another ongoing debate in West on a1 vs a2 milk which I feel everyone should know.
Milk contains lots of water, carbohydrates, proteins and fat. Debate is on its protein part which are caseins and whey proteins. Among caseins it's a1 and a2 variant which has brought so much of debate.
A2 is by default in our desi cows and a1 is supposed to be mutant type prevalent in European cows.
A1 and a2 proteins differs by an amino acid, In a1 at 69th position histidine is there whereas in a2 proline is there.
This difference leads to a major change when these proteins are digested in our body. A1 protein because of histidine which form a weaker bond with BCM7, on digestion it gets released which gets absorbed in our body. BCM7 has been found to be associated with type 1 diabetes mellitus, autism, ischaemic heart disease and schizophrenia.
BCM7 is a bioactive peptide beta caseomorphine 7 which leads to harmful effects on immune and nervous system. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475924/)

By default most of our desi cows used to give a2 milk and imported cattles give a1 milk. But now with imported and crossbreed jersey and Holstein Friesian cattles from abroad to increase milk production, We lost our own desi breed in race of quality over quantity of milk.
Those imported cows give a1 milk.

Now since it's been crossbred with our desi cows it's difficult to identify cows giving a2 milk. Although there are genetic tests available in few countries to correctly identify but it's not available everywhere.
It's easy to  identify our desi cows producing a2 milk by the hump on back and flaps of akin beneath it's neck which are absent in exotic cows.

Although it needs more research to substantiate the claims made so far and prove harmful effects of BCM 7, but at present it's better to switch over to our own desi cows for milk.

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ADA - Standard of care in Diabetes - 2017


{Recent changes in ADA guidelines 2017}
1. Emphasis on role of psychosocial care in Diabetes management.
2.Staging of Type 1 diabetes mellitus
Grade 1 - Presymptomatic with Normoglycemia
Grade 2 - Presymptomatic with dysglycemia
Grade 3 - Symptomatic with new onset hyperglycemia
3. New validated screening tool has been added. Its a 7 questions set based on age, sex, weight, family history, gestational dm and h/o hypertension. Score more than 5 signifies increased risk of diabetes.
4. Delivery baby more than 9lb is no longer an independent risk for diabetes.
5. Recommendation to test GDM patient postpartum for persistent diabetes has been changed from 6-12 weeks to 4-12 weeks.
6.In view of emerging evidence on sleep duration and quality on glycemic control, assessment of sleep duration and pattern has been included in comprehensive medical evaluation.
7. Diabetes comorbidities list has been updated with inclusion of autoimmune diseases, HIV, anxiety disorders, depression, disorderedeatingbehavior, andseriousmental illness.
8. In nutrition apart from carbohydrates counting protein and fat counting has been added.
9. Need to interrupt prolonged sitting of more than 30 minutes with physical activity.
10. Long term networking leads to B12 deficiency, requires monitoring and supplementation.
11.Bariatic surgery now referred to as metabolic surgery reinforcing it's role in T2DM management.
BMI cut off has been updated.
12. Pharmacological approach to glycemic control updated:
Empaglifozin and liraglutide recommended reduces CVS mortality in established cardiovascular disease.
Non inferiority of basal plus glp1 agonist versus basal plus 2 rapid acting versus 2 premixed insulin
13. Any of 4 antihypertensives (ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers) may be used in patients without albuminuria.
14. Beneficial effect of specialised therapeutic footwear for patients with high risk of foot problems.
15. there are concern regarding concentration of metformin on the fetal side of the placenta and glyburide levels in cord blood. Insulin remains treatment of choice.
16. In pregnancy target HbA1c is 6-6.5% but optimal is less than 6%.
Targets for T1DM,T2DM,GDM
Fasting - less than or equal to 95 mg/dL
1hr PP - less than or equal to 140mg/dl
2hr PP - less than or equal to 120mg/dl
17. In hospital setting, sole use of sliding scale should be discouraged. Basal insulin or Basal plus bolus should be given, Target 140-180mg/dl.
18.Classification of hypoglycemia
Level 3 - Severe hypoglycemia - severe cognitive impairment requiring external assistance for recovery
Level 2 - clinically significant hypoglycemia is now defined as glucose ,<=54 mg/dL (3.0 mmol/L)
Level 1- glucose alert value is defined as less than or equal <=70mg/dL(3.9mmol/L)







Recommendations of DHR-ICMR Guidelines for diagnosis & management of Rickettsial diseases in India

1. Scrub typhus can occur in areas where scrub vegetation consisting of low lying trees and bushes is encountered, and also in habitats as diverse as banks of rivers, rice fields, poorly maintained kitchen gardens8 , grassy lawns which can all be inhabited by chiggers
2. Presenting manifestations Acute fever is the most common presenting symptom often associated with breathlessness, cough, nausea, vomiting, myalgia and headache
3. the presence of eschar is highly variable ranging from 7-97 per cent. Eschars are painless, punched out ulcers upto 1 cm in width, with a black necrotic centre (resembling the mark of a cigarette burn), which is surrounded by an erythematous margin. Eschar is a pathognomonic sign of scrub typhus.
4. untreated cases have case fatality rates as high as 30-45 per cent with multiple organ dysfunction, if not promptly diagnosed and appropriately treated
5. Presence of rash is common in spotted fever and is extremely rare in scrub typhus. Rash usually becomes apparent after 3-5 days of onset of symptoms. Initially rash is in the form of pink, blanching, discrete maculae which subsequently becomes maculopapular, petechial or haemorrhagic
6. The complications of scrub typhus usually develop after the first week of illness. Jaundice, renal failure, pneumonitis, acute respiratory distress syndrome (ARDS), septic shock, myocarditis and meningoencephalitis are various complications known with this disease

Guidelines for management
1. Definition of suspected/clinical case: Acute undifferentiated febrile illness of five days or more with or without eschar should be suspected as a case of rickettsial infection (if eschar is present, fever of less than five days duration should be considered as scrub typhus)
2. Definition of probable case: A suspected clinical case showing titres of 1:80 or above in OX2, OX19 and OXK antigens by Weil-Felix test and an optical density (OD) > 0.5 for IgM by ELISA is considered positive for members of typhus and spotted fever groups of Rickettsiae.
3. Definition of confirmed case: A confirmed case is the one in which (a) Rickettsial DNA is detected in eschar samples or whole blood by PCR, or (b) Rising antibody titres on acute and convalescent serum samples detected by indirect immune fluorescecnce assay (IFA).
Laboratory criteria
1. Weil-Felix: This test should be carried out only after 5-7 days of onset of fever. Titre of 1:80 is to be considered possible infection.
2. IgM and IgG ELISA: a significant IgM antibody titre is observed at the end of 1st week, whereas IgG antibodies appear at the end of 2nd week. The cut-off value is optical density of 0.5
3. Polymerase chain reaction (PCR)
4. Immunufluoroscence assay (IFA):
5. Indirect immunoperoxidase assay (IPA)

1. Haematology (i) Total leucocytes count (TLC) during early course of the disease may be normal but later in the course of the disease, leucocytosis is seen, i.e. WBC count > 11,000/µl. (ii) Thrombocytopenia (i.e. < 1,00,000/µl) is seen in majority of patients.
2. Biochemistry: Raised transaminase levels are also observed.
3. Imaging: Chest X-ray shows infilterates, mostly bilateral.

Treatment
Without waiting for laboratory confirmation of the rickettsial infection, antibiotic therapy should be instituted when rickettsial disease is suspected.

In adults: (a) Doxycycline 200 mg/day in two divided doses for individuals above 45 kg for a duration of seven days. Or (b) Azithromycin 500 mg in a single dose for five days.
In children: (a) Doxycycline in the dose of 4.5 mg/ kg body weight/day in two divided doses for children below 45 kg. Or (b) Azithromycin in the dose of 10 mg/kg body weight for five days.
In pregnant women: Azithromycin 500 mg in a single dose for five days. Azithromycin is the drug of choice in pregnant women, as doxycycline is contraindicated.
At secondary and tertiary care level
Intravenous doxycycline (wherever available) 100 mg twice daily in 100 ml normal saline to be administered as infusion over half an hour initially followed by oral therapy to complete 7-15 days of therapy.
Or (b) Intravenous azithromycin in the dose of 500 mg intravenous (iv) in 250 ml normal saline over one hour once daily for 1-2 days followed by oral therapy to complete five days of therapy25.

Or (c) Intravenous chloramphenicol 50-100 mg/kg/day 6-hourly doses to be administered as infusion over one hour initially followed by oral therapy to complete 7-15 days of therapy



Rendezvous with Family health centres of Rio de Janeiro

Public health system developed over past few years in state of Rio de Janeiro, Brazil  is definitely one of the better models of primary health care available anywhere. It was indeed a great opportunity to visit family health clinic in urban area and also in slums which is being known as favelas in Rio.

                   

The first thing which you will notice is their commitment towards providing a hygienic environment, well cleaned clinic without much noise and chaos even in the health centre locate in favelas which is the most congested and densely populated area of Rio de Janeiro.








 These health clinics have HIS which stores all the data of patient electronically. 
These clinics are equipped with X ray machine, USG and laboratory which collects all the samples and sends it to a central laboratory.



At the entry you will find a health worker with “may I help” sign. Their duty is to guide everyone towards appropriate place of their need.
As some people only come to collect report, others for investigations, dressing, vaccination or for taking drugs. For these purposes they don't need consultation with doctors and are being managed efficiently at entrance itself. It reduces time and crowd in the clinic.
Next you will find a big map which is google map snapshot of the catchment area of that clinic. This is equally divided based on total number of families in 7-12 groups. Each group is being taken care by team which consists of 1 doctor mostly family physician, 1 nurse, 1 technical nurse, and 5 community health workers. Out of 5 community workers 3 goes out to community and remaining 2 works in clinic daily and they rotate among themselves. Each community Worker has been assigned families out of their area for which they are responsible. Doctor has to spent 40 hrs per week in the clinic and out of this 4 hrs in the community. During the visit, doctor has to see those patients who couldn't come to hospital for various reasons.

Public health care is completely free. All the investigations, drugs, consultation are free. Every 2-3months dental kit with tooth brush and paste are provided free of cost.


For every 2 team 1 dentist is there to look after oral hygiene.
Consultation with specialists from ENT, Ophthalmology, Paediatrics etc are also provided only on reference of their family physicians. These specialist visit these hospital on a weekly schedule.
Each patient has got their health book where all the consultation made are written. They have also got a health app in their mobile to schedule their consultation etc. Whenever they visit the clinic they have to go to their respective team registration area from where they will be given necessary directions.
Each team has got their own team office and consultation area. In the team office you will find data of individuals assigned to each community worker. On an average each team has to look after 2000 individuals. On a big chart You will find picture of Doctor, nurses and technical nurses and below there are 6 groups with picture of respective community worker. In each group there is space for 296 families. By the side of each Family there are 6 Colour coded boxes which is To be filled by community worker. Important data which is to be entered according to colour code in the boxes are age less than 1 year, age 1-5 year, tuberculosis, pregnancy, HTN/DM, HA.


These all details are also available electronically through their HIS. Same goes for vaccination they track all the children in their area electronically and monitor them for vaccination.

 This not only eliminates any form of error but makes healthcare more accessible to the population. Community participation is also there as they are receiving good quality service at affordable price. Affordable because they have to only pay taxes to the govt and in turn get free healthcare.
There are so many things we can learn from their health system, First is the politival commitment of health secretary of Rio towards building a strong public health system which is entirely based on principles of primary health care that are affordable, available, accessible and appropriate. Hygiene and cleanliness can never be achieved only by good administration but also requires community participation and commitment towards keeping it clean.
I would also like to mention few things which are different there like abortion which is illegal, although they promote contraception and condoms are available for free from their health centres. Have a look at this graffiti (anyway in Rio u will find lots and lots of graffiti all around). "FAÇA SEXO SEGURO USE CAMISINHA" which means make safe sex use condoms.
There are many cases reported of early pregnancy in age group of 11-15 years. Only in cases of anencephaly or intrauterine death abortion is recommended.
So would like to thank the health secretary and his team for explaining us everything.



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Family medicine as your career choice.. why and why not!



 Let me clear conflict of interest first. I am Dr. Pratyush and have done my DNB family medicine from Sir Ganga Ram Hospital, New Delhi. I took family medicine at my DNB CET  rank 1725, where during councelling i had options of other clinical specialities like medicine, peds etc at periphery centres. Since i have thought of doing my own “start up” ..to setup my own clinic near to our village, Family medicine was the best option for me.
Every one of us (postgraduate aspirant) may not have decided their plan post their pg courses. Some decide based on their rank, some are clear about their choice and they wait till they get their dream branch. But most of them finally end up doing postgraduate courses and with time everything settles. Life moves on.
Family medicine is not a new branch, in fact its into existence for past so many years. Family medicine is that speciality which finds its place most of govt health reforms plan. But beyond that there is still need of more political committment.
Family medicine is a broad speciality which is designed for specific purpose and that is primary care. Need for primary health care is huge in country like India with over a billion population. Family medicine deals with all age groups and all body systems, its a concept of generalism. There is huge potential for this specialty in terms of job, affordable and quality health care. Only thing we need is more structures health care with defined role of family physicians.
Training in family medicine covers various specialty like internal medicine –  9 months, obs – 3 months, peds 3 months, surgery 3 months, ICU and emergency medicine – 3 month, ent,ophthal, psychiatry, dermatology postings. It also include posting in primary health care. Duration of these postings is not uniform across all institutes. But over all, major posting is medicine then peds, surgery and obs gynae.
Rest all other rules are similar, you have to submit a thesis for which your guide and co -  guides can be from any speciality belased on your thesis topic. At the end you have to give exam which consists of 4 papers. Paper 4 is mcq based only from community medicine. Rest all subjects are asked in other 3 papers. Theory exam is not that tough as it seems because you are expected only the basics.
In practical exam you get 2 cases of medicine, 2 cases of peds and 1 case of surgery or obs/gynae. There will be a separate medicine viva, peds viva and community medicine viva.
Frequently asked questions.
1. I want to do only medicine posting/surgery posting during my tenure as i am intrested only in surgery/medicine.

No, its not possible.

2. Can i extend my posting in few specialities of my choice?

Look, generally u have to follow the set pattern which your institute have made it for its DNB trainees and is also based on NBE guidelines.

3. Can i do superspeciality/subspeciality courses in neurology, cardiology, gastroenterology?

No, if you are interested, u should only take general medicine not family medicine.

4. Any other courses available after family medicine?

Yes, u can do geriatrics, palliative care and various other skill based courses.

5. Are family residents being treated equally in departments being posted?

Mostly yes, you will be treated at par with other residents of department and will be given opportunities in various academic programs of that department. But it also depends on your sincerity and dedication.

6. Is it similar to community medicine?

No, Both are different and their curriculum is different. Family medicine is a clinical speciality where you are going to practice as family physician.

7. Is it a approved/recognised course?

There should be no confusion regarding it. Its approved by MCI and after completing your training you can update it in your MCI and state medical council registration.

8. Is their any postgraduation MD family medicine courses?

Yes, it has been started. New AIIMS which have been set up have also got Department of community and family medicine.

9. What about research opportunities ?

There are lots of research opportunities in this field. We have many journals like journal of family medicine and primary care, rural and remote health etc. If you are interested in research, family medicine and primary care will never disappoint you.

10. What about family medicine conferences?

There are many conferences which takes place at national and international level. WONCA which stands for world organisation of family doctors conducts various confernces on various themes in association with regional groups. Details you can check it on website wonca.net .
In India we have Academy of family physicians of India which supports and promotes family medicine. AFPI has got a journal jfmpc.com . AFPI has got various state chapter which conducts regular CMEs and orientation programs. AFPI conducts national level family medicine and primary care conference. Next conference is at Kochi from 26 jan 2017. There are various bursaries and awards to support you for your travel in many international conferences.


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