Dengue fever: All facts which you should know




"Dengue Fever : Don't Panic, Know How to Deal With It" by Pratyush kumar mishra - https://www.practo.com/healthfeed/dengue-fever-don-t-panic-know-how-to-deal-with-it-29261/post

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Lychee deaths due to pesticides or hypoglycin A and MCPG toxicity bcoz of lychee consumption???



This news article was there in all leading newspapers recently. All of them carry  the same mistake of misrepresenting facts.
As these are two different studies published in  Lancet and AJTMH.
Both research papers can be accessed online.
The mistakes are :
1. Lancet study was done in Muzaffarpur while AZTMH study in Bangladesh.
2. Lancet study sample size was 104 whereas in AJTMH is just 14.
3. Lancet study also included pesticide sample in their study methodology.
4. In AJTMH, no acute samples were taken.
So Both research studies  are significant papers but may not be unviersally applicable.
So we should not jump to any conclusion very quickly.
Lancet study - http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30035-9/fulltext

AJTMH study- http://www.ajtmh.org/content/journals/10.4269/ajtmh.16-0856

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Snake Bite management guidelines


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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)