HCFIe-Medinews A Service of IJCP Publications Pvt. Ltd.WFR
Address: 39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: www.ijcpgroup.com

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Member,
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)


 

FIRST NATIONAL DAILY MEDICAL NEWSPAPER OF INDIA

30th November Monday

Dear Colleague,

 Exposure to HIV, Hepatitis B and or Hepatitis C Blood

Following are the excerpts of a press conf held a DM and addressed by Dr Naresh Chawla, dr Ashwini Dalmiya and dr KK Aggarwal


Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV.

Co infection with HIV and hepatitis C infection or HIV with hepatitis B infection is also common since all three infections share similar routes of transmission. Approximately 30 percent of patients who are HIV infected are also co infected with HCV and 10% with chronic hepatitis B infection.
The prevalence also depends on the route of transmission. Hepatitis C virus seroprevalence in HIV infected patients is seen in up to 73 percent in intravenous drug users and 4 percent in patients considered to be at low risk.


Injection drug users usually acquire hepatitis C virus before HIV infection while men who have sex with men typically are infected with HIV before they acquire hepatitis C virus infection. Hepatitis C virus is transmitted efficiently via percutaneous routes, so seroprevalence rates are highest in intravenous drug users. Injection drug use is currently the leading route of HCV transmission.

 
Transmission
In order to be exposed to a blood borne pathogen, one must have contact with virus containing blood, a visibly bloody fluid (sputum or urine containing blood), or another bodily fluid (semen or vaginal secretions). The blood or fluid must come in direct contact with some part of the body. A virus can enter the body through the bloodstream, open skin, or mucous membranes (eye, mouth, or genitals). Contact with skin that is intact (without new cuts, scrapes, or rashes) poses no risk of infection.
Thus, exposure to a blood borne pathogen is possible after a skin injury such as a needle stick or cut with a sharp object or contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or vaginal tissues are injured) or non intact skin.
Hepatitis B virus is the most infectious virus that can be transmitted through the blood or bodily fluids. A healthcare worker who is stuck with a needle containing blood infected with hepatitis B virus has between a 6 to 30 percent chance of developing hepatitis B. The risk of hepatitis C virus and HIV in the same situation is 1.8 and 0.3 percent, respectively.
Hepatitis B virus gets transmitted by percutaneous and mucosal exposures and HUMAN BITES. It has also been transmitted by FOMITES such as FINGER STICK BLOD SUGAR CHECK, multi dose medication vials, jet gun injectors, and endoscopes. The virus can SURVIVE ON COUNTER TOPS FOR SEVEN DAYS and remain capable of causing infection.

Transmission of hepatitis C virus from blood splashes to the conjunctiva has been described. Hepatitis C virus has been demonstrated to survive on environmental surfaces for at least 16 HOURS but not four or seven days.

WHAT TO DO AFTER BLOOD OR BODY FLUID EXPOSURE?


1. The first and most important step after being exposed to blood or bodily fluids is to wash the area well with soap and water. One can clean small wounds and punctures with an antiseptic such as an alcohol based hand gel, since alcohol kills HIV, hepatitis B virus, and hepatitis C virus. For mucosal surfaces (mouth, nose), the area should be flushed with copious amounts of water. Eyes should be flushed with saline or water. THERE IS NO EVIDENCE THT EXPRESSING FLUIDF BY SQUEEZING the wound will further reduce the risk of blood borne infection.


2.  The risk of becoming infected with hepatitis B is greater than the risk of becoming infected with other viruses. Hepatitis Vaccine should be given to anyone who is exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to fully protect you against future infection. If a person is already vaccinated he or she should receive a single booster dose of the vaccine after being exposed to potentially infected blood.


3.  If the exposed blood is positive for HBV and the exposed person is unvaccinated treatment with hepatitis b immune globulin is recommended. It contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. A dose of hepatitis B vaccine is recommended at the same time. HBIG is not needed if the exposed person is already fully vaccinated. If not sure about the vaccine status do a blood test to determine if there are adequate levels of antibodies to the virus. If antibody levels are low, HBIG and the series of three Hep B vaccines are recommended.


4.  Hepatitis C Virus can cause chronic liver disease. There is no vaccine for it. Blood tests should be done immediately after exposure to measure the liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop.


5. For HIV teatments are available to reduce the risk of becoming infected with HIV after exposure. The use of an anti HIV drug zidovudine, can reduce the risk of healthcare workers becoming infected with HIV by 81 percent. This means that the number of people who are likely to become infected from a needle stick that contains HIV infected blood can be reduced from 3 in 1000 to 0.5 in 1000 as a result of taking anti HIV medication.


6.  The risk of becoming infected with HIV as a result of exposure to  trauma and rape  is even lower than the risk of infection after a needle stick. All rape victims should be given anti HIV drugs.


7. All women of childbearing age should be tested for pregnancy before beginning treatment, although being pregnant does NOT mean that a woman cannot take anti HIV medications.

8. Anyone who is exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months post exposure.


9.  Experts from the US CDC recommend use of drugs to reduce the risk of HIV infection if all of the following criteria are met:
  1. Exposure occurred less than 72 hours previously
  2. One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle)
  3. One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood


10. The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when intact skin was exposed; or when the bodily fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.


11.  Anyone who is exposed to blood or bodily fluids should consult with doctor if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks.


Treatment regimen
1. Anti HIV preventive treatments should be started as soon as possible after exposure, within a few hours rather than days.
2. Preventive treatment is not likely to be helpful and is not recommended if more than 72 hours have elapsed since exposure.
3.  The CDC recommends a combination of two or three medications to prevent developing HIV after exposure.
4.  Four weeks of treatment is generally recommended.

FOLLOW UP
1. For people who are given the hepatitis vaccine, it is important to return for the second and third injection to be completely protected.
2.  People exposed to a blood borne infection during sex are often tested for other sexually transmitted diseases. Tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later.


PROTECTING OTHERS AFTER EXPOSURE
1. PRECAUTIONS are important during the first three months after exposure, when most people who are infected with HIV become antibody positive.
2.  Precautions include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting hepatitis B, hepatitis C, or HIV infection to others.
3. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time.
4.  Individuals who were exposed to HIV infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow up period.
5. Women who are breastfeeding should stop breastfeeding due to the risk of passing the infection to their child.

Dr KK Aggarwal

Editor

 


 

Daily Dose of Nuts is Good for Heart

Take a daily dose of nuts: walnuts, almonds, pistachios. They helps to control cholesterol. They include unsaturated fats, omega 3 fatty acids, and fiber, 1 arginine and plant sterols. Nuts have been shown to reduce LDL, or bad cholesterol. Eating nuts also can reduce the risk of developing blood clots and improve the health of the lining of the arteries. Patients can take, choose unsalted or low salt versions and use nuts as a substitute for saturated fats, such as those found in meats, eggs and dairy products. (Mayo clinic)

Autoimmune Disorder Linked to Stroke, Heart Attack in Women
Women under 50 and who smoke or take birth control pills have great risk for heart attack and stroke if they suffer from autoimmune condition called Antiphospholipid syndrome. The syndrome occurs when auto antibodies attach to cell membranes and interfere with the normal clotting mechanism of the blood. Women with lupus anticoagulant who smoke or take birth control pills have a much higher risk of stroke and heart attack. (SOURCE: The Lancet Neurology)
 

Kidney stones, malaria, depression and respiratory illness all may increase with global warming.
Kidney stones, malaria, Lyme disease, depression and respiratory illness all may increase with global warming, researchers at Harvard Medical School said.Climate change from the burning of fossil fuels will add to risks to public health, said Paul Epstein, associate director of Harvard's Center for Health and the Global Environment in Boston.

HIV/AIDS said to overshadow biggest threats to children.
Diarrhea does not  make headlines. Nor does pneumonia. AIDS and malaria tend to get most of the attention.  But, data indicate that pneumonia and diarrhea kill an estimated 3.5 million kids under five each year,  more than HIV and malaria combined.

Treating patients with darbepoetin to improve hemoglobin levels may cause more problems than it solves.
According to a study presented at the American Heart Association's annual meeting, treating patients with diabetes, kidney disease, and anemia with the colony stimulating factor darbepoetin  to improve their hemoglobin levels appears to cause more problems than it solves.

Chronic secondhand smoke exposure may increase risk for type 2 diabetes.
According to a study published online Nov. 13 in the journal Diabetic Medicine, chronic secondhand smoke exposure significantly increases the risk for type 2 diabetes.Chronic exposure to secondhand smoke significantly increased the likelihood of having type 2 diabetes by 63 percent.Each year of exposure to secondhand smoke is associated with a two percent increased chance of developing the condition.


Intravenous iron may increase odds for improvement in patient-reported heart failure symptoms.
Treating iron deficiency in heart failure patients makes patients feel better even in the absence of anemia according to a study presented at the American Heart Association meeting and published online in the New England Journal of Medicine.
 
 

 

Letters to the editor

1. A recent review of 117 trials and 26,000 patients suggested that, among second generation antidepressants, escitalopram and sertraline were best, and sertraline seemed the best overall because it is cheaper. However, this editorial says that the conclusions may be wrong. 

Among SSRI's, Sertraline and Citalopram/Escitalopram are among the most prescribed antidepressants worldwide and their safety in general population including special categories (like pregnancy and breast feeding) is well known clinically based on atleast level 4 or 5 evidence(since RCT is not ethical). Dr Neeraj.

2. Respected Sir, Kindly enlighten me on the legal validity of  DO NOT RESUSCITATE POLICY that administrators like me have to face especially in cases of terminal illness like end stage of some carcinoma and in cases where a patient is suffering of multiple organ disease and the family has exhausted all its financial resources. Hoping for an early reply. Kindly permit me to say that emedinews has been an enlightment for physician-administrators like me. Dr. Sanjay Durani

Emedinews comments: the policy is under consideration with the law ministry. As on today there is no such policy in India. We may have to take decisions from case to case basis.

3. With due respect to Dr Veena`s personal experience, I suggest use of IM Adrenaline, to begin with, in case of anaphylaxis. This is the evidence based current best practice in view of giving the appropriate dosage for desired action in a patient having anaphylaxis besides easiest and fastest to deliver. This also is my personal experience in the emergency rooms overseas where we get more numbers of anaphylaxis then compared to India. In fact, all the patients in developed world are trained how to use the auto-injector (both adult and pediatric fixed dose available) before being discharged from the hospital after they are treated for anaphylaxis, and are able to save themselves in austere environments if anaphylaxis strikes them again. Another advantage is, that you can use these auto-injectors without exposing the patient as the needle can safely and easily penetrate through the trouser/jeans for IM route, thus saving further precious seconds. In India, DRDO is the only Indian organisation making auto-injectors which appear of questionable quality on gross appearance when compared to what is available in the west  and I am not sure if DRDO is making Adrenaline auto-injectors. I am also told that contrast auto injectors (imported) are being used by radiologist: well reflects our priorities! Dr Vivek Chhabra,
4. Are not topical NSAIDs also known to exacerbate peptic ulcer like their oral counterparts? Why not consider another safer group of potent painkillers like tramodol or codeine, as the patient is crying (meaning severe pain) Dr Vivek

Emedinews comments: both are valid options.

5. Sir, why govt. servants are not allowed to consume branded medicine written by medical consultant. Rather Delhi govt. insist ( Delhi govt. employees health scheme) on consuming generic medicine or, medicine available in the government store or, govt. hospital. If these have any adverse effect on health ( if yes) how do you help us in bringing about a change in the legislation as our leader. D Bijan dey
Emedinews comments: Generic drugs are as safe and efficacious as branded ones. Even MCI talks about using the generic versions. You can have a company marketing both the branded and the generic version at the same time. Generic does not meal local made. The cost of generic is lower as the brand market cost is not there.

6. Is Dabigartan (Anticoagulant) and coagucheck (for home INR monitoring) available in India. Dr TM Agrawal
Emedinews comments: a. coaguckeck is available by Roche diagnostics
b. dabigartan is available internationally under the name pradaxa. NA in India. 

 

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Funny clinical notes (Dr. Minakshi)
The patient is tearful and crying constantly. She also appears to be depressed.

Dr Good Dr Bad
Situation:   A diabetic was found to have HDL cholesterol of 29 mg%.

Dr Bad:  No treatment is required
Dr Good: You need treatment for this

Lesson:  Drug therapy should be started in all diabetics with a serum HDL cholesterol concentration <35 mg/dl or marked hypertriglyceridemia.

 

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medinews: revisiting 2009

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OPTICAL PRINCIPLES (Dr. Narendra Kumar)

Dioptre. It is the unit of measurement (D) in optics, used to describe the power of a lens. A one dioptre lens focuses light one metre away from it. The dioptre is the reciprocal of the focal length in metres; thus a 2D lens has a focal length of 0.5 metre.

Reflection. Light rays traveling through space are either absorbed, reflected, or pass through the object they hit. A black object absorbs light rays, converting these to heat energy. A white object reflects light rays. And, a transparent object allows light to pass through it. Reflection is the phenomenon of seeing yourself in a mirror.

Refraction. It is the bending of a ray of light passing through a transparent medium. Refractive index (n) is a comparison of the speed of light in air and when it passes through a transparent material (medium). The amount of refraction (converging or diverging) through a lens depends on its index of refraction.  Crown glass has a refractive index of 1.523.

Plus lenses  (+) produce magnification. In a plus lens, the centre is thicker than the edge. The higher powered lens is also heavier in weight.  Its optical property is to converge light. These lenses correct hypermetropia (or hyperopia). The lenses are also used for patients who cannot focus at close distances (presbyopia).

Minus lenses (-) produce minification. In a minus lens, the centre is thinner than the thick edges, and the bigger the lens and higher the power, the thicker the edge. Too much minus power in the prescription sometimes results in stress, leading to visual fatigue especially while doing near work for a long period. Accommodation can usually be relaxed by giving rest to the eyes in-between continued near work.

Cylindrical lenses. A spherical lens has the same power in all directions from the optical centre. A cylindrical lens has power in one direction only. To an astigmatic person a point of light may look like a line of light in a specific direction and a circle may look like an oval shape. Cylindrical lenses have a direction of power and a direction of axis. In writing prescriptions, it is important to record the direction of axis in degrees.
 
Aphakic lenses. In old age, the lens inside the eye becomes opacified, resulting in cataract. Since a cataractous lens does not allow light to enter the eye, vision gradually gets diminished. This lens is removed by means of surgery, and the patient becomes aphakic (without lens). Removing the lens removes about +10.00D optical correction of the eye. However, cataract surgery is now done along with the implantation of an intraocular lens (IOL). In cases not receiving an IOL at the time of cataract operation, contact lens is an excellent alternative to achieve good vision and a better field of view. Aphakic lens is a high plus lens. This is thick and heavy, and makes the patient's eye appear enlarged.

Bifocal lenses are a combination of two powers, one for distance and the other for near. Bifocal lenses are generally prescribed for presbyopic persons. Bifocals are a fearful thing for many persons. But judiciously fitted bifocals are a real boon for someone requiring two different optical corrections for two different working distances. The near add power needs to be increased as age advances, as the older the person the weaker the accommodation.

Progressive power lenses. The one reason behind the non-acceptability of bifocals by early presbyopes is that they themselves don't want to admit, and at the same time don't want to tell others, that they are approaching middle-age.  And, the no-line bifocal, or the progressive power lens, is in a way an effective answer to this problem. Progressive power lenses are designed to provide a smooth range of near focusing distance, with no sudden jump between power zones. These lenses have a large distance area with stable (or near stable) power, stable reading area, and a progressive power in between.

Lens forms. Lenses may be of plus, minus, or plano (plus minus)variety. A spherical lens has the same curvature and same surface power in all directions. A cylinder or a toric lens surface is made of two different curves at 900 to each other. And the axis of a cylinder surface is the meridian having the least power.

Prism. Movements of the two eyes together in different directions is made possible by the action of six external muscles. However, the muscles of the two eyes must respond together so that there is no squint. A tropic eye is the eye turning in an abnormal direction and is a hindrance to binocular vision. In phoria, patient's eyes are interrupted from working together. Rather than actual squint, there is the tendency of the eyes to deviate when binocular vision is disturbed, in the presence of fatigue, stress or illness. The ophthalmologist or optometrist may prescribe prism in the presence of high phorias. The property of a prism is to bend light. There is a base at one end and an apex on the other end of a prism. The light is bent toward the base of the prism.

Decentration. When we put two prism bases together, a plus lens is formed. When we put two prism apexes together, a minus lens is formed. When the optical centres of the lenses are placed in a spectacle frame exactly in front of the pupils of the eyes, there is no creation of the prism.  But if the pupillary distance is set incorrectly, prism will be created. Induced prism is especially harmful to persons with strong prescriptions.

Pupillary distance. Pupillary distance (PD) is the distance between the centres of the two pupils.  Distance PD is always more than near PD. When the distance between the optical centres of the two lenses in spectacles is different than the pupillary distance, induced-prism is created which gives  rise to eye strain. And the higher the prescription power, the higher the amount of induced prism.

Dispersion. All colours travel at the same speed through air. In a denser medium, colours travel at different speeds; red colour travels the fastest, and violet colour the slowest. When a ray of white light enters a prism, its component colours bend differently at each of the prism’s surfaces. The prism, thus, breaks light into its component colours, and the phenomenon is called dispersion.

 

 

 

 


 

 

 



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