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Address: 39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: www.ijcpgroup.com


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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

3rd December Thursday

Dear Colleague,

Excerpts of seminar at DMA held on World AIDS day. Dr KK Aggarwal, Dr Nalin Nag, Dr S C Sharma, Dr Naresh Chawla, Dr Manjul Mehta.

1. When to suspect a patient is HIV positive?
Ans. Always make a habit of asking history of high risk sexual behavior, sexual orientation and sexual practices from a patient. High risk patients need HIV testing.

2. What is Opt out policy?
Ans. In US, now a day, HIV testing is done compulsorily unless the patients themselves opt out. In India, this policy is not applicable though it is under consideration with NACO.

3. What is acute retroviral syndrome?
Ans. It is a phase of acute veronica usually seen three to four weeks after exposure to HIV infected blood/secretion.  The patients present with fever, rash, enlarged lymph nodes. The viral lode is very high at this stage. It is controversial whether or not to treat such cases.
 
4. How is HIV testing done?
Ans. Screening for HIV is done either by Elisa or by Rapid Testing. Unless 20 samples are available at a time, most laboratories are doing rapid testing. Both technologies have equal sensitivity.
 
5. What is HIV testing policy?
Ans. If the first Elisa or rapid testing is negative, no further testing is done. However, if the first is positive, second testing is done by a different method. If two tests are positive and clinically patient has AIDS related illness, treatment can be started. However, if the patient is asymptomatic, if two tests are positive, then third test by Elisa or Rapid technology needs to be done. Unless all three are positive, patient is not labeled as HIV positive.  If the first is positive and second is negative, the patient is not labeled positive. In such cases, one may go for Weston blot test.

6. What are AIDS related illnesses?
Ans. They are defined by presence of opportunistic infections:

a) Tuberculosis: Normally, in healthy persons, 70% people have lung TB and 30% people have extra pulmonary TB. In HIV positive patients with good immune status, the percentage is the same. But when the immunity is low, one comes across more extra pulmonary TB. 

7. What is TB HIV link?
Ans. The dictum is, when you see TB, get HIV done and when you come across a patient with HIV, look for TB.

8. What is the link of Candida with HIV?
Ans. Candida is normally present in diabetic patients, children and in patients on chemotherapy. If oral Candida infection is seen in adults, always rule out HIV illness.
 
9. What is the link of herpes zoster with HIV?
 
Ans. If there is bilateral herpes, recurrent attacks or herpes lesion present in multiple dermatomes, rule out HIV infection.

10. What is the link of Herpes simplex with HIV?
Ans. Ulcerative lesions, big lesions, non healing herpes, rule out HIV.

11. What are other AIDS related illnesses?
Ans. Taxoplasma, Cryptococcus, PCP (Pneumocystis carinii pneumonia), Organ Lymphoma.
 
12. When to do CD4 count?
Ans. This test is a must in all patients at the time of diagnoses. If it is less than 350, treatment must be started irrespective of symptoms. If it is between 350 to 500, treatment is started if there is AIDS related illness.

13. Should viral load be tested in every patient?
Ans. Not at the time of diagnosis, however, after 6 months of treatment, viral load should be done as it helps in diagnosing early resistances
.
14.Should HIV treatment be started in pregnancy?
Ans.Yes, at 14 weeks if HIV test is positive.

15.How do we treat mix infections: HIV, Hepatitis B and Hepatitis C?
Ans.If a patient has a mix infection, always treat all of them together; do not treat one particular infection.

16.If a person is diagnosed to have HIV and an opportunistic infection, can they be treated simultaneously?
Ans. Treat opportunistic infection first. For example, if the patient has TB, give ATT for two weeks and then start ART.

17. What are the drugs of choice for opportunistic infections?
Ans. For diarrhea, it is Septran DS 1 BD or Cipro 500 mg 1BD; for taxoplasma, it is sulpha group; for PCP pneumonia it is very high dose of Septran DS (six  tablets a da0), for Herpes zoster or simplex, no difference in the treatment whether it is HIV positive or negative.

18. Is there role of prophylaxes?
Ans. If the CD4 count is less than 200, patients should be put on Septran DS one daily till CD4 count is more than 200. If the CD4 count is less than 50 patients should be given MAC Prophylaxes with Clarithromycin 500 mg daily or Azithromycin 1250 mg per week. This prophylaxis should continue for minimum three months after CD4 count is more than 200. If the patient in the past has suffered from Cryptococcus infection, he should be given fluconazole 200 mg daily till CD4 count is more than 200.
 
19. What is the standard drug to be started in a patient who cannot afford much?
Ans: He should be started on DUOVIR N or VIROCOM N (combination of lamivudine, Ziduvidine and Nevirapine). The protocol is
a)To start Duovir N one daily in the morning and Duovir one daily in the evening for 14 days and after that Duovir N 1BD to continue.
b)The next alternative is to give DUOVIR E or VIROCOM E.  It is available as a kit and contains lamivudine, Ziduvidine and Efavirenz.
c)Efavirenz is not given in pregnancy.
d)Nevirapine is not given if a patient has Hepatitis.
e)If CD4 count is more than 250 in females and more than 400 in males, Nevirapine is not given.  
f)The goals of ART include viral suppression to a viral load <50 copies/mL

20. What is the role of Stavudine?
Ans. In private sector, this drug is practically not used. Available in 30 mg it has potential side effects.  After two years of use the person develops Catchexia. The three drug combination is available in the name of Trimune 30 (lamivudine, Stavudine and Nevirapine).

21. Is treatment of HIV 1 and HIV 2 different?
Ans. Most Elisa cannot differentiate between HIV 1 and HIV 2. When we are doing HIV testing, out of three one test should be rapid testing. HIV 2 is present in 1% of the HIV population and is resistant to Nevirapine and Efavirenz. It has a slow transmission and more neuro toxicity. These patients should be treated by protease inhibitors (PI based regimens).
 
22. If a patient can afford, what treatment to start?
Ans. One should start with VIRADAY (Tenofovir 300 mg OD + emtricitabine 150 mg + 600 mg of Efavirenz). It is given as OD dose.
The other alternative is TRIODAY (longer acting lamivudine 300 mg + Tenofovir 300 mg and Efavirenz 600 mg). Given as OD dose. Caution: Tenofovir is renal toxic.
 
23. When to start PI drugs?
Ans. They are secondary drugs given when a patient cannot tolerate Nevirapine or Efavirenz. Drug of choice is LOPIMUNE 2BD (Lopinavir 400 mg
plus Ritonavir 100 mg) (PI Booster Regime).

24. Regimens for PEP
1)Low risk exposure: Duovir 1BD for 28 days (monitor CBC, LFT every 15 days. Baseline HIV HBV and HCV testing)
2)High risk exposure; LOPIMUNE 2BD for 28 days.
3)PEP: HIV screening on the exposed individual should be performed at baseline, six and 12 weeks, and at six months after exposure. The majority of individuals who seroconvert will do so within the first three months.
4)PEP is continued for four weeks. PEP should be discontinued if testing shows that the source patient is HIV negative.
5)PEP should be started as early as possible after an exposure (ideally within one to two hours, or sooner, if possible).
6)HIV screening on the exposed person should be performed at baseline, six and 12 weeks, and at six months after exposure. The majority of individuals who seroconvert will do so within the first three months.

26. Regimes for pregnancy
a)No Efavirenz,
b)Duovir N best drug combination
c)At labour add Ziduvidine to the mother 300 mg every 4 to 6 hours till delivery
d) In pregnancy Ziduvidine and Nevirapine are must.
e)If CD4 count is more than 350, do not give Nevirapine, no Efavirenz. PI is a must.
f)Treatment depends on the HIV viral load during pregnancy. Women with low HIV viral loads (<1000 copies/mL) may be able to deliver vaginally. Women with higher HIV viral loads (≥1000 copies/mL) are usually encouraged to schedule a cesarean delivery at 38 weeks of pregnancy.
g) The antiretroviral drug Ziduvidine is usually given during labor, regardless of how the woman delivers, because Ziduvidine helps to reduce the risk of HIV transmission.
h)Other antiretroviral drugs are also continued on schedule during labor or before a cesarean section; this helps to provide maximal protection to the mother and infant and to minimize the risk that the mother could develop drug resistance due to a missed dose of medication.

27 How to treat at birth?
A: Birth: give single dose of Nevirapine within 72 hours + Ziduvidine 200 mg per hour for 7 days. If the mother has received less than four weeks treatment, then child should receive treatment for 6 weeks.  Ziduvidine can help to prevent the infant from becoming infected with HIV as a result of exposure to the mother's blood during delivery.
In infants whose mothers took an antiretroviral medication during pregnancy, the child may be considered HIV negative if at least two HIV PCR tests are negative at >1 month and >4 months of age. If the HIV PCR is positive, it will be repeated to confirm that the child is HIV positive.

28. Can HIV positive mother breast feed?
A: If top feeding is available, breast feeding should not be allowed. Women with HIV who breastfeed can pass HIV to the infant. The risk of transmitting HIV to the infant through breast milk is 7 percent for infants who breastfeed for one year and 10 percent for infants who breastfeed for up to two years.

29. Can an HIV positive patient become father?
Ans. It is possible to take sperms, process wash them and use.

30. What are the latest WHO guidelines?
a.Once CD4 cell count, drops to 350. Currently, patients are put on ART when their CD4 cell count drops to 200.
b.To prevent mother to child transmission, all HIV positive pregnant women should start using the drugs at 14 weeks of pregnancy instead of the previously recommended 28 weeks.

31. What is the importance of viral load?
A. Aim of treatment is to keep it < 50 copies /ml, if <1000 one can go for vaginal delivery and if > 1000 go for LSCS, if > 100,000 treat the patient irrespective of CD4b count.

31. What are the current indications of ART?
Indications of ARV in HIV positive person
c.WHO: once CD4 cell count, drops to 350. Currently, pts are put on ART when their CD4 cell count drops to 200.
d. To prevent mother to child transmission, all HIV positive pregnant women should start using the drugs at 14 weeks of pregnancy instead of the previously recommended 28 weeks.
e.History of an AIDS defining illness 
f.CD4 count of 350 to 500 cells/microL if the CD4 slope of decline exceeds 100 cells/microL/year or the baseline viral load exceeds 100,000 c/mL.
g.In patients with AIDS related neurocognitive disorders and HIV associated nephropathy. 
h.In patients over the age of 50 years
i.Patients who need treatment for HBV related liver disease, but who do not need therapy for HIV, should be considered for early ART initiation with dual active agents against HBV and a fully suppressive regimen versus HIV.
j. In discordant monogamous couples to reduce transmission to the HIV-seronegative partner. 
 

Editor

 

Dr KK Aggarwal

 


Dr Prachi Garg

Reflux Esophagitis Due to Immune Reaction, Not Acute Acid Burn
Dr. Rhonda Souza, of UT Southwestern Medical Center has shown that Gastroesophageal reflux disease might not develop as a direct result of acidic digestive juices burning the esophagus.  Gastroesophageal reflux spurs the esophageal cells to release chemicals called cytokines, which attract inflammatory cells to the esophagus causing the esophageal damage. The condition is manifested by symptoms such as heartburn and chest pain. Currently, we treat GERD by giving medications to prevent the stomach from making acid But if GERD is really an immune mediated injury, may be we should create medications that would prevent these cytokines from attracting inflammatory cells to the esophagus and starting the injury in the first place.


Secondhand Smoke Exposure Worse for Toddlers, Obese Children
Toddlers and obese children suffer more than other youth when exposed to secondhand smoke, according to research presented at the American Heart Association's Scientific Sessions 2009.
Secondhand smoke in children is not just bad for respiratory issues but cardiovascular effects are also important, particularly for the very young and those who are obese.

Sleep Apnea and Risk for Stroke and Death
An observational study of more than 1,000 patients at the Yale Center for Sleep Medicine found that obstructive sleep apnea significantly increases the risk of stroke or death from any cause, and that the risk is linked to sleep apnea severity.  The researchers found the increased risk to be independent of other factors, including hypertension. Participants were over age 50 without a history of heart attack or stroke at the start of the study.

Untreated obstructive sleep apnea has been shown to increase the chance of cardiovascular disease and associated risk factors -- including high blood pressure, heart attack, stroke, and diabetes, as well as injuries or deaths from work-related accidents and vehicular crashes.

Saliva Proteins Change as Women Age
Human saliva can tell whether those stiff joints, memory lapses, and other telltale signs of aging are normal or red flags for disease as protein content of women's saliva change with advancing age. The discovery could lead to a simple, noninvasive test for better diagnosing and treating certain age related diseases like lupus, Sjögrens syndrome. (Dr John Yates and colleagues)

EKG Can Show False Positive Readings for Diagnosing Heart Condition
The electrical measurements on the electrocardiogram can often mislead physicians in diagnosing left ventricular hypertrophy, according to a Henry Ford Hospital study. The study of 500 patients presented at the American Heart Association annual scientific conference Nov. 14 -18 in Orlando found a false positive reading between 77 and 82 percent in patients screened by electrocardiogram. CT scans are considered highly accurate for diagnosing left ventricular hypertrophy. The EKG criteria for diagnosing left ventricular hypertrophy have a very poor sensitivity. So when the EKG shows left ventricular hypertrophy, it doesn't allow the physician to make an accurate assessment, and further screening tools such as cardiac CT, MRI scan, or an echocardiogram are warranted.

Bypassing the Blues: Telephone Treatment for Depression Post Bypass Surgery Improves Quality of Life
Coronary artery bypass graft (CABG) patients who were screened for depression after surgery and then cared for by a nurse led team of health care specialists via telephone reported improved quality of life and physical function compared to those who received their usual care, according to a study from the University of Pittsburgh School of Medicine.

Previous Seasonal Flu Infections May Provide Some Level of H1N1 Immunity
Researchers at the La Jolla Institute for Allergy & Immunology and colleagues have found that previous influenza infections may provide at least some level of immunity to the H1N1 flu. According to Alessandro Sette, Ph.D., an internationally recognized vaccine expert and director of the La Jolla Institute's Center for Infectious Disease swine flu has similarities to the seasonal flu, which appear to provide some level of pre existing immunity. This suggests that it could make the disease less severe in the general population than originally feared.


Three IVF Attempts Double Chances of Live Birth
Just one in three women gives birth after a single IVF attempt, but the cumulative chance of a live birth increases with each cycle. Where women are offered three cycles nearly two thirds go on to have babies, reveals a thesis from the Sahlgrenska Academy at the University of Gothenburg in Sweden.

Current Cigarette Smokers at Increased Risk of Seizures
A recent study determined there is a significant risk of seizure for individuals who currently smoke cigarettes. Boston based researchers from Brigham and Women's Hospital and Harvard Medical School also found that long term, moderate intake of caffeine or alcohol does not increase the chance of having a seizure or developing epilepsy.

Acute Heart Attack Patients Receiving High Ionizing Radiation Dose
Acute heart attack patients received an average total dose of ionizing radiation equal to 725 chest X rays from medical tests during their hospital stay, according to research presented at the American Heart Association's Scientific Sessions 2009.


It was found that heart attack patients admitted to academic hospitals had a cumulative effective radiation dose of 14.5 millisieverts (mSv) - about one third the annual maximum accumulation permitted for workers in nuclear power plants and other ionizing radiation environments. Prashant Kaul, M.D., lead author of the study and a fellow in cardiovascular medicine at Duke University Medical Center in Durham, N.C said that physicians should not only have a greater awareness of dose accumulation from the tests they are ordering, but also understand the testing patterns they use for common diagnoses.


 

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Sleep Apnea May Cause Heart Disease in Kidney Transplant Patients
Sleep apnea is common in individuals who receive a kidney transplant and is associated with increased risk of high blood pressure, heart disease or stroke, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN).
Researchers found that kidney transplant patients are just as likely to have this sleep disorder as dialyzed kidney disease patients who are on the transplant waiting list. Therefore, both types of patients who have sleep apnea should be considered at high risk for developing serious heart related complications.

Cardiovascular disease is the most common cause of death in individuals who receive kidney transplants, and doctors monitor transplant recipients for high blood pressure, or hypertension, and other signs of heart trouble. Obstructive sleep apnea occurs when an individual stops breathing momentarily during sleep due to obstruction of the airway and has been linked to hypertension.

Why Bird Flu Has Not Caused a Pandemic
Bird flu viruses would have to make at least two simultaneous genetic mutations before they could be transmitted readily from human to human, according to research published November 19 in PLoS One.
It is very unlikely that two genetic mutations would occur at the same time that is why avian influenza has not yet caused a pandemic. Besides avian influenza viruses do not thrive in humans because, at 32 degrees Celsius, the temperature inside a person's nose is too low.
H5 strains of influenza are widespread in bird populations around the world. The viruses occasionally infect humans and the H5N1 strain has infected more than 400 people since 2003.


H5N1 has a high mortality rate in humans, at around 60 per cent, but to date there has been no sustained human to human transmission of the virus, which would need to happen in order for a pandemic to occur.
At present, H5 viruses can only infect one of the two main types of cell in the mouth and nose, a type of cell known as a ciliated cell. In order for H5 to transmit from human to human, it would need to be able to infect the other, non-ciliated type of cell as well.


Professor Wendy Barclay, corresponding author of the study from the Division of Investigative Science at Imperial College London, said: H5N1 is a particularly nasty virus, so when humans started to get infected with bird flu, people started to panic. An H5N1 pandemic would be devastating for global health. The new research suggests that it is less likely that H5N1 will cause a pandemic, because it IS far harder for it to infect the right cells. The odds of it undergoing the kind of double mutation that would be needed are extremely low. However, viruses mutate all the time, so we should NOT be complacent.

Infections Such as Pneumonia and Herpes May Heighten Stroke Risk
Infections increase the risk for stroke through an aggregate effect on vascular inflammation. The results, published online November 9 in the Archives of Neurology, suggest a new modifiable risk factor for stroke. Mitchell Elkind, MD, from Columbia University in New York City, has proved that there is an association between various infections and risk of stroke and heart attacks.

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medinews: revisiting 2009

IJCP Group is organizing emedinews: Revisiting 2009, a day long conference on 10th Jan  2010 at Maulana Azad Auditorium. It will be attended by over 1500 doctors. Topics will be happenings in the year 2009. There is no registration fee however advanced registration is required.  Top experts will deliver lectures. CME will be followed by lively cultural evening, doctors of the year award, dance and dinner. For regiatration mail  emedinews@gmail.com. We have crossed 700 registrations.

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Important links sent by Dr Manoj Aron
1. ARBITER 6-HALTS: HDL Raising With Niacin Superior to Ezetimibe
http://www.medscape.com/viewarticle/712399?src=emailthis
2. Distribution of Body Fat Important in VTE
http://cme.medscape.com/viewarticle/711775?src=emailthis

Views:
Concerns about the H1N1 flu vaccine have led some parents to decide not to vaccinate their child. If parents refuse to vaccinate their child with the H1N1 or another vaccine, even after discussing its advantages, is it ethical or not ethical to dismiss the child as a patient, provided that they are given plenty of notice to find another physician? DR.G.M.SINGH.

emedinews comments: you just will have to record it on the file. If they do not want vaccine some doctor will have to take the case.
 

FLU Watch: Financial Times (Vivek Chhabra)
Low public take up of vaccine signals swine flu skepticism
Just one million of the 10 million doses of the swine flu vaccine distributed to immunize the general public have so far been used, indicating slow progress in fighting the current pandemic. David Salisbury, director of immunization at the Department of Health, said yesterday he remained hopeful that more than 11 million people judged at high risk would be vaccinated well before Christmas. Sir Liam Donaldson, chief medical officer, cautioned that the virus was a greater threat to children than normal seasonal flu and could mutate into a more serious form, from which the vaccine could provide protection.
 
 


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