Transmissible Spongiform Encephalopathy – Prion Protein – Kuru Disease

Transmissible Spongiform Encephalopathy – Prion Protein – Kuru Disease

Introduction: Prions or infectious protein were big news in 1980, when it becomes clear that these proteins cause diseases.

In year 1997, B. Pruisner received the noble prize in medicine for his discovery of prions “An     entirely new genre of disease causing agents.” Even though Prusiner’s work started in 1972, by 2017 we have got only a sort of understanding about prions.

Researchers from case Western Reserve University have synthesized an clear that artificial human prion in June 2018, which is deadly contagious and responsible for causing transmissible spongiform encephalopathy. Their works were published in the journal “Nature Communication” in the first week of June.

Now there may be arousal of a transmissible spongiform encephalopathy?

It is the rare form of brain wasting diseases and the name signifies ‘transmissible’ means infectious in nature, ‘spongiform’ means sponge like and ‘encephalopathy’ signifies disease process in brain or ‘infectious brain disease process where brain become sponge like.’

It is a fatal neurodegenerative conditions in human and animals where the healthy brain tissues are replaced by cluster of tiny liquid filled thin wall cavities and making the brain ‘sponge like’ due to accumulation of misfolded proteins i.e. Prion proteins.

After many years of discovery until now our understanding of prions in the brain has been limited and till now it is a curable, invariably fatal diseases.

History: It is a known for approximately 200 years and is proto-typical prion disease affecting sheep, goats had been known since 18th The crucial break through was achieved in the 1930s by the experimental transmission of Scrapie to goats.

Carleton Gajdusek demonstrated the kuru, a disease affecting the aboriginal people of Papua New Guinea was a TSE. The incubation period of the disease was longer than investigator’s persistence.

William Hadlow suggest that kuru resembled scrapie hence might exhibit a very long incubation period. After influencing by this Gajdusek achieved transmission of Creutz-feldt Jakob Disease(CJD).

History and discovery of prion disease
Pic.1- History and discovery of prion disease

 

Whereas, CJD in human was exceedingly rare. Its incidence is typically  inhabitants / years in Switzerland. However, several aspect of CJD epidemiology continue to be enigmatic and a screen for recognized / hypothetical risk factor for CJD has not exposed any causal factor to death.

 

  • Prion Protein: Prions are the natural human protein, coded by PRNP gene located on the short arm of chromosome no. 20 (between the end of the arm and position 12) known as CD230 (cluster of differentiation).

Expression of the protein is most pre-dominant in the nervous system (cell membranes of neurones), though it found in many other tissue of the body.

  • Structure of the Prion Protein: PrP is highly conserved through mammals consists of a globular domain with 3α-helix and a two strand anti-parallal β-sheet and -NH2 terminal tail and a sort -COOH

The primary sequence of Pr, 253 amino acids converts into mature protein having 208 amino acids long after post-translational modification.

PrP messenger RNA contains a pseudoknot structure (Prion pseudo-knot) which is thought to be involved in regulation of PrP protein translation.

Structure of PrP^c and PrP^sc
Pic.2- Structure of  Pr  and Pr

 

  • Functions of Cellular Form of Prion Protein: All though the exact functions of Pr is unknown and based on structural similarity, it has been proposed that Pr might function as a member of the Bcl-2 family of protein. It might have role in-

 

  • Synapse between neurons that can cause long term memory
  • Uptake of copper into the cell
  • Differentiation neuronal stem cell
  • Neurogenesis
  • Neuritogenesis
  • Neuronal survival via anti-/pro-apoptotic function
  • Red-ox haemostasis
  • Long term renewal of haemopoetic stem cell
  • Activation of T-cell
  • Differentiation and modulation of phagocytosis of leukocytes
  • Altering leukocytes recruitment to site of inflammation

 

  • Difference between Prand Pr:

 

Features   Pr (Normal cellular isoform) Pror Pr  (Scrapie isoform)
1.  Cellular dimorphism 43% α-helical and 3% β-sheet 30% α-helix and 43% β-sheet
2.  Sensitivity to enzyme protease Sensitive  Resistant
3.  Solubility in water Soluble Insoluble
4.  Location Located anchoring to the cell membrane Mainly present in cytoplasmic vacuoles

 

  • Transformation of Prfrom Pr: Prdifferent domains that play different roles in the conversion of PrPr. The first one is stable and ordered ‘core’ domain which contain GPI lipid anchor (Glycosyl Phosphatidyl Inositol) that tethers Pr to the plasma membrane, 3α- helix (helix A, band C) , 2 asparagines amino acid linked oligosaccharides and a protein binding sites capable of lowering the energy barrier for the conversion of Pr to Prwhen Prbinds to protein X (a species specific co-factor necessary for conversion of Prto Pr
Changes after transformation from Pr  to Pr
Pic. 3- Changes after transformation from Pr  to Pr

  

The second domain is a ‘variable’ or disordered domain which interact with Prand changes the Prconformation from unstructured form to the β-sheet of PrDuring conversion, helix A of the core domain of Pr also gets converted into β-sheet.

According to Sanley B. Prusiner’s theory,1997 once infected prion protein (Pr/ Pr) are carried to the neurones, they bind to the normal Pr on the cell surface, as a result, there is release of Pr from the cell surface followed by conversion into Pr/ Pr (as described before), by pot-translational modification by Pr.

When the cells synthesize Pr (new) by repeated cell cycle, a large no. of Pr is formed.

Pr being aggregated forms amyloid like plaques in the brain. As these plaques consist of host proteins, so there is no immune response or inflammation.

Abnormal misfolded proteins are internalized by neurones and get accumulated inside the cytoplasmic vacuoles mostly in the cells of the neurone. Thereby it enhances apoptosis with the help of 14-3-3 protein and large no. of cells are died off and cyst is formed in the brain that causes appearance of sponge form and it degenerates mainly cerebral cortex and cerebellum.

Due to above reasons there is following changes ultimately-

  • Vacuolation of the neurones
  • Formation of amyloid containing plaques and fibrils
  • Proliferation and hypertrophy of astrocytes
  • Fusion of neurones and adjacent glial cell
Coronal section of brain showing the vacuolation in brain due to prion disease
Pic. 4- Coronal section of brain showing the vacuolation in brain due to prion disease

 

  • Disorganisation of Prion Protein: Though it is hypothesized that Pr, the protease resistance forms are responsible for the prion disease, there is a protein sensitive (Pr) but disease associated translational form has also been described.

According to “Protein Only Hypothesis”, we are accepting Pr as the infectious agent, whereas there is “Not Only Protein Hypothesis”, because it is found that 25nm long virus like particle demonstrated in the cell culture with Creutz-feldt Jakob disease and Scrapie. Interestingly, these particles are similar to tubulo-vesicular structure found in all TSE form.

It is generally accepted that prion diseases are prion disease are transmissible, hence the name is transmissible encephalopathy and it is invariably fatal. Though transmissibility may fail in certain disease form associated with amyloidogenesis and there may be a sub-clinical carrier state in different species including human beings.

 

  • Classification of Prion Disease/Transmissible Spongiform Encephalopathy:

No distinct rules/theories can be applied for this classification. TSEs are classified on the basis of their pathogenesis mainly-

  • TSE in Animals:
  • Scrapie Disease: This phenotype of prion disease has been extensively studied. It is commonly found in sheep, goats, mouflons. They are of two types-
  1. Natural Scrapie: It is spreaded by vertical transmission i.e. parent to offspring or rarely by direct contact. After incubation period of 2 years, the affected sheep become irritable and develop intense pruritus, scraping themselves against trees and rocks and hence the name Scrapie . Gradually, emaciation and paralysis occur leading to death.
  2. Experimental Scrapie: The disease can be experimentally transmitted to various animals (research purpose) to several breeds of sheep and other animals by infection of natural tissues of infected sheep. In hamsters and mice, the incubation period is less and facilitated the study of the disease. Different breeds of sheep exihibit marked genetic defects in susceptibility to the infection 0-80% , whereas goats have 100% susceptibility.
  • Transmissible Mink Encephalopathy: Scrapie like disease in mink transmitted by feeding the mink on scrapie infected sheep meat.
  • Bovine Spongiform Encephalopathy / Mad Cow Disease: It commonly occurs in cows, lions, tiger, cheetah, puma, bison and exotic antelopes. It was enzootic in cattle in Great Britain since 1986. The epidemic in 1993 infecting over 1 million cattle with infection spreading to European countries. BSE in transmitted due to practice of feeding the cattle with meat and bone meal contaminated with Scrapie / BSE proteins.
  • Chronic Wasting disease: It occurs in captive and free range cervids of mule deer, elk.

 

  • Human TSE:
  • Familial CJD: It is the second most group of human prion disease. Disease prevalence rate is approx 10-15%. It occurs due to mutation in PRNP gene. Most common mutation occurs at 200th codon where glutamic acid is converted into lysine and as a result the entire potein is misfolded.

 

  • Variant of familial CJD: It runs in families. There are following variants-
  • Fatal familial insomnia: It is due to the germ line mutation in PRNP gene at 178th codon where aspartic acid is converted into asparagines. Therefore, misfolded prion proteins build up mainly in the thalamus, that regulates sleep rather than causing the typical spongiform degeneration in the cortex and cerebellum, occurs in most other types.
  • Gerstman- Straussler- Scheinker Syndrome: It is extremely rare form of neurodegenerative disorder of brain. It is almost always inheritent and is found only in few families around the world. Onset of the disease usually occur between the ages of 35 and 55 years. It slowly progresses and is usually lasting for 2-10 years. There may be polymorphism at codon 129/ codon 219 of PRNP gene and may associate with pro to lew point mutation at codon 102 of the PRNP gene, as found in large new Italian family in 1997.

 

  • Variant CJD: It is caused by eating the meat of animals having prion in the muscle tissues. Prions enter into blood stream after absorbing through intestine. Somehow these proteins crosses blood brain barrier and enters into the neurone by a process called adsorptive endocytosis, where the plasma membrane of the nerve cell folds inward to bring in substance otherwise not able to cross plasma membrane by themselves. As the prion is in the blood stream, this disease can be spread by blood transfusion. As it was occurred in UK, 1980. In Britain,1996, there was raised fears of infection through eating BSE infected beef among younger (below 45 years).

 

 

  • Iatrogenic CJD: It is caused by medical procedures or by equipment used for that procedures like-
  1. Corneal transplant gets contaminated and infects healthy individuals
  2. Electro-encephalogram (EEG) electrode implantation
  3. Duramatter graft implantation (>160 cases have been recorded
  4. Human growth hormone and pituitary gonadotropin therapy (>180 cases have been recorded)
  5. Mostly iCJD occurs in patient between 50-75 years.

 

  • Total cases of iatrogenic CJD world-wide:*
Mode Cases(n) Mean incubation period (years) Clinical
Neurosurgery 4 1.6 Visual/cerebella
Depth electrodes 2 1.5 Dementia
Corneal transplant 3 15.5 Dementia
Dura mater 136 6 Visual/cerebella
Human Growth Hormone 162 12 Cerebellar
Human Gonadotropin 5 13 Cerebellar

*Data courtesy of Dr P. Brown.

 

  • Sporadic CJD: It is the major type of human prion disease (85-90%). There is no clear cause behind it. It mainly occurs due to spontaneous mutation in the 129th codon of the PRNP gene where valine is converted into methionine.

 

Different types of Prions affecting different areas of brain
Pic. 5- Different types of Prions affecting different areas of brain

 

  • Kuru Disease: (‘kuru’ = tumor)

It was identified in 1957. Kuru was a mysterious disease seen only in the fore-tribe inhabitating the eastern highlands of New Guinea. The disease has incubation period of 5-10 years and led to progressive cerebral ataxia and tremors, ending fatally in 3-6 months.

The infection is believed to have been introduced through cannibalism and maintained by the trial custom and eating the dead bodies of relatives after death as a part of ritual. The disease disappears following the abolition of cannibalism in New Guinea. Carlton Gajdusek was awarded Noble prize for medicine in 1976 for his important contribution on Kuru.

 

  • Clinical manifestation of Prion Disease:

Prion disease is a slow virus infection. Incubation period of prion diseases from months to years (longest 30 years) but once the disease sets in, progression is very fast. There are 3 phases –

  • Pro-dermal phase (3-5 months)
  • Disease symptoms
  • Death

The disease symptoms vary depending on the type of prion disease-

  • Sporadic CJD: The symptoms mainly affect the workings of the nervous system (neurological symptoms) and these symptoms rapidly worsen in few months.
  • Variant CJD: Symptoms that affect a person’s behaviour and emotions (psychological symptoms) will usually develop first.
  • Initial neurological symptoms:
  1. difficulty in walking caused by balance and co-ordination problems
  2. ataxia
  3. numbness or pin and needles in different parts of the body
  4. slurred speech
  • Initial psychological symptoms:
  1. Severe depression
  2. Intense feeling of despair
  3. Difficulty in sleeping (insomnia)
  • Advanced neurological symptoms:
  1. Muscle twitches and spasms
  2. Loss of bladder and bowel control
  3. Swallowing difficulty (dysphagia)
  4. Loss of voluntary movements
  5. Extreme muscle weakness that causes inability to walk and stand
  6. Fatal familial insomnia
  7. Myo-clones (quick, jerky movement of the muscle)
  8. Exaggerated startle response
  • Advanced psychological symptoms:
  1. Dementia (no memory, power of decision making an reasoning)
  2. Loss of memory which is often severe
  3. Problems concentrating
  4. Feeling agitated
  5. Aggressive behaviour
  • Final stages: As condition progresses to its final stages, people with all forms of CJD will become totally bedridden. They often become totally unaware of their surroundings and require around the clock care.

Death inevitably follow, usually either as a result of an infection, such as pneumonia (a lung infection) or respiratory failure where the lung stops working and the person becomes unable to breathe.

 

  • Diagnosis: The diagnosis should be considered in any individual presenting with a rapidly progressive dementia. When other common causes have been excluded and there is other early neurological feature (especially cerebellum/visual). There are mainly 3 investigations of particular diagnostic utility – 1) Electroencephalogram (EEG)

2) CSF 14-3-3 protein

3) MRI

Testing the different types of human prion disease are distinguished by the clinical characters and classified according to internationally recognised published criteria, updated in 2010 and retrospectively applied to all referral since January 2010. The surveillance was last updated in January 2017.

 

Diagnostic criteria NCJDRSU for CJD surveillance across the UK: (The National CJD Research and Surveillance Unit is part of the centre for Clinical Brain Science, University of Edinburgh and is a part of the Deanery of Clinical Science in the College of Medicine and Veterinary Medicine)

  • Electroencephalogram: The EEG shows a progressive deteriotion in the normal background rhythms and in around 2/3rd of cases, appearance of Periodic Sharp Wave Complexes (PSWCs). The important points to be noted-
  • The absence of PSWCs does not exclude the diagnosis
  • PSWCs may be in other conditions (for example hepatic encephalopathy drug toxicity and rarely Alzheimer’s disease)
  • If PSWCs are absent on an initial EEG, repeat EEG may show development. (repeat testing should be considered at around weekly intervals)

 

  • CSF 14-3-3 proteins: CSF 14-3-3 proteins is a normal neuronal protein that has no specific connection to CJD, being released into the CSF following neuronal damage. It has specific diagnostic utility in CJD. However, CSF 14-3-3 concentration can be reasonably readily differentiated from sporadic CJD on clinical grounds. A positive CSF 14-3-3 test may therefore strongly supported specificity and sensitivity (both 94%) are valid only in an appropriate clinical context.

 

  • MRI (Magnet Resonance Imaging): Cerebral imaging is a vital part of the exclusion of other diagnosis and normal brain imaging in the face of a rapidly progressive, devastating encephalopathy, may lead to a consideration of sCJD. However, in some cases MRI shows a characteristic signal change in putamen and caudate. Occasionally high signal may be seen in the cerebral cortex, generally focal and reflecting the particular clinical feature at the time imaging. Significant atrophy is usually if imaging is undertaken within 3 months of onset of disease.

 

  • Measurement of Pr: It is measured by conformation dependent immunoassay is the most definitive diagnostic tool for prion disease.

 

  • Neuropathological diagnosis in Brain biopsies: The pathologic hall-marks of prion disease seen under light microscopy, are spongiform degeneration and astrocytic gliosis with lack of inflammatory response.

 

  • Sequencing the PRNP gene: It is to identify the mutation – this is important in familial forms of prion disease.

 

 

  • Treatment:

There was no disease like prion before. So till now it is not clear which strategy will lead to a treatment or cure. Scientists are investigating a lot of different possible ways of treating these disease.

  1. Small molecules: Within the fields of molecular biology and pharmacology, a small molecule is a low molecular weight organic compounds (<9000 Daltons) that may regulate a biological process, with a size of 1nm. Most drugs are small molecules.
  2. Antibodies: Anti-PrP antibodies have shown to eliminate Pr from the cultured cell but they failed to do so in vivo.
  3. Gene Silencing
  4. Several drugs like quinacrine

 

  • Decontamination: Prions are resistant to most of common sterilization procedures.
  • Autoclaving at 134ᵒc for 1-1.5 hours
  • Treatment with 1(N) NaOH for 1 hour
  • Treatment with 0.5% sodium hypochlorite for 2 hours

If the prions bound to the stainless steel should be treated with an acidic detergent solution prior to autoclaving; rendering them susceptible to inactivation.

  • Conclusion: Though it is a rare form of neurodegenerative disorder, for example 300-350 cases are reported in the USA per year, but it often progresses rapidly and currently it is incurable. So, till now prions are scary ailment.

In this year June 2018, researcher from case Western Reserve University have synthesized an artificial prions, though a new strain of prion sounds terrifying, but this research could be a bold new step in helping to treat prion disease by discovering auxiliary factors and developing therapeutic approaches to block them.

Artificial prion protein
Pic. 6- Artificial prion protein

 

 

  • Reference:
  1. Essential of Medical Microbiology by Apurba Shankar Sastry and Sandhya Bhat k. Page no.- 521-524
  2. Ananthanarayan and Paniker’s text book of microbiology, 10th edition, Page no.- 560-561
  3. Transmissible spongiform encephalopathy from ‘Zoonotic Disease is in Northern Euresia ,2015’. Prion disease- Pawel P. Liberski, James W. Ircnsicle in ‘Neurobiology of Brain Disorder’; Prion disease- Adrano Aquzzi (M.D., PhD, DVM, hc, FRCP, FRC Path), Markus Glatzel (M.D.) in Neurobiology of Disease.
  4. ISRN Infectious Disease, Volume 2013, Article ID 387925, 11Pages
  5. Prion disease: Am J Pathol. 2008 March; 172(3) Page no.- 555-565
  6. Athena Yenko, June7, 2018
  7. GEN News Highlights, June 6, 2011
Throat Inflation can initiate to Rheumatic Heart Disease

Throat Inflation can initiate to Rheumatic Heart Disease

Introduction

In day-to-day life, one of the most commonly occurring contagions is a sore throat medically acknowledged as Pharyngitis or Streptococcal infection (strep throat). The cause is almost always by a bacterium called Group-A Beta-Hemolytic Streptococcus. The familiar symptoms are Discomfort or a prickly sensation in the throat, Dysphagia, scrambled voice. Generally, to overcome it many clinicians advise taking bed rest with a soft diet and plenty of fluids intake, in case severe unruly condition the prescribed medicine is antibiotics, analgesic, corticosteroids, and etc. The interesting doubt ascends i.e. why & how strep throat is it related to heart diseases? In general, the heart diseases are classified into various types such as atherosclerotic diseases, heart arrhythmias, cardiomyopathy, and congenital heart defects etc. Rheumatic Heart Disease is precisely triggered due to Rheumatic Fever.

Roughly 97-98 percent of the population can overcome to sore throat infection but for remaining, it can lead to Rheumatic Fever at post-sore-throat infection. This article mainly deals with a sore throat leading to Rheumatic fever. Which further may lead to chronic rheumatic heart disease, and comprises of numerous symptoms of this disease.

Initiation of Rheumatic Fever

Rheumatic fever is a non-contagious acute fever, marked as inflammation & pain in the joints. The word rheumatic generally termed as rheumatism which means inflammation and pain in the joints, muscles, or fibrous tissue stained by disease. And fever is an abnormal rise in body temperature.

All in all rheumatic fever caused to a very small percentage of the population, the prone individuals are children (5-15 years) and is rare after age 35 years. Rheumatic fever is an autoimmune inflammatory process that progresses as a corollary of streptococcal infection. The most significant complication of rheumatic fever is Rheumatic Heart Disease, which usually occurs after frequent bouts of severe illness.

Rheumatic Heart Disease

Initially, the human is attacked with Streptococcal Pharyngitis leading to Rheumatic Fever, typically occurs several weeks after Pharyngitis. Streptococcus cell membrane consists of a protein called M-Protein and the bacteria is highly antigenic to human. The immune system identifies the antigens through macrophages and counter attacks by producing antibodies against the M-protein cell membrane of Pharyngitis bacteria. But these antibodies also attack body own cells consist of M-protein which is similar to foreign body protein (this similarity is known as molecular mimicry) and finally leads to damage of body organs, which is known as the type-2 hypersensitivity reaction. The similar M-protein body cells or organs are myocardium of the heart, joints, subcutaneous layer (skin), Basal ganglia of the brain.

In rheumatic fever, there is a variety of clinical findings Jones’ criteria further classified as major and minor as follows

Minor

  • Fever: the Abnormal rise in body temperature.
  • Arthralgia: Pain in regular joints.
  • In blood, there is an increase in ESR/CRP.
  • The ECG shows a prolonged PR interval in heart-block.
  • Previous repetitive episodes of Rheumatic fever.

Major

  • Migratory Polyarthritis: Multiple large joints Inflammation one after another in a symmetric way.
  • Subcutaneous nodules: These are firm lumps under the lining of the skin made of collagen which is painless and extensor.
  • Erythema marginatum: These are the reddish rash ring formed on trunk and arms.
  • Sydenham’s chorea: It is categorized by rapid or awkward jerking moment primary affecting face, hands, and feet caused by the destruction of basal ganglia of the brain.

The Carditis/Pancarditis caused by Rheumatic Fever

In the main, the heart is affected by auto-immune response during Rheumatic fever known as Rheumatic Heart Disease. This occurs when attacks of Rheumatic fever cause scarring and damage to the heart. Normally heart consists of three layers namely: pericardium, myocardium, and endocardium, these consist of M-protein in their tissue cells. But the antibodies released from immune system cause inflammation to the layers of heart leads to Carditis/Pancarditis. The inflammation is fibers type due to an accumulation of fibrin.

Pericarditis

Inflammation of outer covering of heart is called Pericarditis, leading to sharp localized chest pain and reliefs on flexion of the spine (forward bending). On auscultation doctors can notice friction rub/pericardial rub in additional it weak heart sound is observed. When fever subsites there is no long-term pericarditis issue is seen in future.

Myocarditis

Another effect of Rheumatic Heart Disease is Myocarditis, caused due to inflammation in Myocardium of heart. In Myocardium there is a formation of Aschoff body, it is very small pin head inflammatory lesions and these are the immune-mediated granuloma. It also contains large ribbon-like nucleated macrophages called Anitschkow cells. Myocarditis is the most dangerous and recorded most common cause mortality in children if it is untreated. The Myocardium becomes loose and flabby, unable to contract which may lead to other complications like congestive heart failure. This complication is not a long-term issue.

Endocarditis

The serious and long-term complication is Endocarditis, inflammation of endocardium of heart and attacks specifically on valves of the heart. During fever, tachycardia occurs that leads to rapid closing and the opening of valves. Due to inflammation, there is a rupture or erosion of leaflets at valves. However, ruptures lead to deposition of platelets and fibrin which results in the formation of multiple small vegetation (sterile) on the valves. During post-fever healing occurs but this vegetation leads to fibrosis due to this the valves become fibrotic and distorted.

Above three conditions Pericarditis, Myocarditis, and Endocarditis usually leading light to Acute Rheumatic Heart Disease during Rheumatic fever in children. Whereas Endocarditis leads to severe complications like mitral stenosis, mitral regurgitation, and aortic stenosis and regurgitation in adults because of untreated recurrent episodes of Rheumatic fever which finally result in Chronic Rheumatic Heart Diseases.

General treatment

  • Take bed rest, Intravenous fluids and a healthy diet.
  • Conventional medications such as antibiotics (without carditis up to age 18/21 years, with carditis up to age 25/45 years), anti-inflammatory drugs.
  • In-take of Cardiac drugs on doctor’s prescription.
  • In severe, case surgical treatment of heart is required.

References

http://rhdaction.org/

https://emedicine.medscape.com/article/236582-overview

Rheumatic Fever

https://www.medgag.com/anatomy-10-years-2018-2017-question-papers-1st-prof-mbbs-wbuhs/

What Is Liver Cirrhosis ? Symptoms, Treatment & Causes

What Is Liver Cirrhosis ? Symptoms, Treatment & Causes

What is Liver Cirrhosis?

Cirrhosis is a type of chronic disease (slow processing) that’s relative to the liver. Cirrhosis is identified when the cells of the liver are getting replaced by fibrosis (i.e. fibrous thickening of tissue) or the replacement of normal tissue with scar tissue. Basically, cirrhosis leads to damage to our liver and their functions. The liver plays a significant role in metabolism, detoxifying harmful substances, purify the blood and also including bile production and excretion too. Mostly, cirrhosis caused in alcoholic person and also more chances in a patient of viral hepatitis (B and C).

By examing and performing various experiments the medical science finds out a way to limit the further effects of cirrhosis but still cannot be able to cure. The ultimate way to rescue from cirrhosis is liver transplantation.

Globally, At present, there are more than 1 million cases of liver cirrhosis are.

 

Symptoms of Liver Cirrhosis

  • Joint pain
  • Fever
  • Fatigue
  • Vomiting
  • Abnormal personality
  • Neurologically deprived
  • Hepatic encephalopathy
  • Peripheral neuropathy
  • Asterixis
  • Integumentary
  • Jaundice (icterus)
  • Spider angiomas
  • Palmar erythema
  • Purpura
  • Caput medusa
  • Itchy skin
  • Gastrointestinal
  • Dull abdomen pain
  • Dyspepsia
  • Fetor hepaticus
  • Flatulence
  • Varices
  • Gastritis
  • Gynecomastia’ testicular atrophy
  • Hematemesis
  • Feel like overeating
  • Hemorrhoidal varices
  • Digestion problem
  • Increase size of liver
  • Loss of appetite
  • Hematologic
  • Anemia
  • Thrombocytopenia
  • Leukopenia
  • Coagulation disorders
  • Splenomegaly
  • Metabolic
  • Hypokalemia
  • Hyponatremia
  • Hypoalbuminemia
  • Fluid retention
  • Peripheral edema
  • Ascites

 

Causes of Liver Cirrhosis

  • Hepatitis B
  • Hepatitis C
  • Biliary atresia
  • Wilson’s disease
  • Fat accumulated in the liver
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Infection (schistosomiasis, peritonitis)
  • Enlargement of the spleen (splenomegaly)
  • Portal hypertension
  • Esophageal varices
  • Malnutrition
  • Bone disease
  • Gallstones
  • Heart failure
  • Obstructed blood flow
  • Hormonal imbalance
  • Production of toxins
  • Prevent the functions of protein and drugs too
  • Non- alcoholic fatty liver disease (NAFLD)
  • Non- alcoholic steatohepatitis (NASH)
  • Greater chance of Liver cancer

 

Prevention of Liver Cirrhosis

  • Stop or reduce intake of alcohol
  • Focus on the balanced diet
  • Less intake of salt
  • Less intake of sugar too
  • Prevent from taking of non-veg and spices.

Tests to be Performed for Liver Cirrhosis

  • Blood test
  • Liver function test ( ALT, AST, ALP)
  • Creatinine
  • Hepatitis B And C
  • Imaging test (CT, MRI, ultrasound, MRE)
  • Biopsy
  • TREATMENT
  • Endoscopy
  • Medication
  • vaccination
  • Rehabilitation
  • Consume diet with low sodium content
  • Avoiding nonsteroidal anti-inflammatory drugs
  • Hemochromatosis (reduce the levels of iron)
  • By the excretion of copper in urine
  • Liver transplant

 

Conclusion

The liver is the most workable organ within our body, performs various functions relating to circulation too. The liver performs both functions like production and excretion too.

LIVER CIRRHOSIS is the most advanced form of liver disease that’s related to generally drinking alcohol and viral hepatitis B and C. Liver cirrhosis occurs when the liver cells are killed or injured, and after that when the inflammation occurs, the injured want to repair itself by forming scar tissue that consequences in forming new liver cells in clusters form that leads to regeneration of nodules of liver within the scar tissue.

The disease is a part of the progression. It may start with the fatty liver disease, then progress to alcoholic hepatitis, and then to liver cirrhosis.

Liver cirrhosis main identified by jaundice, loss of appetite and fatigue. There are various types of complications occur in liver cirrhosis including liver cancer.

Diagnosis of liver cirrhosis can be started firstly with examing patient history, family history also, the vital signs (physical examination), blood test, and we can also perform complete diagnosis by confirming liver cirrhosis by performing the liver biopsy.

Treatment of liver cirrhosis prevents further damage to the liver, liver cancer, other complications related to liver cirrhosis and other adjacent organs from any damage. By suppressing the immune system by prescribed medications like prednisone and azathioprine to prevent further inflammation related to the liver in such as autoimmune hepatitis.

We can’t cure liver cirrhosis, but we can provide treatment to the patient as medication and further types of test like endoscopy. The best recommendation for the liver cirrhosis patient is to liver transplant surgery, still, the medical science working on the curing of liver cirrhosis by medications and some other remedies.

 

Gandhi had a vision towards health promotion of the society

Gandhi had a vision towards health promotion of the society

Introduction

When we think about Gandhi, what are all the things which come to our mind? Father of the nation, fought for independence, non-violence movement, his adherence to truth, etc. we never realized the immense knowledge on health he had. Yes, he had a vision towards health promotion of the society. Though initially, he hated modern medicine, at the end he himself stressed the need for an evidence-based medicine

My life experiences on Gandhi:

My first experience is with our ENT department. In our college ENT department, there will be a quote told by Gandhi. He says, “It is not our patient who is dependent on us, but we who are dependent on him. By serving him, we are not obliging him; rather, by giving us the privilege to serve him, he is obliging us “. The need for a patient-centered healthcare facility is insisted on by him long ago. This quote is also inscribed in the OP suite at AIIMS, New Delhi.

My second experience was in Velammal Medical College, Madurai in a neurology quiz. There was a question called what are Gandhi neurons. I didn’t expect that question. I was like, there is a neuron named after him? They told those mirror neurons, appears to underlie feelings of empathy was named so by Indian born American neuroscientist Ramachandran on 2008

Keys to health:

Gandhi’s book on “keys to health” is one of his most famous writings. He believed in the 5 element concept of human body earth, water, vacancy, air, light.

  • Air: he insisted on breathing exercises, cleaning the nostrils and the importance of sleeping under the open sky.
  • Water: he insisted that everyone have the right to get pure water and proper drainage facility. It is the duty of government to provide that. He also believed in hydrotherapy
  • Earth: he believed that mud has the potential to cure scorpion sting, constipation, boils, etc.
  • Light: he had faith in yoga and sunbath.
  • Vacancy: it is also called Aakash or ether. Gandhi believed that brahmacharya led to a healthy life.

He insists that we should not abuse the body we have. He says” everything in the world can be used and abused and it applies to our body too. We abuse it when we use it for selfish purposes, in order to harm our body. It is put to right use if we exercise self-restraint and dedicate ourselves to the service of the whole world ”.He wrote about his experiences in his publication, ’Indian option’ under the title ‘guide to health’ and some articles on nature cure and five elements and their effects. Those articles were published in Aga Khan Palace in 1942.

His approach towards diet:

Nowadays people are very concerned about their diet. Now we have paleo diet, Atkins diet, etc. Gandhi during his period stressed the importance of dietary habits in the health of a person. He divides people into vegetarian, flesh and mixed and considered vegetarian diet the best. He insisted on the importance of adequate nutritional proportion in food. Regarding sweets, he supported jiggery, yes the only sweet which contains lots of iron content. He insisted to avoid fried food. Gandhi says,” Food should be taken as a matter of duty even as a medicine to sustain the body, never for the satisfaction of palate. There should be self-control as such habits of elders influence children to some extent”.

His approach towards smoking and drinking alcohol:

Gandhi states that ” Drugs and drink are the two arms of the devil with which he strikes his helpless slaves into stupefaction and intoxication ” .At that time people were drinking to get attention from British, social availability etc. police training schools made it compulsory to drink wine and eat meat. This makes the individual health and the community health in question. He starts that prohibition should start from not selling in shops, etc. he asks the women to actively participate against alcoholism.

He opposed smoking explaining the ill effects of it. The British tobacco company humiliated him by selling cigarettes named “Mahatma Gandhi” cigarettes. But he didn’t lose hope. He fought against tobacco throughout his life. He says,” He opposed smoking explaining the ill effects of it. The British tobacco company humiliated him by selling cigarettes named “Mahatma Gandhi” cigarettes. But he didn’t lose hope. He fought against tobacco throughout his life. He says, “if every smoker stopped the dirty habit of making his mouth a chimney to foul breath by making a present of his savings to some national cause, he would benefit both himself and the nation “.

Hygiene and health, the universal principles:

Gandhi made committees in Africa and Ahmadabad to conduct surveillance on open defecating areas and to promote sanitation there. Today around Tanjore we can see lots of villages with signboards promoting construction of latrines in the home and to avoid open-air defecation. Still, we cannot make people avoid open-air defecation and we cannot expect Gandhi to successfully establish that long ago. But we should never forget his ceaseless effort for health promotion.

Though he had a strong belief in God, he hated the untidy pilgrimage practices in India. He incorporated health education and hygiene in his 18 points constructive programmes

His initial disappointment over Western Medicine:

He suffered from digestive complaints while practicing law in South Africa. He took some medicine but they were ineffective. One of his friends gave him a book “Return to Nature” by Adolf. The book told about dietary reforms, mud application over the abdomen, use of wet compresses, etc. he got relief from these. He insisted that such drugless therapy is needed in countries like India where people don’t have access to the healthcare facility. But in this view, I bet to differ from Gandhi. We need to establish evidence-based medicine all over the country. In Tamil Nadu lots of quarks have arisen to provide the cure for jaundice, AIDS, etc. recently a person calling himself healer Baskar promoted the state to practice domiciliary delivery and as a result, a woman from Thiruppur lost her life. He also claims that sambhar vada is the cure for gallstones. We should never promote such evidence less medicine

His later positive attitude towards modern medicine:

In his 50s he suffered from hemorrhoids he first went seeking a solution from naturopathy. Then he went to Dr.Dalai and he underwent surgery and got cured of the illness. He even suggested others suffering from hemorrhoids to go for surgery. In January 1924, in Yerwada jail, he suffered from appendicitis and was operated by British surgeon Maddock. This life-saving surgery promoted his mind the need for modern medicine.

Gandhi against ancient medicine:

While opening an ayurvedic pharmacy in Chennai, he spoke that Ayurvedic physicians are just living by the glory of their past. The system is less evidence-based than the western system. He wanted the Ayurvedic practitioners to practice research and give evidence for modern medicine practitioners.

The next month he wrote to an ayurvedic physician,” I have faith in the Ayurvedic drugs, but very little in the diagnosis of physicians. I therefore never feel sure about a patient under an Ayurvedic physician if his diagnosis is not checked by a trustworthy practitioner under the Western system “.

My Gandhian views regarding independence for doctors:

As a third-year Medical student, I ‘ve been traveling to lots of colleges for intercollegiate conferences. I’ve seen lots of interesting research papers and case presentation from various Medical Colleges. But when I discuss with them and ask about their ambition most of them would like to join PG in central University in India like AIIMS JIPMER etc or to clear international exams to pursue their career abroad.

Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) ,AIIMS and JIPMER in the mind of the young medical students and doctors in Tamil Nadu who don’t see or don’t want a future here.

I didn’t say such aims are wrong. But I question why a young medic with great rank which would allow him/her to choose their favorite PG course in their own state, where they tend to interact with their patients in their own language, to choose a college where they must learn a new language, culture, epidemiology difference, climatic variations etc.

And when all the competent Doctors our state for a place with better job security, job satisfaction, pay grade, respect then Tamil Nadu will be left with lack of manpower and will go through a medical crisis with lack of manpower.

Let’s see the PG stipend across the country

Sino. state Stipend for MD/MS 1st yr Stipend for DM/Mch 1st yr
1 Tamilnadu 27,100 32,800
2 Central government 86,335 89,634
3 Kerala 43k 47k
4 Maharashtra 53,360 48,413
5 Madhya Pradesh 45k 50k
6 Rajasthan 47k 54k
7 Uttar Pradesh 55,830 62,633
8 Bihar 50k 90,411
9 Goa 60k 71,238

Of course, after a lot of struggle, the stipend was increased to 40k 45k for PG and superspeciality respectively. Still, this is very low when compared around the country.

Across the world, Indian doctors are paid less. Across the country, TN doctors are being paid less. This is one of the reasons which implant the dream of studying abroad in young minds.

People may argue “Doctors should not work for money, they should do well to the society,” I ask WHY? Does anyone tell the society to provide all services to doctors free of cost for “betterment of the society”? OR ask the banks to give away money to all doctors for the same cause. No!

I would tell you an anecdote of myself. I finished my schooling in my hometown which is Mannargudi. I’ve chosen to study at Tanjore MC because it was the best College near my home. I didn’t think of studying in central University or in big cities. I really saw and I really wanted my future here. I didn’t have any calculation to join here; I got an emotional bonding which made me choose here.

I really wanted to join MD pediatry here in our college after I finish my MBBS. But when I came to know about the stipend paid across the country and the situation of TN, my dreams shattered. As a student from the middle class, I would rather sacrifice the comfort of living in my dream College over an increased stipend to support my family economical

So should I choose to join AIIMS or JIPMER? The answer is a big NO. We know the status of TN medical postgraduates in central Universities. Every month we are seeing at least one death news regarding PG death in AIIMS who is from Tamil Nadu. I had a senior friend who joined MD pathology in KEM Mumbai, whose bike was shattered just because it got a number plate TN. We have such a welcome from North Indian states. After all hard work, I don’t want to die in a central University.

The assault on doctors is not restricted to TN doctors alone. These past few years in India have witnessed growing instances of assault on doctors. Many newspaper columns have been devoted to the issue. Recently a doctor in Maharashtra’s Dhulia lost his eye after being assaulted by the relatives of a patient. Assault on doctors by angry patients and their kin is only a reflection of the issues troubling the healthcare system.

Let’s continue my story, where should I pursue my post graduation now? This pushes me to think that I should try writing USMLE. Let’s jump to my statement in the beginning of my essay.

Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) ,AIIMS and JIPMER in the mind of the young medical students and doctors in Tamil Nadu who don’t see or don’t want a future here.

Do I see a future here? NO. Do I want a future here? NO. But this is my new ambition. This is what I should answer when a stranger asks me what you are going to do after finishing MBBS. I’ve been pushed like the majority of students in TN.

We must accept that corruption has found its way in the health sector too. However, I will be unfair in not adding that majority of the doctors remain committed to the ethics of the profession.

Let’s see another scenario; young Indian doctors are making the country proud through their work in developed countries such as Canada, the US, and many European countries. These doctors are working in a better medical ecosystem unlike doctors in India, who are forced to continuously fight unheeding authorities both for the rights of unaware citizens and overworked doctors.

Only 1.3 percent of the GDP is directed towards healthcare. As per the Universal Health Coverage NHP (National Health Policy) in 2017, four percent of GDP should be allocated for health. This data doesn’t reflect that health is a priority for the country.

India has only 10 lakh doctors working in government and private sectors. According to the World Health Organization, the doctor to patient ratio should be 1:1000. Which means India cannot afford the migration of young minds abroad.

We must find a way to prevent this migration. I didn’t mean preventing the true ambition of students who really know and want a career abroad. I want to stop the migration of students like me who are pushed out due to insecurity.

Recently the NMC Bill was tabled in Parliament and sent to the parliamentary standing committee. The panel has advocated “bridge courses” for indigenous and alternative medicine practitioners such as Ayurveda, and Homeopathy. If bridge courses could have been a real solution then I want a bridge course for local panchayat leaders to fix the shortage of judges in the country.

Thus we are facing a major crisis in TN of loosing young talented doctors to central Universities and abroad. We need to increase the stipend and salary of doctors here and we must provide a safe environment for the doctors. For this, we need a strong political will and planning to prevent such migration.

The basic concept is – rather than counting on what others can do for you, make your life count

Conclusion:

It is better to die on your feet rather live on your knees. Gandhi is an iconic man the world has ever seen. The time when people believed that war was the only solution, there stood a man against violence and proved to the world that humanity, love, and non-violence can win too. He stood up to his lines “Be the change that you wish to see in the world. “ His life itself was a message. In this essay, I have dealt my best to explain my life experiences and my Gandhian principles and Gandhi’s contribution to medicine.

References:

Gandhi M. K., “An Autobiography or the Story of My Experiments with Truth”, Navajivan Publisihng House, Ahmedabad, India, 1927.

Gandhi M. K., “Keys to Health”, Navjivan Publishing House, Ahmadabad, India, 1948.

Gandhi M. K., “Social Service, Work and Reform” (Vol-1), Navjivan Publishing House, Ahmadabad, India, 1976.

Gandhi M. K., “Diet and Diet Reform”, Navjivan Publishing House, Ahmadabad, India, 1949.

Keywords: Gandhi Health, Health promotion by Gandhi

 

A Doctor’s View on Doctor – Patient Relationship

A Doctor’s View on Doctor – Patient Relationship

MBBS (Bachelor of medicine and bachelor of surgery ) the most inspiring and attractive word for me throughout my whole childhood. But it becomes toughest on 5th June 2015 when the first time I was successfully failed to get an eligible rank in my West Bengal joint entrance examination for medical. Though the word inspiring was existing in my life for MBBS. I desperately accumulate all my courage and restart my preparation to crack the same examination for the next year.  And that time I successfully able to get the entry in my childhood wish. I was started my journey as an MBBS student at the BURDWAN MEDICAL COLLEGE, WEST BENGAL and from the beginning of that, I was an active part of the world medical association.

‘Doctor Babu ‘when I heard the word indicating to me for the first time it was such a pleasure to feel that astounding feeling. In the first year one day I went to visit the hospital for the first time with my white apron. Then a short height, an unhygienic man came towards me and ask for ECG room. But at that time I was not able to help that man because I also didn’t know this. As a doctor, my duty was to help that man.

A healthy doctor patients relationship is the most important part of treatment. Healthy means professional. Some foremost characters should have to be developed to become a successful doctor. At first, a doctor must have to be helpful towards his patients but obvious within his professional limit. Secondly, justice with patients, equality among patients, and equal division of limited resources only and only based on priority need and next one is fidelity means the ability to truths about our each and every action because mistakes are forgiven but lies are strongly punishable. We must have to be understood that patients are not help-seeking rather we are the help provider.

Doctor patients relationships are of different types. One may be doctor-centric in which doctors are superior and patient must have to follow doctors advice and another one is patients centric in this doctors are flexible in their point of views and they give opportunities to his patients to choose their options.

A doctor can play different roles in appearance to influence his patients. We must have to be flexible in our behavior and it will be the strongest ladder to achieve effective care. The term ‘placebo’ is a substantial term conjoin with the medical profession. Sometimes we have to use strongly directive approach to make better treatment. Some pessimistic patients are not aware of their health so they ignore the treatment process. It is our duty to strongly put our advice and make the better health of the patient. But as besides this, it is also important to remember that the right to refuse is the personal choice of the patient. We can’t pressurize them in any aspect rather we can motivate them. As a good doctor, we have to use tremendous politeness and respect during the treatment of geriatric patients and it is an appropriate doctor-patient relationship.  Another one is protectively paternalistic approach and this is maximally used in pediatric treatment. A doctor can advise his patients by gathering kindness, protection, strength, and patience. Because pain is the fearest foe of a child and as a doctor, our responsibility is not to destroy the fear but to achieve the power to fight against it so that he can tolerate it in his upcoming life. Some other aspect is the supportively directive approach. In this type, doctors believe in patient’s choice along with providing reassurance and guidance. Another example of the perfect doctor-patient relationship is the relationship between doctor and female patients. Most of the female patients always choose female gynecologists for their treatment but as a male doctor also our duty is to provide equal safety and security to them so they can trust us . A doctor can play an active role in the treatment of terminally ill patients. As a doctor, our responsibility not only in cure purpose but also provide the hand in care. In the case of terminally ill patients, we can’t stop our treatment by accepting upcoming death but it is our duty to provide a peaceful death to our patients.

Relationship means the mutual connection between two peoples. So both sides effort is necessary to make a relationship healthy. Patients also have to believe in the doctor to make the relationship more trustworthy. Some people told that feel your patients as your family members but I think rather it is important to feel our family members as our patients when they suffer from disease because a professional relationship can handle effective treatment rather than a coherent relationship. As besides the importance of establishing relationships, it is also important to perfectly terminate our relationship with our patients because we can’t expose us as available and as sympathetic so that we become emotional during termination.

As a future doctor, I will definitely maintain these in my working phase and I wish my other co-workers who are reading this may also influence through my words.

 

 

Five Years of My MBBS Life

Five Years of My MBBS Life

I had joined the medical college with all the excitement that is humanly possible. Getting merit-based scholarship and not having to pay a single penny as a donation to college, I had made my parents proud. Not that I had always wanted to be a doctor. Being a doctor is the epitome of success academically in our society. The toppers of the country would choose to be a doctor. More than me, my parents were happy that I was studying Medicine. What more could I do than to make my parents proud. Not that I was forced to study medicine. Personally, I was indifferent. I wanted to go through the tough road that elites chose. Deep down inside, I still wanted to explore passion in life. But I was far too lucky (and thinking now maybe unlucky) that I got my name in the successful candidate name list in the MBBS entrance examination.

First year: Crushed euphoria

I was so happy to sign in the admission forms and submit all my certificates. More than that I was happy to see my dad’s smile while I was signing. Getting my hostel room key and filling a small sheet of paper for college identity card filled me with utmost pride.

As classes started, the happiness curve went down. All my expectation of med school became upside down with the reality. As happy I was to get the key to my hostel room, I was more disappointed to open the room of the hostel that was located 3 kilometers away from the hospital right next to the public bus park. Unlike the photos are shown on the website of the college, the hostel was a temporary rented hotel, with zero facilities. The hostel corridor had a leaking terrace and in the monsoon flooded our room if we opened our door for long. The soaked carpet smell mixed with our own sweat smell during the power cuts was in the air. Love definitely wasn’t in the air.

Second year: Exams

Literally, the second year was nothing but the exams. We had monthly big exams, and countless small posting examination. The syllabus was vast and time very limited. On top of that, we would hear about the terror of HODs of departments during practical Viva examinations. Our only aim was to pass every internal examination so that we would not be barred from giving board examination.

Third year: Honeymoon year

We were posted in the hospital. We had our first share of exposure to the patients. Only two subjects whose exam would be there. Taking history and learning physical examination. It was far different kind of learning compared to learning from the cadavers of first-year anatomy class. For the least, all we had to do was to maintain our attendance to 80 percent.

Fourth Year: Minors

We had already spent a year in the hospital wards and OPDs. The place felt familiar and we had been quite familiar with the history taking and physical examination. Watching POP casts and slabs in the Orthopedics OPD was exciting. Learning to use an Otoscope and be able to visualize the perforated eardrum gave all of us some happiness of sorts.

Final Year: The real exams

We were the same as the third year and our posting was the same. But the way our teachers treated was entirely different and that increased the fear. They would constantly remind of us being the ‘exam giving batch’ and that we had to cover each and every topic. Everyone was seriously studying except for the legends who still got time to flaunt the new bike they had bought.

Time passed in a blink of an eye. There was so much to study and so less of time. Nothing except the syllabus mattered. The frequency of mom and dad calling to ask about my whereabouts decreased. Going out for parties were almost nil. Birthday parties got postponed.

Internship: Three Ds

Dressing. Discharge. Daru (alcohol). The dressing of wounds and especially of the burn patients was really difficult and time-consuming. Making discharge sheets of patients who were admitted for delivery of babies was hectic as hell as the number many a time crossed half-century. And a chilled beer once in a while was the answer for releasing the frustration of doing ‘clerk-type’ work every day.

Right now, I am almost halfway through my internship. The days are so varied. Some days, we get all the time in the world to talk about all the things that are shitty in this country. Other days, we are so tired we fall asleep right as we close our eyes. The way we are treated also varies greatly. Some patients treat as if we are magicians wearing white gloves applying elixirs in their wounds and heal them. Other patients treat as if we don’t even exist there.

Final Note:

With all the free ‘no-need-to-read-compulsorily’ time that I have got in the internship, I get plenty of time to introspect. I think about the situation in the country. I talk with the residents and learn about the things I could do during my internship days to make the future a little bit easier when I would be working in a hospital far from cities. And some nights when I am alone in my room and it is raining outside, I wonder with one question on my mind:

Would I be a good doctor?

ARTIFICIAL INTELLIGENCE, MACHINE LEARNING AND DOCTORS

ARTIFICIAL INTELLIGENCE, MACHINE LEARNING AND DOCTORS

 

|| Vaidyo

narayano hari ||

As goes by the Hindu mythology, a doctor is an incarnation of Lord Vishnu, savior of the

World. Thus given the highest respect and honor in the society.

The happiness in the gratitude shown by the patient is no less than that of heaven. For a small task done the knowledge which is obtained in the same age of schooling adds an added advantage to technical students, the health sector people have a lot of unfair advantage. Some say they have absorbed all the bitterness in life during the late teens and early 20’s but I don’t agree. If passionate enough though practically challenging all the pains could be simply hidden behind a great smile before the gratitude of the patient and their family.

Definitely people like saint Mother Teresa come only once in an era and it’s highly impossible to completely mimic her. In the present day scenarios, a few private clinicians have started wearing the mask of this holy profession, but unable to curb the greedy demons inside from being exhibited out. In this battle among themselves as a holy professional and desire of an exclusively luxurious life, they are forgetting the Hippocrates oath of grad walk which could be witnessed by inhumanly practice like money first treatment next as a result of which there is a loss of respect and gratitude towards a doctor. No matter money is the fuel of today’s world but we as professionals are the only one to be paid and respected both exclusively from a single person so does money weighs more than the next. Thus it’s just not our duty but even responsibility and also a humanitarian act to let this noble profession be ranked highest and even avail the medical facilities to each room and corner of this world. As gifted humans, we must take an interest not just to work but even manipulate the existing technology in order to provide better services even in once absence. Sometimes health care professionals apply their own version of Newton’s first law ” a doctor remains in a state of ignorance and doesn’t update himself until an external force is applied ” ,and this external force is generally money from the other perspective it is very difficult to teach a set of people living in beautifully built ego palaces to convince their old protocols being followed from long time need an update, since they find it comfortable with the existing methods and ideology . Apart from these issues on the other side of wall accessibility to hard to reach areas, India is having the majority of the hospitals situated in urban areas and a few in suburban, but unfortunately, it is the rural sector which exhibits a greater needs for health care facilities. In rural areas most of the times it’s the rural medical practitioner or the pharmacist who take the act of doctor. No added economical advantages given to the doctor’s as discouraged many to settle in rural areas despite the need to do so. Our deep-rooted bias of sex, caste, and gender fed by several political and superstitious people, and this bias has its own place in India prevent the precision and quality of treatment from reaching people of all diversities and labeling them as underprivileged.

In order to curb the greedy few and re-establish the respect for the profession as a whole, there is an immediate need for some revolutionary change to be taken over.

Coming to me as a son of an engineer coming from a remote village with limited resources who dreamt of a primary health care center in his village after hearing the word “I won’t be coming to that village as it lacked roads sanitation and people over there are poor” when consulted to save a person in . This small incident had a major impact in my life and my vision towards health and ways to avail them to everyone to a different path altogether. I as student of Vishnu dental college an upcoming dental fraternity which recently underwent stereotypical changes in the dental college standards with an entire change in its infrastructures, an unusual move generally for such colleges, has introduced digitalized case records for patients with several options of updating every record of him in it along with the prescription so there could a strong record of his data followed with hassle-free paperwork and record maintenance . Thus availing all the information of the patient without any manipulations and even in the absence of patient. It was my privilege to see some new technology which none of my pals from various colleges could experience. My past experiences and the newer technology woke the curious kid hidden somewhere in me started to search for ways to link technology and medicine. It was then for the first time in my 4th year BDS I got to know regarding the various software technologies available in the world of medicine slowly browsing through net I got to know several technological advancements and it was then I started searching for things and early this year I got to know regarding the bots which have been using ai to book appointment (google conclave 2018) and do few of our routine daily chores less stressful. my lazy mind dreamt of things by which the ai could take an accurate case history which could have an added feature as recording the patient’s chief complaint in their own voice so that confusions can be avoided among clinicians and can also be used in case of medical-legal cases this could even save time especially during peak clinical hours. Many times it also came to my mind to add the knowledge and experience of physicians with the energy of a fresh graduate to treat a condition. I used to feel if we could really feed the computer with appropriate programs of different clinical scenarios and train it through several clinical photographs and radiographs for providing a provisional and differential diagnosis by analysing and scrutinizing the conditions using the symptoms and clinical photographs and radiographs thus allowing us to directly involve in final diagnosis and treatment planning. As a human its never possible to remember, recollect, correlate to produce several differential diagnoses, moreover the correlation of all symptoms need a lot of knowledge and experience which is quite challenging for a single person. several problems could be avoided if a properly programmed computer could be operating over a patient. evolution and upgradation is a common phenomenon of technology. A day not too far from today using this ai and machine learning technologies we allow us to connect ourselves with doctors universally, check for various treatment plans, feasible costs and if the technological advancements grow than my dream of a practitioner operating from his place to the remotest region harnessing the required equipment (medical robots operate from surgeons console) and carry on his surgery using robots controlled electronically through internet or any other data transfer means. even rare diseases could be diagnosed through the correlation from symptoms as its unimaginable to human mind due to lack of daily practice on rare cases and its the tendency of the brain to forget the ones which aren’t regularly recollected. ( use-disuse theory)

Not only for saving patients from being exploited it even increases the

comfort of doctors by reducing several stressful jobs of diagnosing critical cases and consultancies journey, it would be available round the clock unlike the time-starved human mind and body, though it could be a platform for doctors whole over world to take part upon treatment on several patients throughout the globe at the same time, as simple commands to the robots could finish the task. As like ever new technology a period Of acknowledgeable progress cannot be made unless apprehensions such as overestimations of a particular condition and treating an apprehensive patient. Apart from this the practitioner is to be taught regarding the adoption of machine learning and aI in the medical field.

Even ai needs to be developed a lot in order to aromatize with the medical fields lifestyle, which exhibits the major difference between theoretical knowledge and practical reality. It has a lot to learn from several doctors and there countless cases and their experiences and as ai could analyze mammoth data in no time it wouldn’t take much time and be possible to work upon it and build a super doctor which a lot of experiences and analysis power of all the doctors from all parts of the world in order to serve mankind better in technically less time and more efficiently than a human. While the early stages of development scientists need to be very careful regarding the efficiency of it in emergency, life and death situations as its an inanimate thing any failure of it in early stages would leave an unerasable mark on peoples minds regarding the technology and may even lead to the death of the new technology and it make take a lot of time to prove it right and its penetrating levels into society could be hindered.

In this world, medical care should become a basic need and it should be

accessible to every individual beyond all sorts of diversities. It’s not just advancements in the field of medicine even engineering advancements of communication and information technology could increase accessibility to this technically progressing medical field to the doorsteps of everyone. Seeing the present day trends it could be ai and machine learning which if programmed effectively and constantly updated to a world-class level would be using several communication tools coupled with the best diagnostics methods and sophisticated procedures could bring down disease rates and increase accessibility. This could bring a great change in peoples lives. I think no patient would feel sad for being treated for free.

so in order to control the emotionally and mentally unstable human mind which flutters behind greed and comforts more reliable greed proof, cumulative knowledge and experience through a non living computer could be a game-changing weapon and a missile in the field of medicine I remember Swami Vivekananda’s words “give me a hundred youth so that I will make a strong nation” I guess he studied human incognito mind far ago and expected today’s world long back. similarly right now if we could get a few exceptionally good software designers coupled with the rarest breeds of the most talented and greed-free doctors of several specializations we could make this whole medical facility available to the remotest of the country’s throughout the world and make them available as Coin boxes for telephone which was present down the line 10 year’s from now and eventually it would automatically take the transfer orders to the pockets of their customers. no doubt!!!

FAITH IS THE FOUNDATION OF A DOCTOR-PATIENT RELATIONSHIP

FAITH IS THE FOUNDATION OF A DOCTOR-PATIENT RELATIONSHIP

 

“ There are two sorts of doctors: those who practice with their brains and those who practice with their tongues”

-William Osler

The big evolutionary step that is relevant to the mechanism of the doctor-patient relationship occurred when animals started grooming others rather than themselves. It represents an elementary form of medical care. It is the first example of social interaction. The doctor-patient relationship is considered to be the core element in the ethical principles of medicine. The people used to exhibit a lot of faith in doctors and at the same time, doctors exhibited high traditions of Hippocratic oath and morals enshrined in Vedas where the doctors’ aim was total dedication towards treating ailing living beings. Doctors were considered as demi-gods.

With the passage of time, setting up of corporate hospitals and commercial mottos the sacred doctor-patient relationship is spoiled. Thereby in today’s scenario, there is a deficit in the doctor-patient relationship which is leading to chaos. Continuity of care is something that is known to improve patient satisfaction and patient outcomes. You should be able to see the humanity on the other side of the white coat. It makes sense that if a patient trusts his doctor, the doctor will be in a better position to know the patient’s illness. This is a milestone in a doctor-patient relationship.

Various studies have shown that patients who went back to the same physician had a lower chance of dying, compared to patients who visited different doctors. The rationale for this is when you see the same physician you would talk more freely and give the doctor more information and build up a harmonious relationship with the doctor. This highlights the importance of relationships in the well being of an individual including in the medical care. A word of care and sympathy by a doctor to his sick patient can really restore a patient’s faith and confidence.

But today’s visual of deteriorating doctor-patient relationship was a manifestation system-wide malaise of decreasing respect for institutions, decrease in the value system and increasing violence and materialism. The lack of trust in a doctor-patient relationship is increasing the laws and regulations being imposed on the medical sector. In doctor-patient relationship, honesty is important from doctor’s point of view and a provider who listens, followed by one who is compassionate and one who can clearly explain what any medical problem is and how it will be treated is needed from patient’s point of view. Patient with a lower level of trust in their physician is more likely to report that requested or needed services are not provided. Understanding this relationship may lead to better ways of responding to patient requests that preserve or enhance patient trust, leading to better outcomes. A person may forget your name, but they will never forget how you made them feel. Every doctor should put in efforts to develop a good doctor-patient relationship to treat the patient who has the disease rather than treating the disease.

Therefore,

“The doctor-patient relationship is critical to the placebo effect”

Irwing Kirsch

PERCUTANEOUS BILIARY DRAINAGE

PERCUTANEOUS BILIARY DRAINAGE

 

Introductions:

Both ultrasound and computed tomography (CT) can be used to guide to percutaneous needle intervention. The choice of methods depends on multiple factors including lesion size, locations, equipment availability etc.

Ultrasound has several strengths as guiding percutaneous interventions. It is readily available, relatively inexpensive, and portable. It has no ionizing effects and can be used in almost all anatomical plane. The greatest advantage, however, is that it allows real-time visualization of needle tip as it passes through the tissue into the target. Ultrasound provides precise needle guidance to allow for needle aspiration

or catheter drainage of superficial and deep fluid collections throughout the body.

First, introduced in 1921 with direct puncture of the gallbladder. The technique was revolutionized in the 1960s with the introduction of fine-gauge (22- to 23-gauge) needles. It is an interventional radiology procedure undertaken for those with biliary obstruction. Biliary drainage relieves obstruction by providing an alternative pathway to exit the liver. If the bile duct becomes blocked, the bile cannot drain normally and backs up in the liver.

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Indications:

  • Biliary stones – within the gallbladder or within the bile ducts
  • Pancreatitis
  • sclerosing cholangitis
  • Tumors of the pancreas, gallbladder, bile duct, liver
  • Biliary Strictures
  • Malignancy: eg pancreas, Lymph nodes
  • Undiagnosed jaundice
  • Injury to the bile ducts during surgery

Contraindications:

  • Sepsis
  • bleeding disorders
  • contrast hypersensitivity

Patient preparations:

-The procedure and risk should be explained to the patient.

-The patient needs to empty stomach at least 4 hours.

-Patient need to get IV antibiotic before the procedures start

-We routinely require platelets and PT for the drainage procedure

-IV access is obtained to the patients for administration of medications and emergency access for complications

Technique and stenting

-The patient will lie on supine position

-Educate the patients about the whole procedure

-Skin will be cleaned with an antiseptic solution, and most of the rest of your body will be covered with a sterile towel

-The radiologist will use an ultrasound machine to decide on the most suitable point for inserting the fine plastic tube (the drainage catheter)

-Normally inserted between two of your lower ribs, on the right side

-Apply local anesthesia lidocaine 1% solution. The usual maximum adult dose for local anesthesia is 4.5 mg/Kg

-A small incision was made.

– Catheter insertion can be performed using the Seldinger technique; the choice usually depends on operator preference.

-When the radiologist is sure that the needle is in a satisfactory position in one of the bile ducts, a guide wire will be placed through the needle into the bile duct; this enables the plastic drainage catheter to be positioned correctly. The procedure may end at this stage, with the catheter being fixed to the skin surface, and attached to a drainage bag.

-Repeat ultrasound is done to look for drainage site and any complications.

-In some cases, a permanent metal tube, called a stent, may be placed across the obstruction to relieve the blockage. Even if this is done, a temporary external catheter may be left in place, attached to a drainage bag.

Percutaneous biliary drainage is considered a very safe procedure, designed to save you having a larger operation. Sometimes the bile may leak around the catheter and form a collection in the abdomen that can cause pain and may require drainage.

It usually takes 30 to 40 minute.

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Biliary Drain

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Biliary stenting

Post Procedure:

-The patient will send to ward

-Monitor vitals 8 hourly

-Take care of drainage bag so that catheter doesn’t get pulled out.

-All drains must be irrigated regularly. Injection and aspiration of 10 mL of isotonic sterile saline three or four times daily is usually sufficient

-Empty the drainage bag 8 hourly and record the output.

-If the patient goes home, educate the patient about catheter care and drainage output

Catheter Removal: Three criteria for catheter removal are as follow:

1. Negligible drainage over 24 hours

2. Afebrile patient

3. Minimal residual cavity

The catheter should be removed gradually over a few days, which promotes healing by secondary intentions.

Advantages of biliary drainage:

If a patient is suffering from symptoms of a blocked bile duct, such as skin discoloration, itching, rashes, nausea and tiredness, a biliary drainage may relieve some of these symptoms over time (it often takes a number of days after the procedure for these benefits to become apparent). If the bile in the blocked bile ducts is infected, biliary drainage is an important part of the treatment. Hepatic functions may be improved after biliary drainage.

NIPAH VIRUS (NiV) INFECTION- A NEWLY EMERGING ZOONOSIS CAUSING DANGER TO HUMAN

NIPAH VIRUS (NiV) INFECTION- A NEWLY EMERGING ZOONOSIS CAUSING DANGER TO HUMAN

  • Introduction: Nipah Virus is a newly emerging zoonosis that causes a severe disease in both Animals and Humans.
  • This may worsen into a state of a coma over a day or two.
  • Complication can include Encephalitis and Seizures.
  • This is a highly contagious and deadly virus.
  • What is Nipah Virus: The virus, a member of the family Paramyxoviridae (genus Henipavirus) is named after the Malaysian Village of Sungai Nipah, where many Pig farmers became ill.

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  • Epidemiology: Nipah Virus was first isolated & identified about 2 decades ago in 1998-99 When Malaysian & Singaporean Pig farmers & others in close contact with the animals suffered from respiratory illness.

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  • Outbreaks: Nipah Virus outbreaks have been reported in Malaysia, Singapore, Bangladesh, and India.
  • The Highest Mortality Rate has been reported about 2 decades ago in Bangladesh in 1999, where about 300 human cases of Nipah Virus were reported, including 100 deaths.

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  • At that time, more than one million pigs were euthanized to contain the outbreaks.
  • In 2001, NiV was again identified and isolated as the causative agent in an outbreak of human disease occurring in Bangladesh.
  • Recent Outbreaks In India: Recently, Nipah Virus came into the limelight when there is 17 people have died due to this fatal contagious viral disease in the Indian State of Kerala, According to the Health Ministry Official.

The virus is more frequent in Bangladesh & India, where exposure to Nipah Virus has been associated with eating raw date palm sap with contact with infected Bats Or Human.

  • Transmission: Transmission of Nipah Virus to human may occur when one comes in direct contact with infected bats, infected pigs or infected people.

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  • The recent outbreak of Nipah Virus in Kerala (May 2018), occurred when people consumed fruits bit by infected fruit bats, When bats carrying the virus bites into fruits, the virus enters the fruits and then infects the humans who consume it.

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  • Bats shed the virus in their excrement and secretions which can infect humans, as well as animals such as pigs, dogs, cows, etc who come into contact with the droppings.
  • The “Hospital-Acquired Infections” – are a major path of human to human transmission.
  • The Nipah Virus is also suspected to get transmitted through coughing. This infection can also easily affect people who come in direct contact with contaminated bodies.
  • Incubation Period: The symptoms may take from 4 to 14 days to appear after a person gets infected.
  • Risks of Exposure: Consumption of raw date palm & contact with bats. Human to Human transmission has been documented & exposure to other Nipah infected individuals is also a risk factor is reported in India & Bangladesh.
  • Signs & Symptoms: NiV infection can progress silently in humans without showing any symptoms. However, people infected with this deadly virus may display Influenza-like symptoms.
  • The Sign & Symptoms of Nipah Virus include:
  • Acute Respiratory Infection, which can be mild to severe and cause interference in breathing.
  • Fever, Muscle Pain, Headaches, Nausea, Vomiting, Sore Throat.
  • Dizziness, Drowsiness, Mental Confusion & Disorientation, Atypical Pneumonia.
  • Brain Swelling or fatal encephalitis. Gradual progression to Coma within 24 to 48 hours.
  • People who survive the infection may suffer from long-term side effects such as Convulsion and Personality Changes.
  • Mortality Rates: The virus can kill between 40% to 100% of those infected by it. Surprisingly, more than 60% of this infection in humans comes from animals.
  • How is Nipah Virus Infection Is Diagnosed:

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  1. Throat & Nasal Swabs.
  2. Blood Tests.
  3. Virus Isolation & Detection.
  4. CSF Analysis, Urine Tests.
  5. ELISA (IgG- IgM).
  6. Real-Time Polymerase Chain Reaction (RT-PCR).
  7. In Fatal Cases, immunohistochemistry on tissues collected during Autopsy may be the only way to confirm it.
  • What is the treatment for Nipah Virus Infection:

Currently, there is no vaccine or treatments available for Nipah Virus, Supportive Care and Prevention is the key to stop the spread and remain safe from this virus.

The drug Ribavirin has been shown to be effective against the virus in vitro, but the usefulness of Ribavirin remains uncertain.

  • How We Can Prevent The Nipah Virus Infection:
  1. People Should prevent the animals from eating fruits contaminated by Bats since the Fruits Bats are the Primary cause of Nipah Virus Infection.
  2. Stay away from consuming date palm for some time.
  3. Avoiding direct contact with Pigs, Bats, Human in Endemic.
  4. Health-Care Professionals to such patients should take precautionary measures such as Wearing Masks, Gloves etc.
  5. To avoid Hospital-Acquired Infections raise awareness about signs & symptoms & transmission to avoid human to human infection in such settings.

 

 

 

 

 

 

 

 

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