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.

 

 

 

 

 

 

 

 

THE IMPACT OF CURRENT HEALTH CARE SITUATION ON MEDICAL STUDENTS AND YOUNG DOCTORS OF NEPAL

THE IMPACT OF CURRENT HEALTH CARE SITUATION ON MEDICAL STUDENTS AND YOUNG DOCTORS OF NEPAL

 

The current situation of doctors in Nepal is one of the major factors that is causing the doctors of our generation to practice medicine in a foreign country. At least we won’t have a fear to be beaten up by an angry mob when the patient dies (even after the doctors did all they could).

This type of situation is highly demotivating and will have an impact on the health sector of Nepal for a long time. Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) in the mind of the young medical students and doctors who don’t see or don’t want a future here.

And when all the competent Doctors leave the country for a place with better job security, job satisfaction, paygrade, respect then the country will be left with lack of manpower and will go through a medical crisis with lack of manpower.

People may argue “Doctors should not work for money, they should do good to the society,” I ask WHY? Does anyone tell an engineer to build houses/roads for “betterment of the society”? OR ask the banks to give away money for the same cause. No!

Then why should we do that? Is it wrong that I would want luxuries of modern society after doing my job to the best I can? If I paid a large sum of money for my education is it wrong that I would like to earn a lot more?

So someone who spends their better part of their life and a large sum of money to be a doctor, why would he/she like to remain in a place with minimal pay, lack of freedom to practice their skills and fear. of getting beaten! And they know they have way better alternatives abroad.

I don’t believe Doctors are next to God, I don’t want to be called that either. The medical profession is like just another profession and we are just like other people. We have our own set of skills and limitations just like any other professionals and people seem to forget this.

I am not denying the fact that there is no medical negligence and some doctors are responsible for the wrong outcomes and they are at fault. But it’s not the angry mob or the saddened family of the patient who decides who was at fault.

We have proper laws and the government and Nepal Medical Council(NMC) to investigate it and decide whose fault was there if any. And one can even be banned to practice medicine for life if any major negligence is found. But No! Here, the mob decides that ALWAYS the doctor is at fault. It’s like saying that if some students fail in exams/do bad then the teachers are ALWAYS at fault! If the student doesn’t study properly then whatever the teachers do that student will fail and it won’t be the fault of the teachers. The same analogy applies in case of a doctor and a patient.

If the situation continues like this we will see a decline in the competent people wanting to join medicine in the first place let alone practice here and the quality of the services will degrade causing more mishappenings and the vicious cycle will continue.

KARTAGENER’S SYNDROME

KARTAGENER’S SYNDROME

 

 

ABSTRACT

Kartagener syndrome, a very rare yet life-threatening autosomal recessive disorder. It is a unique syndrome which was initially charactered by a classical triad of situs inversus, chronic sinusitis, and bronchiectasis. Later, male infertility was added to it. It is a classic example of how mutations at the genetic level can alter the orientation of major internal organs within the body.

 

INTRODUCTION

Kartagener Syndrome is an autosomal recessive disorder where genetic mutations can cause anatomical disposition of thoracoabdominal viscera leading to the formation of mirror image of normal. In 1933 Kartagener described the condition as a triad of situs inversus, chronic sinusitis, and bronchiectasis. There is no cure for kartagener syndrome, however, the pathological condition is managed by strict medical treatment and therapy.

 

EPIDEMIOLOGY OF KARTAGENER’S SYNDROME:

According to the Research in Indian Journal Of Human Genetics, an estimation of 1 in every 30,000 live births, babies are born with Kartagener’s syndrome.

 

PATHOPHYSIOLOGY OF KARTAGENER’S SYNDROME:

Kartagener Syndrome is a subclass of primary ciliary dyskinesia in which there is a mutation in DNAI1 and DNAH5 genes both encoding dynein protein responsible for motility of cilia hence leading to ciliary dysfunction.

 

During the 3rd week of embryonal development, the endoderm of the trilaminar disc expresses cilia in its ventral aspect. The movement of cilia controls the concentration of certain molecules such as Nodal, LEFTY1, and LEFTY2 on the left side of the coelomic cavity which is responsible for the development of abdominal and thoracic viscera on the left side.

 

In embryo with primary ciliary dyskinesia, those molecules are not swept efficiently on the left side so, the left-sided organs will be developed on the right side resulting in the formation of mirror image of normal. This transposition of thoracoabdominal viscera is known as situs inversus.

 

20% of individuals with situs inversus may suffer from some additional problems such as chronic sinusitis, bronchiectasis, and infertility in the male.

In case of chronic sinusitis, dysfunction of cilia leads to impairment of mucociliary clearance of paranasal air sinuses predisposing the patient to certain bacterial infections such as Staphylococcus aureus, Pseudomonas aeroginosa etc.

As cilia of the upper respiratory tract are dysfunctional, there is pooling of secretion which predisposes to certain microbial infections ultimately ended up to necrosis, fibrosis and permanent dilation of bronchi and bronchiole and is referred to as bronchiectasis.

Kartagener’s syndrome hampers the motility of sperm leading to male infertility. According to some trials, it is also known to cause infertility in female due to ciliary dysfunction which affects cilia in the fallopian tube.

 

SYMPTOMS OF KARTAGENER’S SYNDROME

Since Kartagener’s syndrome is a genetic disorder, it is diagnosed early in life. A patient usually comes with the complaints of recurrent upper respiratory tract infections such as a chronic cough with purulent foul smelling sputum production, repeated nasal blockage, recurrent episodes of sinusitis. The patient may suffer from infertility especially in the case of a male which is diagnosed later in life.

Patient with Kartagener syndrome has primary ciliary dyskinesia and situs inversus totalis. In situs inversus totalis the position of the thoracoabdominal organ such as the heart, liver, spleen, the intestine is reversed. Hence, the diagnosis of left-sided appendicitis is misinterpreted.

Furthermore, a patient may present to a doctor with a nasal polyp, anosmia, hearing loss and occasionally clubbing of finger and toes.

 

DIAGNOSIS OF KARTAGENER’S SYNDROME:

      Kartagener syndrome is suspected based on clinical signs and symptoms. On general examination, the apex beat would be felt on the right side and liver would be palpable on the left side. Chest  X-ray would show dextrocardia, upon ultrasonography of abdomen shows liver on left side and spleen on the right side. HRCT chest shows dextrocardia with the right-sided aortic arch. Complete blood count would show neutrophil leucocytosis and C-reactive protein.

The diagnosis is confirmed by histopathology and biopsy examination of cilia present in the respiratory tract taken by brush sample or scrapping of nasal cavity or trachea, abnormalities in cilia is seen in the case of Kartagener Syndrome. However, genetic testing can also be used to confirm the diagnosis.

 

TREATMENT OF KARTEGENER’S SYNDROME:

Till date, there is no specific treatment for Kartagener syndrome, hence the cure of the cilia dysfunction is still a myth. However, the associated problems with Kartagener syndrome such as sinusitis, bronchiectasis is treated with medications.

 

Pulmonary diseases-Managing patient with pulmonary diseases is associated with enhanced mucus clearance, preventing repeated respiratory tract infections and preventing bacterial infections.

For mucus clearance, the cough should be promoted, postural drainage is enhanced.

Use of antibiotic is promoted for the bacterial infection usually after sputum culture.

For people with nasal congestion and sinusitis, nasal surgery is recommended.

 

Situs inversus– For situs inversus, there is no surgical intervention needed unless any pathological condition is present.

 

Male infertility– Male infertility is usually avoided by in vitro fertilization. Another option is artificial insemination from a sperm donor.

 

CONCLUSION

Being a genetic disorder, there is no absolute cure for Kartagener syndrome and failure to diagnose this condition may cause the patient to unnecessary and recurrent hospital admissions. However, the pathological conditions associated with it such as chronic sinusitis, bronchiectasis, hearing loss, anosmia etc. can be minimized by circumspective lifestyle and proper medications.

 

Story of Multiple Epiphyseal Dysplasia

Story of Multiple Epiphyseal Dysplasia

 

A very rare disease which you will misdiagnose most of the times.

Let’s me introduce you to this skeletal system disorder called Multiple Epiphyseal Dysplasia.

I have a Friend of mine who has a deformity in both of her legs and being a medic I had a very simple diagnosis in my mind which of course I never discussed with her. But suddenly a few days back she was very depressed and she wanted my help so she said to me. Hey, can you suggest me some simple ways to prevent it from getting more deteriorated?

That was the moment I was stunned and I started to go into the depth of my ignorance.

In a curious manner, I asked her what is the thing that you feel is getting worse. She replied to me that now she cannot sit on a motorbike because the distance between her legs was getting lesser with time and she has a waddling gait. She also said that she cannot even squat and many of the body postures which we do so subconsciously aren’t possible for her and is the reason for her depression. She added that her younger sister had even worse symptoms which also included pain along with postural defects and bowed legs.

Later I discovered that it was a disease which ran in her family and they inherited it from their mother who also had the same disease. So it was her mother and my friend with her younger sister and a younger brother who had the same condition known as Multiple Epiphyseal Dysplasia.

It is a rare disease so not many physicians know about it. People suffering from this disease have very fewer chances of getting a proper treatment in time as it is apparent only after 10-12 years that this becomes physically appreciable in the manner of bowing of legs towards outside and associated knock knees most of the times.

The diagnosis of this condition is very difficult as it requires sophisticated multidisciplinary setups with a facility of Genetic and Molecular Testing.

There are not many treatment options available as many it is claimed that the disease cannot be cured completely but only a few modifications can be made surgically to avoid the daily life problems related to sitting and posturing. Surgeries might include arthroplasty and joint replacement to correct the deformity.

The best approach is to reduce the effects of deformity by regular physiotherapy, weight control, and Psychological Counseling.

Salary of a Doctor in India

Salary of a Doctor in India

As a medical student I strongly believe that being a doctor is one of the nobel proffesion in India. Let’s talk about the salary of a doctor in India after MBBS. It varies from state to state and also the place of work. Here we catagorize the earning of a doctor by his speciality in work and experiences he gather.

Goverment vs Private sector– In general Govt hospital pay less money than a private sector. A MBBS doctor earn 30000/- to 50000/- from a Govt hospital and 40000/- to 70000/- from a Private hospital. Whereas a specialised doctor like MD or MS can earn about 50000/- to 120000/- from a Govt hospital and 70000/- to 300000/- from a private hospital. It seems that there is a huge difference there. Right? Yes, it is. As I have already said that earning by a doctor depends on their speciality, degrees and experiences. It may varies from 30000/- to 2-3 lakhs per day.

Note that– An ex-professor of AIIMS had been offered around 12 crore per annum from a big corporate hospital. That’s almost 3 lakh per day !

But after all an Average salay a doctor can make is described below

Post MBBS- Rs. 10,000 to 40,000/month
Post MD/MS – Rs. 30,000 to 2,50,000/ month
Post DM/Mch/Fellowship – Rs. 50,000 to 5,00,000/month.

A report has seen released by Medscape 2016-2017 on Annual earning of a doctor according to his/her speciality.

 

8 Ways to Maintain a Healthy Spine

8 Ways to Maintain a Healthy Spine

Back pain is one of the most common problem of many people. Among them low back pain is most common reasons for a visit to the doctor these days. Here is the #8 tips for healthy and strong spine.

1. Stand straight– Correct posture can prevent all back pain.

2. Sleep properly–  Adequate sleep required for overall health. But beside this, sleeping in a good posture is a valuable thing to maintain spine health. Sleep on your side, not your stomach: Sleeping on your stomach puts too much pressure on your spine. Sleeping on your side also reduces upper airway collapse, helping to prevent sleep apnea symptoms and give you a better night’s rest, according to the National Heart, Lung, and Blood Institute. Or if you sleep on your back try to place pillow under your knees.

 

3. Lift Right–  Lifting an object in a wrong manner can easily damage your back spine. Try to lift a heavy object in this way given here. Direction-  When lifting heavy objects, kneel to lift the object, keeping the weight close to your body while using the legs to lift rather than the back.

4. Sitting– We office workers spend most of the time by sitting infront of laptop or PC. But they should maintain a proper postion to eliminate the back pain. Direction-Feet should touch the floor or be supported. Keep Spine straight. Look straight without neck strain
Adjust your chair’s lumbar and armrests. Keep monitor at arms’ length. Position monitor & document holders even or slightly below line of sight.

5. Holding mobile– Hold your mobile devices correctly. Sit up when texting or reading. Keep device at chest or eye level to decrease neck and back stress.Use a hands-free device instead of holder to your ear.

6. Stay hydrated– Our vertebral column is 88% made of water. So dehydration can lead degenaration of discs, herniated discs. According to American academy of orthopedics a herniated disc is the most common cause of sciatica, a specific type of back pain that radiates down one of the leg. So drink more to reduce back pain.

7. Maintain weight– The topmost goal to eliminate back pain is to maintain a healthy weight. Being overweight or obese, or quickly gaining a significant amount of weight, are risk factors for low back pain can put added stress on the muscles, ligaments, and tendons in your lower back.

8. Stay Active– You’ll be at a great risk of back pain if you are not physically active or fit. The best excersice routine for back is one that combines stretching, strengthening, and aerobic activity.

Here are pictures of some exercise examples-

 

 

 

Somatoform Disorders

Somatoform Disorders

These are a group of disorder in which the patient presents with multiple clinically significant feature and physical symptoms that cannot be explained.These unexplained physical attributes often leads to anxiety of the patient; We don’t actually understand the actual mechanism of these disorders. There can be a problem with the nerve impulse that send signals of pain, pressure and other unpleasant sensation to the brain.They tend to come and go .Though various underlying causes tends to increase the risk of such disorders.
1. Its mostly occurs in subject under 30 years of age.
2. Genetics has a profound influence over such disorders
3. Negative attitude towards life.
4. Unusual sensitivity towards physical and emotional pain.
5. Family history may be positive.

Clinical criteria which are common to all the somatoform disorder are
1. Cannot be explained by medical condition, another mental disorder, or effect of a substance,
2. Not related to factitious disorder and malingering.
3. Cause significant impairment of social functioning and occupational and other functioning.

Characteristics of Somatoform Disorders

 

1. Hypochondriasis- Subject affected with this type of disorder are always in a false belief that they are suffering from a serious illness.The belief is not fixed and could be removed transiently by explanation and reasoning to have another belief about another organ of the body.The patient expresses fear while discussing their symptom.The patient must have a non delusional preoccupation with their symptoms at least six months before diagnosis can be made.
2. Conversion disorder- The neurological syndrome does not correlate with a medical cause.The symptoms are mainly weakness,tremour,deafness,blindness,etc. It though start as a mental or emotional crisis and converts to a physical problem.Conversion disorder is not conformed to any anatomical pathway or physiological mechanisms, but instead they fit a lay view of physiology. It rarely occurs below 10 years of age or after 35 years of age.It is commonly found in rural population, person of lower socioeconomic status , and those with minimal medical or psychological knowledge.
3. Pseudocyesis- Here the woman feel labour pain along with other indication of pregnancy. Here the somatic symptoms occur less than six months.
4. Body dysmorphic disorder- It is the obsession with with a flaw in his or her appearance which can either be a minor flaw or non-existing.In case of real physical imperfection, the defect is usually slight but the patient’s concern is excessive.The disorder occurs equally in men and women.
5. Somatization disorder- Also known as Briquet disorder, here the patients are
Below 30 years of age and present with unexplained physical symptoms .
The symptoms include-
• One pseudoneurogenic symptom
• One sexual problem
• Four pain symptom
• Two gastrointestinal problem
People with such disorder make frequent clinical visits , have multiple
Diagnostic test done, are referred to multiple doctor due to their myriad
Symptoms.
6. Undifferentiated somatoform disorder- it is a less specific version of somatization , here it extends up to six months or longer , with one or more than one unexplained physical complain with other necessary clinical criteria.Chronic fatigue that is unexplained by any relevant clinical criteria is a typical symptom.
7. Pain disorder- It is fairly common. At its onset , the pain is associated with psychological factors. Though its maintenance may be associated with a general medical condition.Though pain is is the the focus of the disorder, but psychological factor are primary to play in the perception of pain.

Here the result of medical test are either normal or fails to explain the person’s symptoms.And the history and physical examination do not reveal any known medical condition.

Dignosis:-

It is quite a challenge to work with somatoform disorder it requires considering a mental health diagnosis while excluding the medical causes of the physical symptoms.The problem with these type of disorder is the that there is no specific physical examination or laboratory finding that are required for confirmation of the diagnosis.Though appropriate non psychiatric medical condition should be considered by unnecessary laboratory testing should be avoided in such cases.Factitious disorder and malingering though are related disorders should be excluded before diagnosing a somatoform disorder . In factitious disorder the patient has a internal desire to be sick , while in malingering the patient bluff the physical symptoms so that he may have any sort of gain such as financial benefit ,legal benefit , escaping a unfavorable situation. But in somatoform disorder, there is no possible gain for the patient and the physical symptoms are not feigned , rather fear and anxiety stimulates these disorders.

The diagnosis of Somatoform disorders have been assisted by clinical diagnostic tools such as patient health questionnaire .

If the patient is bothered a lot lot by at least three of the symptoms without a medical reason then there is a possibility of somatoform disorder.
Treatment-

The patient have a strong believe that their symptom have a physical cause , though is is contrary .This is due to the false interpretation of the symptoms.
The steps of the treatment are-
1. Discussing the key features of the diagnosis with the patient-
The initial steps in the treatment is to discuss about the disorder to the patient early in the work-up and, after ruling out organic pathology as the primary ethology for the symptom, to confirm the psychiatric diagnosis.The physician must first construct a therapeutic alliance with the patient.then the physician must review with the patient the therapeutic criteria for the suspected somatoform disorder. He must inform the patient that the goal of treatment is management rather than cure.
2. Therapy-
First and foremost is the treatment of the psychiatric comorbidities , since the psychiatric disorders are generally found in union with the co morbidities.
There is limited effectiveness of the pharmacological interventions.
Cognitive behavior therapy have been found to be effective in the somatoform disorder.It focuses on reducing cognitive distortions , imaginary belief , worry and behavior that lead to anxiety and somatic manifestation.

3. Follow up-
Regular and brief follow up with the physician is an important aspect of treatment.This is important for the maintainable of the therapeutic alliance with the physician .The patient can openly ventilate about their worries and the opportunity to be reassured repeatedly that their symptoms are not due to a physical condition

Practice Management Strategies for Somatoform Disorders:-
Accept that patients can have distressing, real physical symptoms and medical conditions with coexisting psychiatric disturbance without malingering or feigning symptoms
Consider and discuss the possibility of somatoform disorders with the patient early in the work-up, if suspected, and make a psychiatric diagnosis only when all criteria are met
Once the diagnosis is confirmed, provide patient education on the individual disorder using empathy and avoiding confrontation
Avoid unnecessary medical tests and specialty referrals, and be cautious when pursuing new symptoms with new tests and referrals
Focus treatment on function, not symptom, and on management of the disorder, not cure
Address lifestyle modifications and stress reduction, and include the patient’s family if appropriate and possible
Treat comorbid psychiatric disorders with appropriate interventions
Use medications sparingly and always for an identified cause
Schedule regular, brief follow-up office visits with the patient (five minutes each month may be sufficient) to provide attention and reassurance while limiting frequent telephone calls and “urgent” visits
Collaborate with mental health professionals as necessary to assist with the initial diagnosis or to provide treatment

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