Zika virus in India

Zika virus infection – India

On 15 May 2017, the Ministry of Health and Family Welfare-Government of India (MoHFW) reported three laboratory-confirmed cases of Zika virus disease in Bapunagar area, Ahmedabad District, Gujarat, State, India.
The routine laboratory surveillance detected a laboratory-confirmed case of Zika virus disease through RT-PCR test at B.J. Medical College, Ahmedabad, Gujarat. The etiology of this case has been further confirmed through a positive RT-PCR test and sequencing at the national reference laboratory, National Institute of Virology (NIV), Pune on 4 January 2017 (case 2, below). Two additional cases (case 1 and case 3), have then been identified through the Acute Febrile Illness (AFI) and the Antenatal clinic (ANC) surveillance. The cases are reported below in chronological order:
Case 1: During the Acute Febrile Illness (AFI) surveillance between 10 to 16 February 2016, a total of 93 blood samples were collected at BJ Medical College (BJMC), Ahmedabad, Gujarat State. One sample from a 64-year-old male presenting with febrile illness of 8 days’ duration (negative for dengue infection) was found to be positive for Zika virus at BJMC, Ahmedabad. This is the first Zika positive case reported through AFI surveillance at BJMC, Ahmedabad, Gujarat State.
Case 2: A 34-year-old female, delivered a clinically well baby at BJMC in Ahmedabad on 9 November 2016. During her hospital stay, she developed a low grade fever after delivery. No history of fever during pregnancy and no history of travel for the past three months was reported. A sample from the patient was referred to the Viral Research & Diagnostic Laboratory (VRDL) at the BJMC for dengue testing and thereafter found to be positive for Zika virus. She was discharged after one week (on 16 November 2016). The sample was re-confirmed as Zika virus positive by RT-PCR and sequencing at NIV, Pune.
Case 3: During the Antenatal clinic (ANC) surveillance between 6 and 12 January 2017, a total of 111 blood samples were collected at BJMC. One sample from a 22-year-old pregnant female in her 37th week of pregnancy has been tested positive for Zika virus disease.
Public health response
National Guidelines and Action Plan on Zika virus disease have been shared with the States to prevent an outbreak of Zika virus disease and containment of spread in case of any outbreak.
An Inter-Ministerial Task Force has been set up under the Chairmanship of Secretary (Health and Family Welfare) together with Secretary (Bio-Technology), and Secretary (Department of Health Research). The Joint Monitoring Group, a technical group tasked to monitor emerging and re-emerging diseases is regularly reviewing the global situation on Zika virus disease.
All the international airports and ports have displayed information for travellers on Zika virus disease.
The airport health officers along with airport organizations, National Centre for Disease Control, and the National Vector Borne Disease Control Programme are monitoring appropriate vector control measures in airport premises.
The Integrated Disease Surveillance Programme (IDSP) is tracking for clustering of acute febrile illness in the community.
In addition to National Institute of Virology, Pune, and NCDC in Delhi, 25 laboratories have also been strengthened by Indian Council of Medical Research for laboratory diagnosis. In addition, 3 entomological laboratories are conducting Zika virus testing on mosquito samples.
The Indian Council of Medical Research (ICMR) has tested 34 233 human samples and 12 647 mosquito samples for the presence of Zika virus. Among those, close to 500 mosquitos samples were collected from Bapunagar area, Ahmedabad District, in Gujarat, and were found negative for Zika.
The Rashtriya Bal Swasthya Karyakram (RBSK) is monitoring microcephaly from 55 sentinel sites. As of now, no increase in number of cases or clustering of microcephaly has been reported from centers.

Medicine line is one where dead teach the living

Nicely written (taken directly from BD Chaurasia's Human Anatomy 6th edn.)

'Thus spoke the Cadaver

Handle me with little love and care,
As I had missed it in my life affair,
Was too poor for cremation or burial,
That is why am lying in dissection hall.

You dissect me, cut me, section me,
But your learning anatomy should be precise,
Worry not, you would not be taken to court,
As I am happy to be with the bright lot.

Couldn't dream of a fridge for cold water,
Now my body parts are kept in refrigerator,
You do students sit around me with friends,
A few dissect, rest talk, about food, family and movies,
How I enjoy the dissection periods,
Don't you? Unless you are interrogated by a teacher.

When my parts are buried post-dissection,
Bones are taken out of the skeleton,
Skeleton is the crown glory of the museum,
Now I am being looked up by great enthusiasm.

If not as skeletons as loose bones,
I am in their bags and in their hostel rooms,
At times, I am on their beds as well,
Oh, what a promotion to heaven from hell.

I won't leave you, even if you pass anatomy,
Would follow you in forensic medicine and pathology,
Would be with you even in clinical teaching,
Medicine line is one where dead teach the living.

One humble request I'd make,
Be sympathetic to persons with disease,
Don't panic, you'll have enough money,
And I bet, you'd be singularly happy.'😊😊😊

50% of Indian doctors have hypertension

A study, conducted by the Indian Medical Association found that 56% of doctors suffered from irregular BP at night and 21% from masked hypertension.



More than 50% physicians have been found to have uncontrolled hypertension or high blood pressure (BP) despite taking hypertensive medicines, owing to high-stress levels, says a study.
Hypertension is one of the most common lifestyle diseases prevalent today with one in three Indian adults suffering from it and is equally widespread in the medical fraternity. However, it is often misdiagnosed given the difference in blood pressure readings at home and in a clinical setting.
The findings found that 56% of doctors suffered from irregular BP at night and 21% from masked hypertension – a condition in which a patient’s blood pressure reading is inaccurate due to specific environments.
This masked hypertension is also associated with an increased long-term risk of sustained hypertension and cardiovascular morbidity, the study said.
“Over 50% physicians had uncontrolled hypertension despite taking hypertensive medicines. While 21% of the doctors surveyed had masked hypertension or isolated ambulatory hypertension, another 56% doctors suffered from irregular BP pattern at night making them prone to future adverse cardiac events,” said Indian Medical Association (IMA) President KK Aggarwal.

Points to remember while prescription

The recent notification of MCI making it mandatory for  doctors to write generic names of drugs in the prescriptions seems to have created both apprehension and confusion among doctors regarding the prescription practices. 

The MCI notification also states that and any violation would be treated as ‘misconduct’ and the violator shall be subjected to disciplinary action.

“The intent of the notification is to improve the quality of prescription, and it advises that every doctor should abide by certain rules to make it  legible as well as descriptive,” said Dr Prem Aggarwal, president, National Medical Forum in a statement.

The statement advised doctors that they should make the prescription legible by writing it in capital letters and make it descriptive by writing the generic content of the drug being prescribed as well as the dose, strength, the route, and its duration.

Writing a complete and legible prescription does not prevent medical practitioners from suggesting one or two best quality manufacturers of the prescribed drug to ensure the quality of the dispensed medicine, said Aggarwal.

“ It is a matter of concern that while the drugs are supposed to be manufactured by a strict drug quality control measures by all manufacturers, the final product in the market varies enormously in terms of its efficacy,” said Dr. Prem Aggarwal
 
National Medical Forum also released 10 points to be kept in mind by doctors while writing a prescription:

It is advised that before writing any prescription, the known allergies must be ascertained and mentioned prominently.

The prescription should always be written by a qualified doctor. If a nurse is repeating the same in nursing records as a transcription, it should be again countersigned before it becomes a legible prescription.

The Patient name, the diagnosis of disease with a unique identifier, must be mentioned clearly

Medicine should be written in capital letters, clear language, should be legible and = dated, timed with the name of the doctor and his signature.

It you are writing a brand name then the generic exposition of that brand must be clearly written.

The prescription should include, generic name of medicine, route of administration, dose and  frequency, time of administrate and the duration it has to be taken for.

The prescription must mention the next date of review of the prescription.

The high risk medicines must be mentioned clearly and special instructions should be specifically written.

Avoid writing rational combination of drugs.
 

How to memorize drug side effects

Study Hacks: How to Memorize Drug Side Effects

I am often asked by students how to study and retain drug information. Given the "drinking from a fire hose" environment of pharmacy school, this is understandable. Although the internet and online databases have put a lot of information at our fingertips, there's still a lot of drug information you must memorize in order to graduate and become a successful pharmacist.

When I was a student asking the same "how do I remember all of this!?" questions to my professors, the general response I got was some variation of the immersion principle (i.e. study harder). For me anyway, this worked to a point, but eventually, I started noticing diminishing returns. I experimented and came across the following process. This article will focus specifically on drug side effects, but it can be applied to just about anything. These "learning by deconstruction" techniques are what got me through pharmacy school (not to mention the NAPLEX and BCPS exams).  

Learning by Deconstruction

Start by breaking down how side effects happen. What are the causes? Take the general overview of "side effects" and break it into its individual parts. We can use toxicology studies to help us with this. In general, there are 4 main "causes" of drug toxicity (and hence, side effects):1

 

1. Mechanism-Based (you'll often see these broken down into "On-Target" and "Off-Target" effects)
2. Toxic metabolites

3. Immune/hypersensitivity reaction to the drug

4. Idiosyncratic reactions

 

With that basic framework in mind, let's look at each category separately. Afterwards, we'll explore some useful tips and tricks for memorization. 

1. Mechanism-Based

The first step is to understand the pharmacology of the drug itself. For any given drug, the majority of its side effects are usually some offshoot of its mechanism of action. It might be the drug working "too well" or it might be the drug binding to the correct receptor in the wrong tissue. If you truly learn pharmacology (and the related pathophysiology), then "memorizing" side effects is easy. It almost becomes unnecessary because you can use reason to figure out most potential side effects.

Mechanism-based side effects are broken down further into "on-target" and "off-target" effects. Going a step further, on-target effects are categorized by where they occur (either the intended tissue or in an unintended tissue). 

 

For example, a "classic" side effect of non-selective beta blockers is asthma exacerbation. This is an on-target effect because beta receptors are being appropriately blocked but it's in an unintended tissue (the lungs instead of the heart). Another side effect of beta blockers is bradycardia, another on-target effect. This time, however, it's in the intended tissue. 

 

For off-target effects, let's look at diphenhydramine. It's "supposed" to bind to H1 receptors, but many of its side effects stem from the fact that it also binds to (and blocks) cholinergic receptors. This leads to the classic anticholinergic effects such as dry mouth and urinary retention.  

 

How do you memorize all of this? These side effects usually extend to the entire class of drugs. So you might learn in class or in a package insert that lisinopril can cause a dry, hacking cough. By learning the mechanism of that reaction (bradykinin build up secondary to ACE inhibition), you can now reason that every ACE inhibitor can cause a dry hacking cough. This is a class-wide side effect. Another example is how all NRTIs can cause both lactic acidosis and hepatic steatosis via mitochondrial toxicity. 

 

You can learn mechanism-based side effects "once" for one drug, and you now know it for all other drugs in the same class. You can make a note card (or similar list) of these on and off-target effects. That will help you see the forest for the trees and connect the dots of the big picture.

 

2. Toxic Metabolites
Another kind of side effect is due to toxic metabolites. As a point of caution, I would not necessarily include active metabolites in this categorization (active metabolites would usually fall under the mechanism-based categorization). Toxic metabolites are substances that can accumulate and cause cellular damage from the normal process of drug metabolism. An example you're likely familiar with is N-acetyl-p-benzoquinone imine (NAPQI): the toxic metabolic product of acetaminophen. As you come across toxic metabolites in your studies, keep a list of them on a notecard and review it periodically. To make it even more useful, you can also include the treatment or medical intervention for dealing with toxic metabolites (such as N-acetylcysteine for NAPQI).

3. Immune/Hypersensitivity Reactions

Immune reactions to drugs are somewhat rare, but severe when they do occur. While there is a theoretic risk of any drug causing hypersensitivity, you'll make the memorization process a lot easier on yourself if you single out the most common offending agents. Here again, it's best to take a class-wide approach. I recommend making a list of drugs (and drug classes) that commonly cause immune reactions. For example, my own list includes penicillins, sulfa drugs, taxanes, and pretty much every monoclonal antibody. Additionally, I include drugs where we might test for human leukocyte antigen (HLA). Drugs like abacavir (HLA-B*5701) and carbamazepine (HLA-B*1502) have a very high risk of an immune reaction if given to individuals positive for the respective HLA. 

 

4. Idiosyncratic Reactions
For idiosyncratic reactions, I find (again) that the best practice is to group drugs together that can cause a certain reaction. For example, you might make a list of drugs that can prolong QTc interval (fluoroquinolones, macrolides, antipsychotics, 5-HT3 antagonists, etc...) and drugs that can cause hyperkalemia (ACE inhibitors, ARBs, aldosterone antagonists, aliskiren, heparin, SMT/TMP, etc...). These drugs don't necessarily need to be in the same class. In fact, I think it's best if you throw in any drug that applies as you come across it. This serves a few purposes. First, and most importantly, it forces you to connect the dots. We learn things in a modular format in pharmacy school.
It's tempting to "learn and dump" the information and to not realize how connected and similar medicine can be. Having a list of drugs grouped together by side effect forces you to make some of those connections (and it allows you to be mindful of synergistic drug-drug interactions). Secondly, every time you add something to one of your side effect lists, you'll naturally review the other drugs already on the list. This repetition is crucial and will help strengthen your drug info foundation.

Useful Memorization Tricks

One of my favorite "study hacks" is to memorize the exceptions to a rule. An example I like to use here is the renal dosing of antibiotics. There are only a small handful of commonly used antibiotics that don't require a renal adjustment. The "rule" here then, is to monitor kidney function for every antibiotic. Then, you can make a list of exceptions to the rule. It's much easier to memorize these few outliers than it is to try to remember the massive list every antibiotic that requires a renal adjustment. There are many examples of drugs that are exceptions to the rule that you can use when you're studying. For example

• Abacavir is the only NRTI that does not require a renal adjustment
• Ethambutol is the only drug in the RIPE regimen for tuberculosis that does not cause liver damage
• Captopril is the only ACE inhibitor dosed 3 times daily (and is the only one used in hypertensive urgencies)

You can create many such exception lists to aid you in your studying. 

 

With those core tips out of the way, there are a couple of other memorization tricks you can explore if you're interested. I'm not even sure if I realized I was using these tricks at the time, but 2 tricks that worked for me in pharmacy school were making personal associations with drugs and placing post-it notes all over my apartment.

I later found out that there are some legit cognitive principles behind both of these (the Baker-baker paradox for making associations, and the Method of loci for my post-it notes). To give you an idea of how powerful these can be, I still remember the brand name for rifapentine (Priftin), that it is dosed weekly for latent TB infection, and that it's generally avoided for active TB, all because it was on a yellow post-it note on my refrigerator door. I have not encountered (or even thought about) rifapentine since the infectious disease test I took in a therapeutics module 5 years ago.

These studying techniques are useful for many things besides side effects. I hope they will be as useful to you as they have been to me.

References
1. Guengerich, F. Peter. Mechanisms of Drug Toxicity and Relevance to Pharmaceutical Development. Drug Metab. Pharmacokinet. 2011; 26(1): 3-14. Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707670/