L-glutamine can help in sickle cell crisis

Sickle cell disease is common in India. The prevalence is higher in the tribal belt of Central, Western and Southern India. Sickle cell disease is rampant in Vidarbha

Acute painful episodes or vaso-occlusive crises are the hallmarks of sickle cell disease (SCD). They are also the most common reasons for hospitalizations in them. Opioids have been used to manage pain, but there are concerns about addictions, adverse effects and tolerance with their long-term use. The association of nephropathy with SCD precludes the use of NSAIDs in these patients. Various non-pharmacological approaches have also been employed for pain relief such as cognitive behavioural therapy, biofeedback, relaxation techniques etc.

Other therapeutic options that target the pathophysiological processes such as hydroxyurea, pharmaceutical-grade L-glutamine, RBC transfusions and hematopoietic cell transplantations are being used to prevent pain. Only hydroxyurea and pharmaceutical-grade L-glutamine are US Food and Drug Administration approved to prevent pain episodes in SCD.

A new multicenter, randomized, placebo-controlled, double-blind, phase 3 trial in patients with SCD who had at least two pain events in the prior year found that compared with placebo, pharmaceutical grade L-glutamine, administered twice daily by mouth in dose of 0.3 g/kg/dose, alone or with hydroxyurea, reduced acute pain events, acute hospitalizations and length of hospital stay.

The observed beneficial effects of glutamine (vs placebo) in the trial were modest: 3 vs 4 pain episodes in a year, 2 vs 3 hospitalizations for pain, respectively independent of hydroxyurea use.

Based on the results of this trial, L-glutamine has been suggested for individuals >5 years of age who have persistent pain despite hydroxyurea, those who are intolerant to hydroxyurea. Although, no significant adverse effects were reported, taking glutamine requires mixing powder with food or beverages twice a day.

However, when given L-glutamine as a therapeutic option, the patient should be explained about the benefits that are only modest as the patient may then choose not to take L-glutamine if he/she finds that the cost of treatment is too high or the burden of taking the drug is prohibitive.

A decision to start L-glutamine should only be taken together with the patient.

Reference

1.    Niihara Y, Miller ST, Kanter J, et al; Investigators of the Phase 3 Trial of l-Glutamine in Sickle Cell Disease. A phase 3 trial of l-glutamine in sickle cell disease. N Engl J Med. 2018;379(3):226-235.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Meri Naina ki Shaadi

A marriage is a joyous occasion. There is happiness all around. The atmosphere abounds with fun and laughter. A marriage is a family affair to be celebrated with close family and friends.

My daughter, Naina, was married on 2nd December.

Like all fathers, I too was a happy and proud father that day. But, for me, the wedding was a different experience all together.  It was very profound and spiritual experience for me.  

It was my endeavour to have something for everybody who was present, so all could experience the ananda of the marriage ceremony.

For those who were vegetarians, the food on the day of Qawali and the marriage was vegetarian, while sangeet and mehendi also had non-vegetarian food for those who enjoy non-vegetarian food.

For people who wanted décor, all the ceremonies of the wedding had a different décor.

Sangeet and a live band catered to those who looked for entertainment. There were folk dances on the day of mehendi.

For people who wanted to experience a journey toward their consciousness, we had Sufi Qawwali.

For people who believe in traditions and wanted to see Vedic philosophy reflected in the marriage ceremony, there was chanting of mantras. The air resonated with the sound of the mantras.

For those who wanted to know the meaning of the various steps of the ceremony, every step was accompanied with an explanation. A book on wedding rituals, which explained the meaning of marriage, especially the four main rituals (ghudchari, varmala, kanyadaan and pheras) was gifted to all present.

Like all Hindu rituals, the wedding ceremony also began with a pooja of Lord Ganesha “Vighnaharta” invoking him to bless the couple and to ensure that the ceremony went off well without any obstacles.

We had photographs of departed souls at the entrance to seek their permission before the ceremony began (pitra rin). All living elders blessed the couple as did the teachers (rishi/guru rin).

The whole family and close friends was gathered to bless the couple.

Padma awardee doctors and eminent persons from the field of performing arts also blessed them.

Dharma gurus of all religions were invited for the marriage, who bestowed their blessings on the married couple.

I have often been given the moniker “Doctor with a stethoscope”. But, this was my daughter’s wedding and for this marriage, I was Krishna Kumar, the father and not KK Aggarwal, the doctor. I did not wear my stethoscope.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

New Practice Changing Guideline: Laparotomy is the preferred approach for radical hysterectomy in women with cervical cancer

For women undergoing radical hysterectomy for cervical cancer with tumors ≥2 cm, the new recommendation is laparotomy rather than minimally invasive surgery (MIS).

Patients with smaller tumors (<2 cm) may be candidates for robotic-assisted surgery.

MIS approaches are done with the goal of reducing operative morbidity. However, two new studies reported in the New England Journal of Medicine have found worse oncologic outcomes with these procedures.

In a randomized trial of women with cervical cancer who underwent radical hysterectomy, MIS compared with laparotomy resulted in a higher rate of death from cervical cancer at 3 years (4.4 versus 0.6 percent) and a lower rate of disease-free survival at 4.5 years (86.0 versus 96.5 percent) (1).

Another cohort study found that MIS radical hysterectomy was associated with a higher four-year mortality rate (9.1 versus 5.3 percent) (2).

This is a recent recommendation. Any such new information or recommendation should be discussed with the patient and informed decision should be taken before proceeding ahead with the line of management.

References

1.    Ramirez PT, Frumovitz M, Pareja R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med 2018;379:1895.

2.    Melamed A, Margul DJ, Chen L, et al. Survival after minimally invasive radical hysterectomy for early-stage cervical cancer. N Engl J Med 2018;379:1905.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

The four stages of dysglycemia-based chronic disease: A new diabetes chronic disease care model

The American Association of Clinical Endocrinologists (AACE) has introduced a dysglycemia-based diabetes chronic disease care model in a position statement published in the November 2018 issue of the journal Endocrine Practice.

The dysglycemia-based chronic disease (DBCD) care model acknowledges that diabetes exists as a continuum and it is not just a distinct disease characterized by hyperglycemia. At the same time, it recognizes that identifying distinct stages in this continuum helps formulation of an actionable preventive care plan. Hyperinsulinemia begins much before the blood sugar levels become high enough to be diagnosed as type 2 diabetes. Hyperinsulinemia leads to insulin resistance, the hallmark of type 2 diabetes. Hence, it has identified four separate stages as follows:

1. Stage 1: DBCD insulin resistance
2. Stage 2: DBCD prediabetes
3. Stage 3: DBCD type 2 diabetes
4. Stage 4: DBCD vascular complications (e.g., retinopathy, nephropathy, neuropathy) and/or type 2 diabetes microvascular events

The statement emphasizes on recognition and management of prediabetes as a necessary component for an effective personalized and population-based type 2 diabetes care plan. 

The authors say that initiating treatment only at Stage 3 or Stage 4 is not an optimal care approach, introduction of aggressive management of cardiovascular disease as early as possible is important as those with prediabetes have significant cardiovascular disease risk factors. Early intervention with exercise and weight loss increase insulin sensitivity and are effective in preventing progression from prediabetes to type 2 diabetes.

As stated in the position statement, “while not commonly recognized as a disease entity, prediabetes falls within the progressive spectrum of DBCD and that the high incidence of complications in this patient population, such as hypertension and dyslipidemia, demands better and more actionable diagnostic criteria and intervention before the disease progresses to type 2 diabetes”.

(Source: Endocrine Practice November 2018, AACE)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Staph epidermidis is now a major cause of nosocomial infections

Staphylococcus epidermidis is a very common commensal bacterium of skin and therefore is generally ignored. However, new research published in the journal Nature Communications says that this seemingly innocent bacterium is now a major cause of post-surgical, often life-threatening, infections; moreover, it is becoming antibiotic resistant.

Researchers from the Milner Centre for Evolution at the University of Bath warn that the threat posed by Staph epidermidis should be taken more seriously and extra caution should be taken for those at higher risk of infection who are due to undergo surgery.

Samples from patients who developed infections following hip or knee joint replacement and fracture fixation surgeries were compared with swab samples from the skin of healthy volunteers. The genetic variation in the whole genomes of bacteria found in samples from diseased and healthy individuals were then compared. A set of 61 genes containing infection-associated genetic elements (k-mers) that correlate with in vitro variation in known pathogenicity traits (biofilm formation, cell toxicity, interleukin-8 production, methicillin resistance) were identified in the disease-causing bacteria that were not present in most of the healthy samples.

These genes helped the bacteria to grow in the bloodstream, avoid the host’s immune response, make the cell surface sticky so that the organisms could form biofilms and make them resistant to antibiotics. Some of the healthy individuals were found to be carrying the more deadly form of the bacteria without knowing it.

Researchers hope that the identification of disease-associated genes may help to separate harmless skin Staph epidermidis isolates from disease-causing genotypes preoperatively in the clinical laboratory.

(Source: University of Bath, Nov. 28, 2018)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Updated ACIP recommendations for prevention of hepatitis A infection

The United States Advisory Committee on Immunization Practices (ACIP) has issued updated recommendations for prevention of hepatitis A virus (HAV) infection in November 2018. Published in the Morbidity and Mortality Weekly Report, the ACIP says that postexposure prophylaxis (PEP) with hepatitis A (HepA) vaccine or immune globulin (IG) prevents infection with hepatitis A virus when administered within 2 weeks of exposure. 

As per the guidelines, hepatitis A vaccine for postexposure prophylaxis provides advantages over IG, including induction of active immunity, longer duration of protection, ease of administration and greater acceptability and availability.

·         Hepatitis A vaccine is now recommended for persons aged ≥12 months who have been exposed to hepatitis A virus within the past 14 days and have not previously completed the 2-dose Hepatitis A vaccine series. These persons should receive a single dose of Hepatitis A vaccine.

·         Persons who are immunocompromised or have chronic liver disease and who have been exposed to hepatitis A virus within the past 14 days and have not previously completed the 2-dose Hepatitis A vaccination series should receive both IG (0.1 mL/kg) and Hepatitis A vaccine simultaneously in a different anatomic site at the earliest post-exposure.

·         Infants aged <12 months and persons for whom vaccine is contraindicated should be administered IG (0.1 mL/kg) instead of the vaccine, as soon as possible and within 2 weeks of exposure.

·         Preexposure prophylaxis with hepatitis A vaccine is recommended for infant travelers aged 6 to 11 months.

Homelessness is now a new indication for HAV vaccination, given the recent increase in infection rates in this group.

In infants scheduled to receive their measles, mumps, and rubella (MMR) vaccine, the vaccine should be administered preferentially to the hepatitis A vaccine; the MMR vaccine should not be administered earlier than 3 months after the immune globulin for hepatitis A. 

Suggested Reading

1.    Nelson NP, et al. Update: Recommendations of the Advisory Committee on Immunization Practices for use of hepatitis A vaccine for postexposure prophylaxis and for preexposure prophylaxis for international travel. MMWR Morb Mortal Wkly Rep 2018; 67:1216.

2.    Foster M, et al. Hepatitis A Virus outbreaks associated with drug use and homelessness - California, Kentucky, Michigan, and Utah, 2017. MMWR Morb Mortal Wkly Rep 2018;67:1208.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

HIV self-testing as a harm reduction strategy to prevent HIV/AIDS

The acquired immunodeficiency syndrome (AIDS) epidemic has had a devastating impact on human health from the time it was first reported in 1981 in the United States. Characterized by fear and ignorance, AIDS took a heavy toll of life in the initial years. The numbers were escalating and death was certain with no effective treatment available at that time. And, many died undiagnosed.

Significant progress has been made since then. While antiretroviral therapy (ART) has improved survival as well as the quality of life of people living with HIV, much more needs to be done.

A new report from UNAIDS “Knowledge is power - Know your status, know your viral load” shows that intensified HIV testing and treatment efforts are making a difference and are accessible to a greater number of people living with HIV. In 2017, three quarters of all people living with HIV (75%) knew their HIV status, compared to just two thirds (67%) in 2015, and 21.7 million people living with HIV (59%) had access to antiretroviral therapy, up from 17.2 million in 2015. However, the report also shows that about 9.4 million people living with HIV do not know they are living with the virus. It is this percentage of people living with HIV that need to be reached.

In 2014, UNAIDS set a treatment target of “90-90-90” to help end the AIDS epidemic by the year 2020. The aim is that 90% of all people living with HIV will know their HIV status, 90% of all people diagnosed with HIV will receive sustained ART and 90% of all people receiving ART will have durable suppression.

One of the biggest barriers to HIV testing is the fear of stigma and discrimination, which deters many from visiting the testing centers. Fear of being seen visiting the test centers, fear of the diagnosis itself and if diagnosed, fear that this information could be shared with their family, friends, or others are factors because of which people are afraid and hesitant to seek HIV testing.

Unless the uptake of HIV testing is increased, achieving the target of “90-90-90” will remain elusive. People with low access to testing facilities and those at higher risk that would otherwise not get tested are the ones that need to be encouraged to test themselves for HIV.

HIV self-testing has been suggested to improve HIV testing. It is a convenient testing approach for those who want to test themselves to know their HIV status in privacy. The WHO has strongly recommended “HIV self-testing” as an additional approach to existing HIV testing services. As stated by WHO, “HIV self-testing (HIVST) is an empowering and innovative way to reach more people with HIV and help achieve the first of the United Nation’s 90–90–90 targets – for 90% of all people with HIV to know their status by 2020”.

Under the National Strategic Plan on HIV/AIDS and Sexually Transmitted Infections (STI), 2017-24, the target by the year 2024, is to ensure that 95% of those who are HIV positive in the country know their status, 95% of those who know their status are on treatment and 95% of those who are on treatment experience effective viral load suppression.

India has a “Test and Treat Policy for HIV”, which means that anybody who is tested and found positive will get ART irrespective of CD count or clinical stage. India also has a “Viral Load testing” for all people living with HIV/AIDS to monitor the effectiveness of treatment of patients taking lifelong ART.

India, however, is in the process of implementing HIV self-testing. The policy on HIV rapid diagnostic tests self-testing is still under consideration. It should be implemented at the earliest.

As a harm reduction approach, HIV self-testing will help reach people who are at risk, including injecting drug users and may not otherwise test themselves for HIV. 

Knowing their HIV status will help them to start ART sooner to lead healthier lives and thence to improve their life expectancy and also reduce the risk of transmission of HIV.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA