Morning MEDtalks with Dr K K Aggarwal 29th July 2018

Undetectable HIV is untransmittable and the Risk Is Zero

If one is on suppressive ART, he or she is sexually non-infectious. The risk is zero as per results from PARTNER2 trial that showed zero linked transmissions after nearly 77,000 condom-less sex acts between sero-discordant gay couples in which the HIV-positive partner had a suppressed viral load.

Myron Cohen, MD, from University of North Carolina at Chapel Hill, announced similar results for heterosexual couples from the landmark HIV Prevention Trials Network 052 study (N Engl J Med. 2016;375:830-839). PARTNER2 followed the 2015 PARTNER study, showed zero linked transmissions from 53,000 condom-less sex acts in gay and heterosexual couples.

The study assessed the protective effect of suppressive treatment to see if it would hold up for HIV-negative gay men who had receptive anal sex with HIV-positive partners without a condom. The researchers also wanted to see whether the results would match the upper confidence interval of 0.46 per couple-year of follow-up reached by heterosexual couples in PARTNER. For the gay men in that study, it was nearly double that, at 0.84. (Excerpts from Medscape)

CDC: Stop washing condoms to re-use them

Between one and three percent of people have washed or reused condoms, according to one 2012 study. Bacteria, viruses and semen are all too small to be broken down and washed away by soap

Condoms are 98 percent effective at preventing pregnancy and are the only way to reduce STI risks, but only if used properly.

Research has found that as many as three percent of people have tried to reuse condoms, and half have put a condom on too late or removed it too soon. Condoms effectively reduce the risks of contracting sexually transmitted infection sand help prevent pregnancy, but only if used correctly. The effectiveness of prophylaxis can be undermined by doing things like unrolling it before putting it on (instead of unrolling it onto the penis) or partially unrolling it, not leaving space at the tip for semen collection and failing to use lubrication. 

Anything that damages a condom - like storing it in the wrong conditions, any contact with sharp object or fingernail or even oils from lipstick - can render it ineffective.  Most importantly, they are no longer sterile after use. After using a condom once, it has already come into contact with bodily fluids.

Hypotension, low BP, fall of BP - Definitions

Former Tamil Nadu Chief Minister and DMK patriarch M Karunanidhi was shifted to Kauvery Hospital in the early hours of Saturday after his blood pressure dropped.

Hypotension: Some definitions

Hypotension may be

1. Absolute (systolic upper blood pressure <90 mmHg; mean arterial pressure <65 mmHg)
2. Relative (a drop in systolic upper BP >40 mmHg)
3. Orthostatic (>20 mmHg fall in systolic BP or >10 mmHg fall in diastolic BP on standing)
4. Profound (drug vasopressor-dependent).

Not every patient who has hypotension has shock (chronic hypotension, drug-induced hypotension, autonomic dysfunction, vasovagal syncope, peripheral vascular disease).

Hypotension with shock

Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization. This most commonly occurs when there is circulatory failure manifest as hypotension (i.e., reduced tissue perfusion). “Undifferentiated shock” refers to the situation where shock is recognized, but the cause is unclear.

Four classes of shock are recognized:

1. Distributive(septic shock, systemic inflammatory response syndrome, neurogenic shock, anaphylactic shock, toxic shock, end-stage liver disease, endocrine shock)
2. Cardiogenic(heart attack, atrial and ventricular arrhythmias, valve or ventricle septal rupture)
3. Hypovolemic(hemorrhagic and nonhemorrhagic fluid losses)
4. Obstructive(pulmonary embolism, pulmonary hypertension, tension pneumothorax, constrictive pericarditis, restrictive cardiomyopathy)

 Clinical classification

1. Warm shock (warm hands):Sepsis, anaphylaxis
2. Cold shock (cold hands):Heart attack, embolism, hypovolemic

World Medical Association condemns killing of medical student 

The killing of a medical student in Nicaragua has been condemned by the World Medical Association. Brazilian student Rayneia Lima was shot this week while driving home from her hospital shift in Managua, Nicaraguas capital city. 

WMA President Dr. Yoshitake Yokokura said this was a tragic death and illustrated the high risks that doctors in Nicaragua are taking every day in coping with the breakdown of the country’s public health care system. ‘We repeat our warning about the rapidly deteriorating situation in the country. Attacks on health workers, medical vehicles and hospitals are unacceptable’. 

He went on: ‘We repeat our call to the Nicaraguan Government to immediately end this state of affairs. The breakdown of law and order has undermined basic health care in the country and is endangering all those medical staff who are striving to deliver health care in the midst of this crisis. It is the duty of all of us to do what we can to bring this appalling situation to an end’.

Bombali virus: A new Ebola virus found in Sierra Leone

A new species of Ebola virus has been discovered in bats in Sierra Leone, the country’s government announced July 26. Researchers looking to identify new viruses before the pathogens spill over into human populations found the new Ebola strain while sampling bats in the northern Bombali district. This is the sixth known species of the virus.

RNA analysis of the virus revealed that it is “definitely related to other Ebola viruses,” says Tracey Goldstein, a pathologist at University of California, Davis, who is with the virus-hunting PREDICT project. “But [it] was quite different.” The researchers confirmed that the Bombali virus can infect human cells, but they still don’t know whether or not it can cause disease in people. “It has the machinery” to enter a human cell, she says, but that doesn’t mean that it can make people sick.

Some species of Ebola, such as the Reston virus, can cause disease in nonhuman primates but do not sicken humans. Other species of the virus however, like the Zaire virus, have been responsible for widespread epidemics including the latest Ebola epidemic … (Science News, July 27, 2018)

Around the globe

1. Patients with well-controlled type 2 diabetes and excess weight had similar reductions in HbA1c after a year of intermittent fasting — fasting 2 days/week and eating normally 5 days/week — versus a consistent low-calorie diet. Patients in the intermittent fasting group also showed a trend toward greater weight loss, but the difference did not reach statistical significance. Intermittent energy restriction is an effective alternative diet strategy for the reduction of HbA1c level comparable to continuous energy restriction in patients with type 2 diabetes, and it may be superior to continuous energy restriction for weight reduction (July 20 in JAMA Network Open).
2. A high-sensitivity blood test appears to accurately identify the need for computed tomography (CT) scan in patients with suspected traumatic brain injury (TBI). Ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) are 2 biomarker proteins that are released into the bloodstream after TBI. In more than 96% of patients, a blood test combining both of these biomarkers accurately predicted the absence of acute intracranial injury, as confirmed by CT scan (July 24 in Lancet Neurology).
3. The use of adrenaline, during an out-of-hospital cardiac arrest (OHCA) offered a slight improvement in survival to 30 days but this was offset by worse neurological function in the double-blind PARAMEDIC 2 trial.
4. Self-treatment of acute SVT with a nasal spray containing a short-acting calcium-channel blocker etripamil is likely to be possible with a high rate of conversion to sinus rhythm, suggests a phase 2 study. (NODE-1, Journal of the American College of Cardiology). 
5. Fibromyalgia is a chronic pain syndrome that experts believe may be caused by a malfunctioning nervous system. Researchers using MRI to examine the brains of people with fibromyalgia have found abnormalities in the part of the brain that processes pain signals from the body. It appears that this part of the brain is essentially boosting the intensity of normal pain signals, potentially causing the body to feel pain without a physical cause.

Video to watch: https://www.facebook.com/drkkaggarwal/videos/1934225719932055/

Participate in survey on inflammatory bowel disease:

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Dr KK Aggarwal

Padma Shri Awardee

President HCFI

Vice President CMAAO