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Medicine Update 2009 (2 Parts)
AK Agarwal, DG Jain, Pushpa Yadav, Ashok Kumar
1:
Health Leadership and Response to HIV/AIDS: The Opportunities Ahead
The historical perspective
HIV/AIDS epidemiology: present trends, and factors driving the epidemic
Monitoring the HIV situation
Factors driving the HIV epidemic in the South-East Asia Region
Individual factors
Societal factors
Notable achievements and health sector interventions
Decreasing incidence of HIV
Decreasing sexually transmitted infections
Reduced mother-to-child transmission
Reduced transmission among injecting drug users
Reduced health-care related infections
Increased survival with ART
Lessons learnt
Grand opportunities ahead for the medical/ health sector
Conclusions
2:
Current Status of Drug-resistant Malaria in India
Malaria: a global and local challenge
Global distribution of P. falciparum drug resistance
Chloroquine (CQ)
Sulphadoxine-pyrimethamine (SP)
Mefloquine (MQ)
Quinine (QN)
Multidrug resistance (MDR)
P. falciparum drug resistance in India (Figs 1 and 2)
Drug effectiveness and treatment failure
Mechanism of drug resistance to P. falciparum
Global distribution of P. vivax resistance
P. vivax malaria in India
Mechanism of drug resistance to P. vivax
Emergence and spread of drug resistance
Prevention of resistance
Theory of combination therapy
Which combination?
How does the combination therapy prevent resistance?
Monitoring of antimalarial drug resistance
In vivo tests
In vitro tests
Conclusion
3:
Drug-resistant TB: The RNTCP Response
Causes of drug-resistant TB
RNTCP achievements and challenges
Global situation of multi-drug-resistant TB
Multi-drug-resistant TB in India
Extensively drug-resistant TB
XDR-TB in India
Consequences of XDR-TB
RNTCP response plan to the threat of MDR and XDR-TB
Status and future plans
4:
Acute Headache: Who Needs Investigations – Which Ones, and When?
Assessment of acute headache
Headache history
Acute severe new onset headache (first or worst syndrome)
Onset
Location of headache
Character of the pain
Associated systemic illness
Physical examination
Which patient with headache should be investigated?
When to consider investigating the patient with headache?
Which investigations are to be done in acute headache?
Neuroimaging
Computed tomography versus magnetic resonance imaging
Electroencephalography
Lumbar puncture
Other investigations
Conclusions
Summary
5:
Erythema Nodosum: A Sign of Systemic Disease
Clinical manifestations
Pathophysiology
Causes of erythema nodosum
Infections
Streptococcal infections
Tuberculosis
Systemic fungal infections
Other infections
Drugs
Sarcoidosis
Other chronic inflammatory and autoimmune disorders
Malignancy
Diagnosis of erythema nodosum
Differential diagnosis
Prognosis
Treatment
6:
Hypokalaemic Paralysis: Emergency Room Management
Familial (primary) hypokalaemic periodic paralysis (Hypo KPP)
Thyrotoxic periodic paralysis (TPP)
Barium poisoning
Renal potassium loss
Endocrine causes
Gastrointestinal potassium loss
Hypokalaemic paralyses — An Indian experience
7:
Clinical Relevance of High Sensitivity CRP (hsCRP) Estimation
History of C-reactive protein (CRP)
Genetics of CRP
Physiological role of CRP
CRP and risk factor analysis
CRP and the metabolic syndrome
CRP and type 2 diabetes
Glucose inflammation and insulin in diabetes
hsCRP and hypertension
hs CRP and alcohol
hs CRP and smoking
Association of hs CRP and coronary artery disease
hs CRP in angina pectoris
hs CRP in myocardial infarction
CRP and its correlation with coronary angiography
CRP in other disease conditions
Conclusion
8:
Antigen-specific Interferon-gamma Release Assays: Clinical Utility in High versus Low-burden Settings
Antigen specific IGRA and the tuberculin skin test
Diagnosis of latent tuberculosis infection
Comparison of performance outcomes in high vs low burden settings
Factors that may modulate test results
Clinical utility for the diagnosis of LTBI in high vs low burden settings
Utility for the diagnosis and management of active TB
Conclusions
Summary
Acknowledgement
9:
The Chest Radiograph
Standard views
Normal chest radiograph
Method of estimating cardiac size
Method of assessing curvature of hemidiaphragms
Homogenous opacity – Consolidation
Radiological differential diagnoses of consolidation are:
Silhouette sign
Homogenous opacity – Collapse
Signs of collapse
D/d of collapse
Homogenous opacity – Pleural effusion
Causes of lack of mediastinal shift in a radiograph suggestive of large pleural effusion
Tuberculosis
Causes of disseminated miliary nodules
Diaphragmatic abnormalities
Pulmonary nodules
Solitary pulmonary nodule
Features of malignant versus benign nodules
Other signs that are seen in Hydatid cysts are:
Differential diagnosis of solitary pulmonary nodule
Hypertranslucency
Method of estimating percentage of pneumothorax
Causes of unilateral hypertranslucency
Vascular abnormalities
Interstitial shadows
Radiographic negative of pulmonary oedema
Hilar enlargement
Some interesting radiographs
Allergic bronchopulmonary aspergillosis
Causes of migratory pulmonary infiltrates
Calcification
Overpenetrated films are useful for
Calcification pattern in various diseases
10:
Multi-detector CT: Thoracic Applications
Post-processing techniques
Two-dimensional multiplanar reconstructions
Three-dimensional minimum intensity projection (MinIP) and maximum intensity projection (MIP)
Three-dimensional shaded surface display and volume rendering
Cardiovascular applications
Cardiac imaging
Pulmonary vessels
Systemic vessels
Pulmonary applications
Diffuse and focal lung disease
Solitary pulmonary nodule
Lung cancer
Tracheobronchial tree
Chest wall and diaphragm
Imaging in trauma
11:
Systemic Anti-fungal Therapy: Recent Advances
Fungal infections in India
Invasive candidiasis
Invasive aspergillosis
Zygomycosis
Cryptococcosis
International experience
Clinical features
Investigations
Definitions of invasive fungal disease12
Revised definitions
Proven IFD
Probable IFD
Possible IFD
Limitations of the revised definitions
Consensus criteria for evaluating therapeutic responses in clinical trials for invasive fungal disease
Candidaemia and other forms of invasive candidiasis
Invasive aspergillosis and other mould diseases
Cryptococcal meningitis
Therapeutic agents for systemic anti-fungal therapy
Polyene group
Azoles
Echinocandins
Disease-specific antifungals
Therapy for invasive fungal disease
Prophylaxis for invasive fungal disease
Combination therapy
Conclusions
12:
Liposomal Drug Delivery System from Laboratory to Clinic
What are liposomes?
Targeting with liposomes
Conventional liposomes
Stealth liposomes
Liposome with homing device
Glycolipid/glycosides bearing liposomes
Immunoliposomes(antibody/peptide-coated liposomes)
Cationic liposomes
Routes of administration of liposomal delivery system
Pharmacodynamics of liposome encapsulated drugs
Liposomal drug delivery systems – clinical applications
Antimicrobial therapy
Cancer therapy
Future trends
Antimicrobial
Gene therapy
13:
Immunisation in Adults
Description of preventive measures
Influenza vaccine
Pneumococcal vaccine
Hepatitis B vaccine
Hepatitis B immunoglobulin (HBIG)
Hepatitis A
Tetanus-diphtheria toxoid and pertussis
Measles-mumps-rubella vaccine
Typhoid vaccine
The whole-cell typhoid vaccine
The Vi polysaccharide vaccine
Oral Ty21a vaccine
Japanese B encephalitis vaccine
Meningococcal vaccine
Varicella vaccine
Rabies vaccine
Post-exposure prophylaxis (dosage and administration)
Pre-exposure prophylaxis
Rabies immunoglobulin
Newer vaccines
Herpes zoster
Human Papillomavirus
Future vaccines
Reasons for under-utilisation
Strategies to improve adult vaccination rates
Conclusion
Conflict of interest
14:
Magnitude of Venous Thromboembolism in India
15:
Evidence-based Indications for Thromboprophylaxis
Magnitude of VTE in medically-ill patients and risk stratification
Thromboprophylaxis in the medically-ill — a review of evidence
Extrapolating the evidence to the Indian setting
ACCP 2008 recommendations
Recommendations for Indian settings
Conclusions
Acknowledgments
Conflict of interest
16:
Conventional and Newer Agents for Prevention of VTE
Agents for prevention of VTE can be broadly classified as follows
Conventional agents
Newer agents
Conventional anticoagulants
Unfractionated heparin (UFH)
Problems with UFH
Efficacy of UFH in prevention of VTE
Low-molecular-weight heparin (LMWH)
Adverse effects of the LMWHs
Efficacy of LMWH in prevention of VTE
Warfarin
Newer anticoagulants
1. Indirect inhibitors of factor Xa
a. Fondaparinux
Adverse effects of fondaparinux
Efficacy of fondaparinux in prevention of VTE
b. Idraparinux
Efficacy of Idraparinux in prevention of VTE
2. Direct inhibitors of factor Xa
3. The direct thrombin inhibitors (DTIs)
4. Inhibitors of factor VII/tissue factor initiation of coagulation
5. Inhibitors of factors Va and VIIIa
Conclusions and summary
17:
Non-pharmacological Methods for Thromboprophylaxis
Pharmacological prophylaxis
Mechanical thromboprophylaxis devices
Indications for mechanical thromboprophylaxis devices
Graduated compression stockings
Mechanism of action
Thigh length versus knee length stockings
Intermittent pneumatic compression: mechanism of action
Haemodynamic effects
Effect on systemic fibrinolysis and other biochemical mechanism of action (Fig. 2)
Effect on vasomotor tone
Physiological parameters to be considered while choosing a device
Effect on venous blood flow
Sequential versus uniform compression
Thigh versus calf compression
Foot compression
Slow versus rapid inflation
Clinical use
Orthopaedic surgery
Total hip arthroplasty
Knee arthroplasty
Hip fracture surgery
Urology
Neurosurgery
Trauma
General surgery
Travel and thrombosis
Advantages
Disadvantages
Complications
Summary
18:
How do I Interpret an Electronic Blood Cell-counter Report?
Histogram
Red cell histogram
Platelet histogram
WBC histogram
Case studies
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
Case 12
Case 13
Case 14
Conclusion
Summary
19:
How to Investigate a Case of Thrombophilia?
Aetiology
Diagnostic approach
Screening laboratory tests
Molecular studies
Pitfalls and cautions
Conclusion
20:
Megaloblastic Anaemia: Prevalence and Causative Factors
Causes5
Uncommon causes of folic acid deficiency in India
Prevalence and causative factors
Indian scenario
Normal homocysteine metabolism
Conclusion
Summary
21:
Refractory Iron Deficiency Anaemia
Definition
Refractory Iron deficiency anaemia
Obscure GIT bleed
Disorders of iron malabsorption
Recommendations for the diagnostic work-up of refractory or obscure IDA
Conclusions
22:
Advances in the Management of Adult Immune Thrombocytopenic Purpura (ITP)
Epidemiology
Clinical features
Diagnosis
Differential diagnosis
Pathogenesis
Management
Who should be treated ?
What is the mortality risk attributable to ITP?
Is there a relationship between the platelet count and the risk of bleeding?
Is age of the patient important?
What are the other determinants?
Emergency treatment
Initial treatment
Corticosteroids
Intravenous immunoglobulin (IVIg)
Anti-D immunoglobulin
Second-line treatment
Rituximab
Splenectomy
Treatment after splenectomy fails
Azathioprine
Cyclophosphamide
Vinca alkaloids
Combination chemotherapy
Campath-1H
Cyclosporin A
Mycophenolate mofetil
Dapsone
Danazol
Eradication of Helicobacter pylori infection
Staphylococcal protein A immuno-absorption
Colchicine
Etanercept
Autologous haematopoietic stem cell transplantation
Thrombopoietin receptor (TPO-R) agonists57–59
Miscellaneous
Other experimental therapies
ITP in pregnancy67
Summary
Conclusion
Carry home message
23:
Eosinophilia: An Approach
Basic aspects of eosinophilia
Clinical and laboratory evaluation of the patient with eosinophilia
Drugs that interfere with eosinophilia or eosinophil products
Haematologic and neoplastic disorders
Miscellaneous causes
Eosinophilia in the context of HIV and other retroviral infections
Conclusion
24:
Haemolytic Anaemia: An Approach
Definition
Normal red cell turnover
Causes of haemolytic anaemia are divided into three groups (Table 2)
Clinical features of haemolytic anaemia
Features specific to some haemolytic anaemias
Leg ulcers
Skeletal abnormalities
Extramedullary haematopoiesis
Features of intravascular haemolysis
Approach to the diagnosis
Investigations
Is there evidence of increased haemolysis?
Basic lab tests to start with
Corrected reticulocyte count
Reticulocyte production index (RPI)
Peripheral smear
What is the precise diagnosis?
Haemoglobinopathies
Red cell membrane disorders
Enzymopathies
Immune haemolytic anaemia
Autoimmune haemolysis
Diagnosis of immune haemolytic anaemia
Non-immune haemolytic anaemia
Hereditary spherocytosis (Fig. 8)
Clinical features
Laboratory features
G6PD deficiency (Table 4)
Clinical features
Laboratory diagnosis
Thalassaemia
Clinical features
Laboratory features
Red cell fragmentation syndromes
Features
Case examples
The ‘take home’ message
25:
Stem Cell Therapy for Haematological Diseases
Conditioning regimens
Allogeneic stem cell transplantation
Autologous stem cell transplantation
Complications of HSCT
Graft versus host disease (GVHD)
Pathogenesis
Acute GVHD
Chronic GVHD
Indications and outcomes of HSCT
Changing Trends in HSCT
Increasing use of peripheral blood stem cells (PBSC)
Increasing use of non-myeloablative transplants
Increasing use of alternative donors
Allogeneic transplantation in the developing world
Summary
26:
Is Auscultation Necessary in Modern Cardiology?
Methods to improve the practice and teaching of auscultation; and how accurate is cardiac auscultation?
We still need cardiac auscultation
Principles of cardiac auscultation
Conclusion
Summary
27:
Pathophysiology and Management of Heart Failure-related Hyponatraemia
Prevalence of hyponatraemia in HF
Pathophysiology of hyponatraemia in HF
Drug therapy and hyponatraemia in HF
Clinical features of hyponatraemia
Prognostic significance of HF related hyponatraemia
Treatment of HF related hyponatraemia
Restriction of water intake
Diuretics
ACE-inhibitors and angiotensin receptor blockers (ARBs)
Lithium (Li2+)
Demeclocycline
Novel approaches to HF related hyponatraemia
Physiological actions of AVP
Role of AVP in HF
Vasopressin receptor antagonists as neurohormonal targets for treatment of HF related hyponatraemia
Clinical trials of AVP receptor antagonists
Conclusions
Summary
28:
Atrial Fibrillation: Current Management Strategy
Classification
Clinical evaluation
Management
Therapeutic options
Rate control or rhythm control
Pharmacological therapy
Rate control
Cardioversion
Out-of-hospital initiation of anti-arrhythmic drugs
Direct-current cardioversion
Prevention of thromboembolism
Prevention of thromboembolism in patients with AF undergoing cardioversion
Non-pharmacological approaches to prevention of thromboembolism
Emerging agents
Catheter ablation
Surgical ablation
Conclusion
29:
Challenges in Endocarditis
Challenges in diagnosis
Changing patient profile
Blood culture and aetiological organism
Echocardiography
Challenges in management
Adherence to guidelines
Surgical intervention
Challenges in prevention
Newer developments
Summary
30:
Coronary Artery Disease in Women
Prevalence of CAD in women in India
The neglected epidemic: Who is responsible – women or physicians?
Gender versus sex: Different, but both matter
Coronary risk factors
1. Age
2. Height
3. Obesity
4. Abdominal obesity
5. Smoking
6. Family history
7. High blood pressure (hypertension)
8. Diabetes mellitus
9. Dyslipidaemia
10. Menopause and dyslipidaemia
Presentation of CAD
Microvascular angina
Coronary artery disease: What's different for women?
Presentation
Risk factors
Prognosis
Primary prevention
Secondary prevention
Sudden death
Evolution of premature CAD in females (≤ 45 years)
Coronary artery disease among Indian women in and outside India
Diagnosing CAD among women
1. Treadmill stress testing
2. Heart scans
3. Coronary angiograms
Coronary angioplasty and stent: Differences between women and men
Prevention
Diet
Physical activity
Psychosocial factors
Aspirin
Hormone replacement therapy
Oral contraceptives
Secondary prevention
Conclusion
Key points
31:
Small Elevations of Troponin with or without ECG Changes: Drugs or Cath. Lab.?
32:
Multimodality Imaging in Coronary Artery Disease
Echocardiography
Myocardial radionuclide perfusion imaging
Risk stratification
Assessment of left ventricular ejection fraction
Myocardial viability
Positron emission tomography (PET) and CT hybrid systems
Cardiac computed tomography (CT)
Cardiac computed tomography angiography (CTA)
Cardiac magnetic resonance imaging (MRI)
33:
Metabolic Modulators in Ischaemic Heart Disease
Myocardial metabolism
Myocardial metabolic adaptations during ischaemia
“Metabolic” anti-ischaemic agents commonly used in clinical practice
β-blockers
Glucose–insulin–potassium (GIK)
Perhexiline
Trimetazidine
Ranolazine
Etomoxir
Conclusion
34:
Advances in the Management of STEMI, including the Role of Thrombolysis
Selection of reperfusion strategy — Important considerations
Fibrinolytic therapy — benefit and contraindications
Comparison of fibrinolytic agents
Combination therapy with glycoprotein IIb/IIIa inhibitors
Facilitated percutaneous coronary intervention
Rescue percutaneous coronary intervention
Pre-hospital fibrinolytic therapy
Complications of fibrinolytic therapy — Risk of intracranial haemorrhage
Conclusion
35:
Multivessel CAD: Stents versus CABG
Role of CABG in multivessel disease
Role of PTCA in multivessel disease
Randomised trials of angioplasty versus CABG (Table 1)
CABG versus plain optimal balloon angioplasty (POBA) (Table 2)
b. CABG versus angioplasty using bare metal stents (BMS)(Table 3)
c. CABG versus angioplasty using drug-eluting stents (DES)
Limitations of randomised trials comparing multivessel PCI with CABG
Complete versus incomplete revascularisation
Staging of PCI
Special subgroups
Acute coronary syndrome
Left main disease
Severe LV dysfunction
Elderly patients
Diabetics
Renal dysfunction
Advantages and disadvantages of PCI and CABG (Table 4)
Advantages of PTCA
Disadvantages of PTCA
Advantages of CABG
Limitations of CABG
Factors to be considered before decision-making
Conclusion
36:
Percutaneous Valve Procedures
Percutaneous mitral procedures
Percutaneous mitral commissurotomy
Paravalvular leak closure
Treatment of mitral regurgitation
Leaflet repair (edge-to-edge)
Coronary sinus annuloplasty
Direct remodelling
Other percutaneous mitral procedures
Percutaneous aortic procedures
Aortic valvuloplasty
Aortic valve implantation
(Pre) clinical studies and trials on percutaneous valve procedures
Percutaneous mitral valve procedures
Coronary sinus annuloplasty
Direct remodelling
Percutaneous aortic valve procedures
Valve-in-valve concept
Performing percutaneous valve procedures: Patient selection
Performing percutaneous valve procedures: Technical issues
Follow-up
Imaging for percutaneous valve procedures
Percutaneous mitral valve procedures
Percutaneous aortic valve procedures
Conclusions
37:
Self-monitoring of Blood Glucose: A Critical Appraisal
Aim of SMBG
Devices for SMBG
Glucometers
Factors affecting the blood glucose readings3
Newer technologies: alternative site testing3
Continuous glucose monitoring system3,10
Glucowatch
Indications for SMBG
How to act on the SMBG values?
SMBG before a meal
SMBG before exercise
SMBG in type 1 diabetes mellitus (DM)
SMBG in type 2 DM
Conclusion
38:
Diabesity
Definition of obesity
Prevalence and progression of diabetes
Is weight gain inevitable with therapy?
Is there a connection between obesity and diabetes?
Insulin treatment and weight gain
Detemir insulin
Basis of the weight-sparing effect of insulin detemir
Summary
39:
Pre-diabetes: Are We Ignoring?
Pre-diabetes
Prevalence
Pre-diabetes—the terminology
Natural history and pathogenesis
Lipid metabolism and pre-diabetes (Table 2)
Why we cannot ignore pre-diabetes?
Age
Physical inactivity
Obesity, abdominal obesity
Low birth weight and catch-up obesity in childhood
Impact of pre-diabetes
Coronary heart disease (CHD)
Non-alcoholic fatty liver disease
Sleep disordered breathing (SDB)
Microangiopathies
Cognitive decline
What to do with pre-diabetes?
Screening test
Management strategies
Novel targets for pre-diabetes treatment20
Conclusion
40:
Prevention of Type 2 Diabetes and its Complications: The Indian Perspective
Zones of intervention and primary prevention
Screening for diabetes
Simple diagnostic tests
Recommendations for prevention of diabetes
Prevention of complications
Lifestyle modification
Tight glycaemic control
Increased prevalence of diabetic nephropathy in South Asians
Dipstick test
The albumin excretion rate (AER) and the albumin/creatinine ratio(ACR)
Screening for diabetic neuropathy
Clinical examination
Prevention
Strategies to prevent diabetic foot infection in India
41:
Translating Research to Clinical Practice in Gestational Diabetes Mellitus
Screening procedures
FPG as a screening procedure
American Diabetic Association (ADA) and WHO Diagnostic Criteria
Prevalence of GDM
GDM manifests in all trimesters
Distinguishing between pre-GDM and GDM
Maternal glycaemia and neonatal birth weight
Detection and care of women with GDM from early weeks of pregnancy results in appropriate-for-gestational age babies
Target glycaemic levels in pregnancy—the lessons learnt from CGMS
Management of GDM: Insulin analogues—safe and effective
42:
Diabetic Coma
Diabetic ketoacidosis
Epidemiology
Clinical features
Precipitating causes
Laboratory evaluation
Treatment
Fluids
Insulin
Electrolyte correction
Complications
Hyperosmolar hyperglycaemic coma
Long-term management
Treatment algorithm for hyperglycaemic conditions – DKA and HHS
Fluids (usual deficit, 5-10 lit)
Insulin
Potassium (usual deficit, 200-1,000 mEq)
Bicarbonate
Monitor
Hypoglycaemia
Signs of hypoglycaemia
Treatment
Prevention of hypoglycaemia
43:
HbA1c: How Low Do We Go?
Summary of ACCORD study
Summary of ADVANCE study
Summary of VA Diabetes Trial (VADT)
Implications in clinical practice
44:
Sub-group Analysis according to 4 Geographical Zones of India: The IMPROVETM Study
Status of diabetes in India
Introduction to IMPROVE study — Indian cohort
Baseline demography of IMPROVE India cohort
BiAsp 30 is safe
BiAsp 30 is effective
Summary
45:
Premix Analogues: A Practical Approach to Type 2 Diabetes Management
Glucose homoeostasis and post-prandial glucose control
Treatment choices and glycaemic targets
Problems with conventional insulins: need for analogues
BIAsp 30 safe alternative to BHI 30
Initiating insulin with premixed analogues
Intensifying premix regimens17
Real life experiences with BIAsp 30
Conclusion
46:
Walking the Tight Rope in Critical Care: Role of Rapid-acting Analogue Insulin
Diabetes in hospitalised patients: Brief statistics1
Changing trend in the hospital management of diseases complicated by diabetes
Hyperglycaemia in hospital settings
Intensive insulin therapy in critically ill patients – morbidity and mortality
Benefits5
Hyperglycaemia in acute coronary syndrome
Cost-effectiveness of intensive insulin therapy
Developments in insulin therapy
Problems with conventional insulins
Need for analogues10
Rapid-acting insulin analogue: insulin aspart (NovoRapid)
Advantages of NovoRapid compared to regular human insulin
Advantages of NovoRapid over regular human insulin in the hospital set-up
47:
Sitagliptin in Therapy for Type 2 Diabetes
Incretin physiology
Sitagliptin—clinical profile
Sitagliptin—efficacy and tolerability
Current clinical indications of sitagliptin
Sitagliptin—as initial monotherapy
48:
Tangible and Intangible Barriers with Pharmacotherapy for “Treating to Target” in Type 2 Diabetes Mellitus: Sitagliptin to the Rescue?
49:
Incretins: Newer Paradigm in the Management of Type 2 Diabetes Mellitus
Insulin secretion
Physiological actions
Basis of glucose dependent insulinotropic effect
Extrapancreatic effects of GLP-1
Cardiovascular action
Action on sodium and water balance
Neurological functions
Therapeutic principle of GLP-1
GLP-1 analogues
Exendin-4
Incretin enhancers
50:
Cardiac Markers in the Emergency Room
Various cardiac markers
Myoglobin
Creatine kinase-MB
Cardiac troponins
Emerging cardiac markers
Which is the best cardiac marker?
Time schedule for cardiac marker testing
Cardiac markers in conditions other than atherosclerotic coronary artery disease
Role of cardiac markers in clinical practice
Conclusion
51:
Management of Acute Psychotic Episode
History
What is an acute psychotic episode?
Epidemiology
Aetiology
History taking
Mental state examination
Prodromal symptoms
Collateral history
Risk assessment
Interview room
Hospitalisation or community treatment
Investigations
Management
Non-pharmacological methods/environmental strategies
Medication
Side effects of antipsychotics
Rapid tranquilisation
Step 1
Step 2
Step 3
Step 4
Physical health monitoring25
Psychosocial interventions
52:
Altered Mental Status in the Elderly
53:
Non-invasive Ventilation in the Emergency Room
Non-invasive negative pressure ventilation (NINPV)1
Non-invasive positive pressure ventilation (NIPPV)
How NIV acts?
Delivery devices2
Interfaces
Nasal masks: advantages are
Facial mask
Mouthpieces
Indications3
Acute respiratory failure
Chronic hypercapnic respiratory failure
Aims of non-invasive ventilation
Selection guidelines4
Clinical parameters
Laboratory parameters
Clinical parameters
Laboratory parameters
Pre-requisites for successful NIV
Exclusion criteria or contraindications
Relative
Advantages
Disadvantages (Complications)
Application of NIV/protocol for NIV5
Modes of ventilation
Continuous positive airway pressure (CPAP)
Bi-level positive airway pressure (BPAP)
Volume limited ventilation
Proportional assist ventilation
NIV in clinical scenarios
Recommendations
Recommendation
Recommendations
Monitoring
Treatment failure
When to stop NIV?
NIV can be stopped when:
Location of NIV equipment:
Referral for domiciliary NIV
Our experience
Key points
54:
Intensive Insulin Therapy in Medically III ICU Patients: A Critical Appraisal
Conclusion
55:
Early Management of Elevated Blood Pressure in Patients with Stroke
Natural history of blood pressure during acute stroke
Cerebral autoregulation
Ischaemic penumbra
Recommendation of blood pressure management in acute phase of ischaemic stroke
Induced hypertension
Blood pressure management in haemorrhagic stroke
Aneurysmal subarachnoid haemorrhage (SAH)
Conclusion
Summary
56:
Aluminium Phosphide Poisoning
Clinical features
Pathophysiology
Diagnosis
Management
Caution
Future options
Prevention
57:
High-dose Pralidoxime in Organophosphorus Poisoning: A Critical Appraisal
Is pralidoxime indicated in organophosphorus poisoning?
Is the efficacy of pralidoxime dose-related?
Conclusion
58:
Chemical Terrorism
History of use of chemical weapons
Ideal chemical agent for terrorism
Epidemiological clues of a chemical terrorist attack
Preparation for a chemical terrorist attack
General approach to a chemical terrorist attack
General approach at the scene of exposure
General approach in the hospital
Classification of chemical agents for terrorism
Nerve agents
Mechanism of toxicity
Clinical features after exposure
Treatment
Irritant gase or choking agents
Systemic asphyxiants
Mechanism of toxicity
Clinical features after exposure
Treatment
Blistering agents
Clinical features after exposure
Treatment
Incapacitating agents
Mechanism of toxicity
Clinical features after exposure
Treatment
Riot-controlling agents
Clinical features after exposure
Treatment
Summary
59:
Hyperprolactinaemia
Prolactin physiology
Causes of hyperprolactinaemia
Clinical presentations
Evaluation
Macroprolactinaemia
Treatment
Management of hyperprolactinaemia in pregnancy
Conclusion
60:
Sub-clinical Hypothyroidism and the TSH Level: A New Perspective
Spectrum of sub-clinical hypothyroidism (SH)
Who are at risk of sub-clinical hypothyroidism?
What is normal TSH level?
Spectrum of sub-clinical hypothyroidism (SH)
Possible reasons to diagnose and treat subclinical hypothyroidism
Reasons for treating sub-clinical hypothyroidism
Treatment of subclinical hypothyroidism is controversial. Arguments in favour of treatment:
Arguments against treatment
Areas of contention
Conclusion
61:
Precise Dosing of Thyroxine Replacement in Hypothyroidism
Pharmacology of thyroxine
Initiation of treatment
Monitoring of therapy
Central hypothyroidism
Serum total T4 or serum free T4: Which is better?
What to do if a patient forgets to take the tablet?
Duration of treatment
Response to treatment
Conditions affecting requirement of thyroxine
Adverse effects of thyroxine
Dosage in patients receiving thyroxine without a clear diagnosis
Patients with persistent hypothyroid symptoms despite normalisation of thyroid function test
Persistently high serum TSH level
Sub-clinical hypothyroidism
62:
Neuromuscular Complications of Thyrotoxicosis
Muscular disorders
Proximal myopathy
Myasthenia gravis
Thyrotoxic periodic paralysis (TPP)
Rhabdomyolysis
Neurological disorders
Movement disorders
Peripheral neuropathy
Corticospinal tract disorder
Seizures
Cognitive function
Conclusion
63:
Vitamin D Deficiency in India: A Perspective
Vitamin D deficiency and skeletal health in Indians
Vitamin D deficiency in newborns and children
Adults and vitamin D deficiency
Vitamin D deficiency and non-skeletal disorders
Type 2 diabetes mellitus
Cardiovascular diseases
Vitamin D deficiency and the immune system
Autoimmunity
Tuberculosis
Malignancy
Vitamin D deficiency and osteoarthritis
Do we have protective bio-adaptation to vitamin D deficiency ?
How to tackle vitamin D deficiency?
64:
The Clinical and Laboratory Profile of Primary Hyperparathyroidism in India
Clinical presentation
Bone mineral density (BMD)
Pathology
Pre-operative localisation
Sestamibi scan
Ultrasound
CT and MRI scanning
Indications for the surgical management of hyperparathyroidism
Surgical treatment
Medical treatment
Conclusion
65:
Hypercalcaemia
Calcium homoeostasis
Causes of hypercalcaemia
Clinical features
Differential diagnosis
Management
Summary
66:
Metabolically Obese but Normal Weight
MONW includes people with
Adult life weight gain, modest adiposity, and higher BMI in sub-obese range
Why central obesity is so risky?
Why hyperinsulinaemia leads to visceral obesity?
What is normal visceral adiposity?
Possible causes of inactivity and IR and/or MONW
Causes of low VO2 max or low level of fitness
Therapeutic value of exercise in IR
Other potential factors
Management strategy in MONW
Pharmacotherapy
Prevention
Conclusion
67:
Challenges in Obesity Treatment: A Physician's Perspective
Recognising and understanding the challenges posed by obesity
Definition of obesity
Classifying obesity
BMI examples of some celebrities
Asian perspective
Recommendations for WC values from three expert groups
WHO classification-based upon BMI (kg/m²)
Obesity is a health risk
Common hormonal abnormalities seen in obese
Evidence that reducing weight decreases disease risk
Some evidence that reducing weight may increase disease risk!
Clinical barriers and the role of the primary care physician (PCP)
Clinics are not “obese friendly”
Clinical bias and “missed opportunities”!
Physicians are not pro-active?
Providing solutions to obesity challenges
Pharmacotherapy
Conclusion
68:
Pharmacotherapy in Obesity: Current Perspectives
Lifestyle management
Dietary therapy
Exercise
Behavioural therapy
Pharmacotherapy
Centrally acting anorexiant medications
Peripherally acting medication
Rimonabant
The endocannabinoid system
Drugs with miscellaneous actions
Surgery
69:
Irritable Bowel Syndrome: Recent Concepts
Criterias for diagnosis of IBS8
Approach to a case28
Management of IBS29
Treatment profile
Mechanism of action
Newer drugs under study for the management of IBS
70:
Amoebic Liver Abscess: Current Perspectives
Epidemiology
Pathogenesis
Clinical presentation
Symptoms
Signs
Diagnosis
Imaging
Serology
Differential diagnosis
Medical therapy
Treatment
Luminal amoebicides
Tissue amoebicides
Mixed amoebicides
Aspiration or drainage of abscess
Surgery
Poor prognostic criteria24
Follow-up
Prevention
71:
Fulminant Hepatic Failure
Definition
Aetiology
Pathogenesis
Pathophysiology
Clinical features
Encephalopathy
Cerebral oedema
Infections
Coagulopathy
Haemodynamic disturbances
Electrolyte disturbances
Renal failure
Nutritional disturbances
Miscellaneous
Diagnosis
Investigations
Management
General management
Management of complications of FHF
Hepatic encephalopathy
Cerebral oedema
Infections
Coagulopathy
Haemodynamic disturbances
Renal failure
Nutrition
Aetiology-specific management
Management of pregnancy
Assessment of prognosis and liver transplant listing
Prognosis
Without transplantation
With transplantation
Recent advances
72:
Acute Pancreatitis: Diagnosis, Prognosis, and Treatment
Diagnosis
Differential diagnosis
Predicting the severity of pancreatitis
Early treatment
Management of pain
Management of nausea and vomiting
Fluid/oxygen resuscitation
Prophylaxis against infection
Nutrition
Limiting the severity of an attack
Management of early organ failure
Delayed treatment of acute pancreatitis
Management of acute fluid collections
Management of pseudocysts
Pancreatic ascites
Management of infected pancreatic necrosis/abscess
Preventions of recurrent attacks
73:
Fatty Liver—A Large Problem: Who, When, and Why to Investigate?
Defining NAFLD and NASH
Epidemiology
Pathogenesis
Insulin-resistance
Oxidative stress
Altered cytokine milieu
Natural history
Histology and grading
Clinical diagnosis and evaluation
Lab anomalies
Imaging studies
Non-invasive markers of fibrosis in NASH
Management
Exercise and diet
Correction of metabolic disorders
74:
Common Bile Duct Stones: Surgery or Endoscopy
The controversy
The approach
Choledocholithiasis known preoperatively
Choledocholithiasis identified during cholecystectomy
Choledocholithiasis identified after cholecystectomy
Recent insights
Practice guidelines
75:
Ursodeoxycholic Acid—Clinical Therapeutics
Mechanism of action
Expansion of the bile acid pool
Choleretic effect and hypercholeresis
Immunomodulatory properties
Cytoprotection
Antioxidant
Clinical uses
Cholestatic hepatic diseases
Primary biliary cirrhosis (PBC)
Primary sclerosing cholangitis (PSC)
Intra-hepatic cholestasis of pregnancy (ICP)
Cystic fibrosis
Non-alcoholic fatty liver disease (NAFLD)
Alcoholic liver disease
Gallstones
Biliary sludge
Graft-versus-host disease (GVHD) of liver
Total parenteral nutrition (TPN)-induced cholestasis
Acute and chronic viral hepatitis
Progressive familial intrahepatic cholestasis (PFIC)
Adverse reactions and drug interactions
76:
Crohn's Disease in India: Searching for a Needle in the Haystack
Rising incidence and prevalence of CD in India and Asia
Why there is an increase in CD in India?
How do we find-out CD from a large pool of patients with ulceroconstrictive diseases of intestine? (Differentiation between CD and intestinal tuberculosis)
Diagnostic criteria for CD
Diagnostic criteria for intestinal tuberculosis23
Site of involvement in CD and intestinal tuberculosis
Types of morphological lesions in CD and intestinal tuberculosis
Differentiating clinical features between CD and intestinal tuberculosis (Table 3)
Differentiating endoscopic features between CD and intestinal tuberculosis
Differentiating histological features
Microbiological features
Radiological features for differentiation of CD and intestinal tuberculosis
Serological tests in patients with CD and intestinal tuberculosis
Role of empirical anti-tubercular therapy
Conclusion
77:
Helicobacter pylori Infection and Gastric Cancer: The Indian Enigma
What is Indian enigma?
Possible explanations for the Indian enigma
Agent factors
Host factors
Environmental factors
Implications of the Indian enigma on future research
Clinical implication of the Indian enigma
Conclusion
78:
Management of Hypertension: A Real-time Experience
Overview of hypertension in India
Targeting compliance to improve blood pressure control
Management of hypertension with a fixed-dose combination of amlodipine and perindopril in daily clinical practice
79:
BP Control in the Management of Diabetic Patients
New onset diabetes (NOD)
Main results
Conclusion
80:
Chirally Active Drugs: New Hopes and New Prospects
New drugs, new promises and new failures
Rediscovery of established safe drugs and the relevance of chiral molecules
Chirality—a re-emerging pharmacological tool
Practical considerations of chirally pure drugs: focus on hypertension
S-amlodipine
Chirally pure β-blockers
Summary
81:
Phaeochromocytoma: Biochemical Evaluation, Imaging, and Treatment
Biochemical investigations
Imaging
Management of phaeochromocytoma
Medical treatment
Surgical treatment
Pre-operative management
Anaesthesia
Surgery
Effect of surgery on BP
Phaeochromocytoma in special situations
Familial syndromes
Phaeochromocytoma in pregnancy
82:
Acute Rheumatic Fever: Diagnosis to Management
Diagnosis
Streptococcal sore throat
Jones criteria for diagnosis of rheumatic fever
Primary rheumatic fever
Recurrent rheumatic fever without previous RHD
Rheumatic fever with previous RHD
Rheumatic chorea (Sydenham's chorea)
Rheumatic carditis of insidious onset (indolent carditis)
Subclinical rheumatic carditis and role of echocardiography
Rheumatic fever in children less than 5 years of age
Rheumatic fever above 45 years of age
Primary prophylaxis in ARF
Management of ARF
Secondary prophylaxis of ARF
Factors affecting duration of secondary prophylaxis
Duration of secondary prophylaxis
Conclusion
83:
Typhoid Fever: Back to the Pre-antibiotic Era
Epidemiology of typhoid fever
Typhoid fever in the pre-antibiotic era and the advent of chloramphenicol
The rise and fall of fluoroquinolones
Status of antibiotic-resistance in India
Current treatment of typhoid fever
Is gatifloxacin the answer?—Not
Azithromycin for typhoid fever—theoretical considerations
Third-generation cephalosporins—current scenario
What lies ahead?
Acknowledgement
84:
Application of New Antibiotics in Clinical Practice
Characteristics of a new antibacterial agent
What are the causes of decreasing antibiotic development?
Newer Cephalosporins
Monobactams
Newer Carbapenems
Newer aminoglycosides
Newer fluoroquinolones
Macrolides
Glycopeptides
Oxazolidinones
Streptogramins
Cyclic lipopeptides
Fosfomycin
Glycylcyclines
New uses for older antibiotics
Conclusion
85:
Your Patient has a Blood Culture Positive for Staphylococcus aureus: How to Proceed?
Background
Pathophysiology
Tissue invasion
Toxin mediated disease
Management
History and physical examination
Bacteraemia (Fig 3)
Bacteraemia or endocarditis? (Table 4)
Endocarditis
Sepsis syndrome
Pulmonary infections
Central nervous system infections
Osteomyelitis
Catheter infections
Infections after cardiac surgery
Laboratory investigations
Imaging studies
Treatment
Isolation
Catheter-related infections
Prevention (Table 9)
Future prospects
86:
Dengue Haemorrhagic Fever: What Not to Do?
The clinical spectrum—myths and facts
Management—myths and facts
Warning signs
Platelet transfusion
87:
Avian Influenza: Current Concepts in Management and Control
History of flu
Pathophysiology
Case definitions
Application of the H5N1 case definitions: Please note the following:
Person under investigation
Suspected H5N1 case
AND
Probable H5N1 case (notify WHO)
AND
Confirmed H5N1 case (notify WHO)
AND
Diagnosis
Summary of clinical management advices
Next pandemic and preparedness
Guidelines for quarantine for avian influenza
Situation 1: Where avian influenza is suspected in birds/ poultry
Situation 2: Where one or more human cases of avian influenza (as per standard case definition of suspect case) have been reported.
Situation 3: Where human-to-human transmission has been established
Additional precautions for cullers
Data collection procedures
Active surveillance
Site of care
The bird flu
Infection control practices
Vaccines
88:
Opportunistic Infections in AIDS: The Five Common Ones
Definition and epidemiology
Tuberculosis
Pathophysiology
Clinical manifestations
Diagnosis
Treatment
Prophylaxis
Pneumocystis jiroveci pneumonia (PCP)
Pathophysiology
Clinical manifestations
Diagnosis
Treatment
Prophylaxis
Candidiasis
Pathophysiology
Clinical manifestations
Diagnosis
Treatment
Prophylaxis
Cryptococcosis
Pathophysiology
Clinical manifestations
Diagnosis
Treatment
Prophylaxis
Diarrhoea in HIV/AIDS patients
Susceptibility of the gastrointestinal tract to HIV-I infection
Major gastrointestinal manifestations of HIV/ AIDS
89:
Three Uncommon Opportunistic Infections in AIDS
Toxoplasmosis
Diagnosis
Serology
CSF analysis
Imaging studies
Treatment of cerebral toxoplasmosis
Mycobacterium avium-intracellulare
Signs and symptoms
Diagnosis
Treatment
Cytomegalovirus
Treatment
Conclusion1–6
90:
Anti-retroviral Therapy: Practice Guidelines and Future Options
Goals of anti-retroviral therapy
Principles of anti-retroviral therapy
Practice guidelines
Initiating anti-retroviral therapy
Factors affecting selection of the ARV regimen8
When to start treatment?
What to start with?
Follow-up of patients on ART
Adherence to ART
Drug interactions
Changing therapy
Change due to adverse effects/intolerance
Change due to treatment failure
Identifying failure: Clinical, immunological, and virological failures
ART and tuberculosis
Important considerations before starting ART
Immune reconstitution inflammatory syndrome (IRIS)
Future options
A. Newer anti-retroviral drugs
B. Immune-based therapies (IBTS)
Conclusion
91:
Immune Reconstitution Inflammatory Syndrome (IRIS): When to Suspect and How to Manage?
Definition
Incidence
Pathogens
Clinical features
MTB
MAC
CMV
PML
Co-infections
Graves’ disease
Management
Summary
92:
INH Preventive Treatment for HIV-infected Patients in India: A Critical Appraisal
Background and scientific rationale for TB preventive therapy
Clinical trials of efficacy of various preventive therapy regimens (drugs and duration)
Tuberculosis prevention in the HAART era
Excluding active tuberculosis
IPT and drug resistance
Tuberculin testing before preventive therapy?
Operational and logistic challenges
93:
Salient Clinical Characteristics of Severe Falciparum Malaria in Adults in the Tropics
Epidemiology
Severe complicated malaria
Salient clinical manifestations of severe falciparum malaria in adults in the tropics
Fever
Neurological manifestations
Cerebral malaria
Coma
Seizures
Other neurological manifestations and sequelae
Jaundice and hepatic dysfunction
Other gastrointestinal manifestations
Renal involvement
Haemoglobinuria
Acute lung injury and acute respiratory distress syndrome
Haematological abnormalities
Haemostatic abnormalities
Algid malaria
Ophthalmological manifestations
Acid-base abnormalities
Metabolic abnormalities
Other metabolic abnormalities
Associated infections and septic shock
Severe falciparum malaria in the intensive care unit
Changing trends in severe falciparum malaria
Severe falciparum malaria in special situations
Pregnancy
Human immunodeficiency virus (HIV) infection
Diagnosis
Peripheral blood film examination
Rapid diagnostic tests
Differential diagnosis
Management
Prognosis
Summary
Conclusion
Acknowledgement
94:
Artemisinin-based Combination Therapy (ACT) for Treatment of Malaria
Anti-malarial combination therapy
Artemisinin-based combination therapy (ACT)
Rationale of artemisinin-based combination therapy (ACT)3,6
Why combination?
Why artemisinin?
Pharmacology of the artemisinin compounds of ACT
Adverse effects of ACT3,6
Available ACTs and practical guidelines for treatment of uncomplicated falciparum malaria (WHO - 2006, NDP - 2007)3,5
AS + MQ
AL
AS + SP
AS + AQ
Second-line anti-malarial treatment when fever recurs after ACT
Future ACTs
ACT in pregnancy
ACT in the lactating mother3
ACT in HIV+ cases
ACT for Plasmodium vivax malaria
Conclusion
Summary
95:
Visceral Leishmaniasis (Kala-azar) in Pregnancy
Prevalence of VL and VL in pregnancy in India
Pathogenesis of kala-azar in pregnancy
Clinical features of VL
HIV-VL co-infection1,13
Laboratory diagnosis
Can anti-VL treatment be started on the basis of serological tests alone?
Management of VL in pregnancy
General management
Specific anti-VL therapy
Summary
96:
Early Goal-directed Therapy and Recent Advances in Septic Shock
Definition
Pathophysiology
Infection and SIRS: Cause and effect
Sepsis: Immune response gone haywire
Is it an immunodeficient state?
Intricate play of chemical mediators leading to a state of leaking vessels
A procoagulant state
Is there an adrenal crisis?
A state of profound insulin resistance
Septic shock and multiorgan failure
Clinical features
How to recognise sepsis?
Clinical peculiarities of different infections
Where is the infection?
Indicators of deterioration
Management
Sepsis is a medical emergency
Fluids and vasopressors (early goal-directed therapy)
Role of vasopressin
Tackling ventilation
Syndromic approach and empirical antibiotics: Hit them hard
Managing insulin resistance
Tackling adrenal crisis
Shutting down of kidneys
Activated protein C therapy
Summary
97:
Intravenous Immunoglobulins in Critically Ill Adult Patients with Sepsis
Rationale for the use of immunoglobulins in the management of sepsis
Types of immunoglobulins
Use of polyclonal immunoglobulins in sepsis
Use of immunoglobulins as prophylactic treatment
Conclusion
98:
Complicated Urinary Tract Infections
Aetiopathogenesis
Risk factors
Population at risk
Micro-organisms
Clinical presentation
Evaluation
Clinical assessment
Urine culture
Urinalysis
Localisation of underlying abnormality
Antimicrobial therapy
Asymptomatic urinary infection
Symptomatic urinary infection
Antimicrobial selection
Duration of therapy
Prophylaxis
Special considerations
Urinary infections in diabetes mellitus
Acute pyelonephritis
Renal abscess
Perinephric abscess
Renal papillary necrosis
Prostatic abscess
Fungal urinary infection
Patients with renal failure
UTI in renal transplant recipients
Prevention
Immunisation
Summary
99:
Acute Renal Failure in the Tropics
Infections
Diarrhoeal diseases
Malaria
Leptospirosis
Miscellaneous infections
Animal toxins
Snake bite
Miscellaneous bites
Plant toxins
Miscellaneus causes of ARF in the tropics
Pigment-induced ARF
Copper sulphate poisoning
Heat stroke
Obstetric ARF in the tropics
Acute cortical necrosis (ACN)
Acknowledgement
100:
Pathogenesis and Prevention of Diabetic Nephropathy
Haemodynamic factors
Angiotensin-II: (RAS)
Role of ACE2
Role of glomerular capillary hypertension
Podocytopathy-mechanical stretch and hyperglycaemia
Endothelial system
Nitric Oxide system
Intracellular factors and cytokines
Diacylglycerol (DAG) – protein kinase C (PKC) pathway or PKC-mapk pathway
Growth factors and cytokines
TGF-β system
Growth hormone (GH) and growth factors (IGF, VEGF, PDGF, CTGF)
Dyslipidaemia
Role of genetics
The unified mechanism
Insulin resistance—key to pathogenesis of DN?
Role of vitamin D
Prevention of diabetic nephropathy
Prevention of diabetes is the surest way to prevent DN.
101:
The Role of Timely Referral to a Nephrologist in the Management of CKD
Magnitude of CKD and referral patterns
CKD and ESRD in India
Referral patterns and outcome
Dialysis patients
Non-dialysis patients
Possible reasons for delayed referrals
What can we expect in the future?
Conclusion
102:
Contrast-MRI in Renal Disease and Systemic Fibrosis
Definition
Extent of the problem
Clinical and laboratory features
Risk factors for NSF
Gadolinium
Gadolinium-containing contrast media
Impaired renal function
Gadolinium toxicity; role of iron and transmetallation
Role of EPO, inflammation, and vascular injury
Cellular basis for the persistence of fibrosis in NSF
Treatment
Key recommendations
Conclusion
103:
Role of Continuous Ambulatory Peritoneal Dialysis (CAPD) in Patients with Chronic Kidney Disease (CKD)
Common peritoneal dialysis solution (Dianeal – Baxter) (Figs 1 and 2)
Newer peritoneal dialysis solution
Icodextrin (Extraneal – Baxter)
Aminoacid (Nutrineal - Baxter)
Bicarbonate solution (Physioneal – Baxter)
Insertion technique of CAPD catheter
Technique
Manual
Peritoneal dialysis cycler (known as automated peritoneal dialysis: Fig. 5)
Prescription
Outcomes
Contraindications of CAPD
Complications
Peritonitis
Treatment
Peritoneal membrane failure
Catheter related
Malnutrition
Metabolic
Indian scenario
Conclusion
104:
Renal Transplantation: Current Practice
Advantages of renal transplant over maintenance dialysis
Contraindications for renal transplantation
Absolute
Relative
Renal transplant recipient
Donor for renal transplant
Surgical procedure
Indications of native kidney nephrectomy
Common differences in surgical procedure between different surgeons:
Immunosuppression (IMS)
Factors assessed for choosing an immunosuppressive medication:
Factors important for good renal transplant outcome:
Immunologically high-risk patients
Induction vs. maintenance IMS
Complications
Surgical complications of RT7,8
Acute medical complications of RT
Acute rejection
Acute tubular necrosis
Infection
Chronic medical complications of RT
Outcome data
1. Percentage of patients having acute rejection
2. Patient survival
3. Graft survival and half-life
Causes of death in RT patient
Risk to donor
Economics of renal transplant19
Future
105:
Infections Transmitted from Donor to Recipient following Organ Transplantation
Donor derived infections
Viral transmission
CMV infections
Pattern of CMV transmission in SOT
Clinical presentation of CMV infection
Diagnosis of CMV infections
Epstein-Barr virus infection (EBV)
HSV infections (HHV-1)
HHV-6 (Human herpesvirus 6)
Human herpesvirus 8 (HHV8)
Varicella-zoster infection (VZV)
Hepatitis virus infections
Bacterial infections and tuberculosis
Fungal infections
Parasitic infections
Pre-transplant screening
Prophylactic strategy for infections
Immunisation
Pharmacological prevention
Conclusion
106:
Asthma over the Decades
History
Pathogenesis
Airways inflammation
Airway smooth muscle
Formulation of guidelines
GINA update 2007
Corticosteroids in asthma
Classification of asthma severity by clinical features before treatment12
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Treatment of asthma
Steroid-insensitive (SI) and steroid-resistant (SR) asthma
Biologic therapies in asthma
Anti-IgE
Conclusion
107:
Managing Asthma in Clinical Practice: The Role of Asthma Control
Goals of asthma management
Severity-based asthma management during the 1990s and early 2000s
Reasons for failure of severity-based asthma management guidelines
Guidelines for asthma management in clinical practice
Step 1: Evaluate level of asthma control
The asthma control test (ACT)
The asthma control questionnaire (ACQ)
The asthma therapy assessment questionnaire (ATAQ)
Step 2: Trouble shoot if asthma is not under control
Physician-related factors associated with poor asthma control
Patient-related factors associated with poor asthma control
Step 3: Educate the patient
Step 4: Bring the patient back for monitoring
Summary and future perspectives
108:
The SMART way to Asthma Control: Is it Effective?
What are the aims of asthma therapy?
Is present treatment adequate to achieve the aims of asthma therapy?
Why optimal control of asthma has not been achieved?
What are the options for improving asthma control?
Can we use LABA as reliever?
Does the concept of single maintenance and reliever treatment (SMART) work in clinical practice?
How does the combination of ICS and LABA (formoterol) act as a reliever?
109:
Leukotriene Inhibitors in the Treatment of Allergy and Asthma
Leukotrienes in the pathogenesis of asthma
Drugs developed to inhibit the effects of leukotrienes
Physiologic effects of LT inhibitors
I. Effects of LT inhibitors on airway inflammation
II. Effects of LT inhibitors on airway remodelling
III. Effects of LT inhibitors on bronchoconstriction
Position of LT inhibitors in asthma therapy
LT inhibitors in the treatment of mild asthma
LT inhibitors in the treatment of moderate to severe asthma
LT inhibitors for the prevention of exercise-induced bronchoconstriction
Role of LT inhibitors in aspirin-sensitive asthma
Leukotriene inhibitors in the treatment of allergic rhinitis
Leukotriene inhibitors in the treatment of atopic dermatitis
Leukotriene inhibitors in the treatment of chronic urticaria
110:
The Impact of Acute Exacerbations of COPD
Definition
Clinical features
Clinical signs
Cardiovascular signs
Aetiology
Respiratory tract colonization in COPD13
Risk factors
Impact of exacerbations
Increased morbidity and mortality — respiratory and non-respiratory
Increased costs of care and hospitalisation
Accelerated decline of lung function
Increased depression with immobility and isolation
Factors improving the outcome
Pharmacologic therapy
111:
Strategies to Prevent COPD Exacerbations
What causes an exacerbation?
What happens in a COPD exacerbation?
What are broadly the types of exacerbation and their treatment?
Why prevent an exacerbation?
How can one prevent excaberations?
Pharmacological therapies
Vaccines and immunostimulants
Inhaled corticosteroids (ICS)
Inhaled long-acting β2-agonists (LABA)
Inhaled anti-cholinergics
Combination inhalers
Phosphodiesterase inhibitors
Tumour necrosis factor-alpha (TNF-α)
Mucolytics
Long-term antibiotics
Non-pharmacological therapies
Smoking cessation
Pulmonary rehabilitation (PR)
Oxygen
Non-invasive ventilation (NIV)
The way forward
112:
Empyema: Back to the Basics
Pathophysiology
Aetiology
Clinical features
Evaluation of empyema and parapneumonic effusion
Initial evaluation
Further radiological assessment
Treatment of empyema and PPE
Advantages of medical therapy
Advantages of surgical therapy
Medical/conservative treatment of empyema and PPE
Serial therapeutic thoracocentesis
Pig tail insertion (small-bore chest tube)
Standard intercostal tube drainage (ICD)
Fibrinolytic regimen
Role of fibrinolytics
Surgery versus conservative management
Medical thoracoscopy (pleuroscopy)
Surgical treatment of empyema and PPE
VATS
Thoracotomy
Fenestration procedure
ACCP consensus statement19
BTS guidelines for management of pleural infection20
The Cochrane database of systematic reviews 200521
Conclusion
113:
Sarcoidosis in India: Not so Rare!
What is Sarcoidosis?
Why is there a confusion regarding its prevalence and incidence?
International
India
What causes sarcoidosis?
Infection
Genetic factors
Immunologic factors
Auto-antigens
Cigarette smoke
Histopathology of sarcoidosis
How does sarcoidosis present clinically in Indian patients?
How does sarcoidosis present radiologically in Indian patients?
The chest radiograph (Fig. 5)
HRCT chest
How to determine disease activity in sarcoidosis?
What overshadows the diagnostic yield of sarcoidosis in Indian patients?
How different is the treatment of sarcoidosis in India from that in the West?
What is the prognosis of Indian sarcoidosis patients?
Conclusion
Learning points
Acknowledgement
114:
The New Antiepileptic Drugs
Felbamate
Gabapentin
Lamotrigine
Topiramate
Tiagabine
Levetiracetam
Oxcarbazepine
Zonisamide
Vigabatrin
Clobazam
Fosphenytoin
Pregabalin
Antiepileptic drugs in development
Comparing new and old antiepileptic drugs
Conclusion
115:
Status Epilepticus: Current Perspectives
Definition
Classification of SE
Refractory status epilepticus
Epidemiology
Aetiology and risk factors
Pathophysiology
Diagnosis
Non-convulsive SE: a diagnosis not to be missed
Pseudostatus epilepticus
Investigations
EEG
Neuroimaging
CSF examination
Other tests
Treatment
Precautions with antiepileptic drug administration2
Paediatric perspective
Non-convulsive status epilepticus
Recommendations
Initial
Early refractory stage
Refractory stage
Refractory status epilepticus
Recommendations15
Coma phase
Weaning phase
If seizures continue, consider the following emerging therapies
Surgery
General measures
Complications
Outcome and prognosis
Mortality
Morbidity
Non-convulsive SE (NCSE)
Refractory SE (RSE)
116:
Bell's Palsy: Current Perspectives
Clinical presentation
Aetiopathogenesis
Investigations
Electrophysiology and testing
Electroneurography
Electromyography
Treatment
Corticosteroids
Antiviral agents
Spontaneous recovery
Other treatments
Complications
Neuromuscular re-training in Bell's palsy
Treatment guidelines during early phase of Bell's palsy
Partial paralysis
Neuromuscular re-training — treatment approaches
Biofeedback
Key recommendations for clinical practice
117:
Preventing Recurrent Ischaemic Stroke: A Multi-faceted Approach
Hypertension1–9
Diabetes mellitus10–25
Lipids26–40
Obesity
Behavioural risk factors
Cigarette smoking41–46
Alcohol47–53
Antiplatelet agents54–73
Aspirin
Ticlopidine
Efficacy
Clopidogrel
Clopidogrel plus aspirin
Dipyridamole plus aspirin
And then came ProFESS!
GP IIb/IIIa antagonists
Cardioembolic strokes74–78
Coronary artery disease (CAD)
Atrial fibrillation
Newer oral anticoagulants in AF
Methods of LAA obliteration
Current practice
Carotid revascularisation79–103
Extracranial vertebrobasilar disease
Intracranial atherosclerosis
Unconventional/emerging risk factors
Hyperhomocysteinaemia104–109
118:
Neurocysticercosis – Elimination of Parasites from the Brain: Is it Possible? Is it Beneficial? Is it Harmful?
Elimination of parasites from the brain: Is it possible?
Elimination of parasites from the brain: Is it beneficial?
Elimination of parasites from the brain: Is it harmful?
What should be done?
Conclusion
119:
Movement Disorders: Approach to Diagnosis and Management
Clinical history and examination
Investigations
Brief details of some specific movement disorders
Hypokinetic movement disorders
Parkinson's disease
Hyperkinetic movement disorders
Tremor
Chorea
Dystonia
Myoclonus
Management approach consideration
Conclusion
120:
Alzheimer's Disease: Evidence-based Treatment
Treatment of Alzheimer's disease
Evidence of each treatment (Table 1 and Fig. 1)
Cholinesterase inhibitors
Donepezil
Rivastigmine
Galantamine
NMDA receptor inhibitor
Memantine
Behaviour management
Psychotropic drugs for behaviour
For slowing progression (Tables 2 and 3)
Antioxidants (vitamin E)
Anti-inflammatory drugs
Hormones (oestrogen)
Alpha lipoic acid
Ginkgo biloba
Lecithin
Piracetam
Amyloid treatments
Non-pharmacological treatment
121:
Surgical Intervention in Parkinsonism
Indications of functional stereotactic neurosurgery
Parkinson's disease
Patient selection
Surgical technique
Intraoperative neurostimulation
Microelectrode recording
Lesioning procedure
Implantation of microelectrodes for deep brain stimulation
Postoperative programming
Different targets used in movement disorders according to predominant symptom
Thalamus
Globus pallidus
Subthalamic nucleus (STN)
Summary
122:
How do I Manage Chronic Myeloid Leukaemia?
The diagnosis of CML
Drug therapy in CML
How long do we have to give imatinib?
How do we monitor a patient on imatinib therapy?
Molecular response post-imatinib
Managing resistant/refractory disease
Role of allogenic stem cell transplant
Where do we stand via-à-vis transplant – different approaches for different people?
Pregnancy and children
Summary
123:
Chronic Myeloid Leukaemia (CML): Experience from Eastern India
Epidemiology
Biology of chronic myeloid leukaemia
Clinical presentation
Differential diagnosis
Underlying pathomechanism of clinical presentations
Monitoring
Treatment (Table 2)
Disease characteristics of the patients in the present series (n = 250)
Conclusion
124:
How Do I Treat Multiple Myeloma?
Clinical presentation
Diagnosis
Treatment
Intolerance or toxicity to thalidomide
Maintenance therapy
High dose chemotherapy
Treatment of poor risk patients
Bisphosphonates
Anaemia
Infections
Renal failure
Relapsed/refractory myeloma
Conclusion
125:
Management of Hodgkin's Disease: Utility of PET Scanning
Use of PET/CT in the diagnosis of Hodgkin's disease
Staging of Hodgkin's disease using PET/CT
Treatment monitoring
Diagnosis of recurrence
Use of PET/CT for radiotherapy
Other uses of FDG-PET in Hodgkin's disease
Shortcomings of PET/CT
Conclusion
Uses of PET/CT in Hodgkin's disease
Combined anatomical and functional imaging
Use of PET/CT in the diagnosis of Hodgkin's lymphoma
Uses in staging the disease
Treatment monitoring
Diagnosis of lymphoma recurrence
Uses of PET/CT for radiotherapy
Other uses
126:
Targeted Therapy: A New Generation of Cancer Treatment
Types of targeted therapies
Monoclonal antibodies
Unconjugated mAbs
Conjugated mAbs
Unconjugated antibodies
Immunoconjugates
Proteasome inhibitors
Angiogenesis inhibitors
Anti-apoptotic agents
Tyrosine kinase inhibitors
Cancer vaccines
Conclusion
127:
Alcohol-withdrawal Syndromes
Pathophysiology
Minor withdrawal symptoms
Withdrawal seizures
Alcoholic hallucinosis
Delirium tremens
Clinical manifestations
Treatment
Prevention
Recommendations
128:
Diagnosing, Screening, and Counselling for Domestic Violence
Epidemiology
Pregnancy
Clinical presentation
Clues to the presence of an abusive relationship
Consequences of abuse
Diagnosing domestic violence
Screening for domestic violence
Intervention for domestic violence
Recommendations by various groups
Treatment
129:
Newer NSAIDs: Expanding Armamentarium through Etodolac
Newer NSAIDs
Newer formulations of traditional NSAIDs
Newer NSAIDs under development
Etodolac
Pharmacokinetics
Actions
Dosage and indications
Adverse reactions
Contraindications
Special situations
Drug interactions
Rational selection of NSAIDs
130:
Gout: An Update
Epidemiology
Pathogenesis of gout9–11
Monosodium urate crystal-induced gouty inflammation1,11–14
Classification of gout
Clinical features1,15,16
Definitive diagnosis is best established by
Co-morbid conditions1,17–19
Treatment of gout
Treatment of acute gouty arthritis1,10,13, 21–24
Nonsteroidal anti-inflammatory drugs1,10,13, 21–24
Narcotic analgesics1
Glucocorticoids1,10,13, 21–24
Colchicine1,10,13, 21–24
Long-term or prophylactic therapy1,10,13, 21–24
Approaches to lowering uric acid levels1,10,13,21–24
Symptomatic hyperuricaemia
Anti-hyperuricaemic therapy
Allopurinol1,10,13,21–24
Uricosuric agents1,10,13, 21–24
Candidates for uricosuric drugs
Probenecid1,10,13,21–24
Sulphinpyrazone1,10,13,21–24
Dietary management of hyperuricaemia
Recent advances in the treatment of gout
Treatment of co-morbid conditions
Gout in the elderly population
Conclusion
131:
Carpal Tunnel Syndrome
Incidence and prevalence
Aetiology
Pathology
Symptoms
Signs
Tinel's sign
Phalen's test
Pressure provocation test
Katz hand diagram
Diagnosis
USG
MRI
Thermography
Differential diagnosis
Management
Conclusion
132:
Contemporary Concepts in the Management of Systemic Lupus Erythematosus
Pathogenesis
Clearance deficiency
T and B-cell abnormalities
Clinical features (Table 1)
Dermatological manifestations
Musculoskeletal manifestations
Haematological manifestations
Cardiac manifestations
Serositis
Renal lupus
Central nervous system (neuropsychiatric SLE-NPSLE)
Secondary antiphospholipid antibody syndrome
How is lupus diagnosed?
Laboratory investigations and their interpretation
Serological tests in SLE (Table 3) ANA
Anti-dsDNA
Imaging
Biopsy
Renal biopsy is indicated when:
Management of SLE: A multidisciplinary approach
Lifestyle changes
Drug therapy
NSAIDs
Corticosteroids
Antimalarials
Immunosuppressive agents– Which agent? When?
Initiating agents
Mycophenolate mofetil (MMF)
Maintenance agents
Therapies for specific types of lupus nephritis based on renal pathology
Protocol for SLE management at KEM hospital (Chart 1)
Methotrexate (MTX)
Lupus in pregnancy or the newborn
IVIg and plasmapheresis
How can a lupus patient prevent disease flares?
Selected complications of SLE
Premature atherosclerosis
Immunosuppressive agents and infection risk
Hypertension and renal disease
Biological agents in SLE
Anti-CD20
LJP 394
Anti-B-lymphocyte stimulator
Co-stimulatory blockade
Dehydroepiandrosterone
Stem-cell transplantation and immunoablation
The course of SLE
Monitoring (Table 8)
Immunisations: beneficial or risky?
Prognosis
133:
Advances in the Therapeutics of Rheumatic Diseases: Ruminations and Reflections
Pain relief
Corticosteroids
Rheumatoid arthritis
Ankylosing spondylitis (AS)
Systemic lupus erythematosus
Osteoporosis
Conclusions
134:
Remission in Rheumatoid Arthritis without the Use of Biologicals: A Clinical Reality or an Elusive Goal
How is remission defined in rheumatoid arthritis (RA)
Paradigm shift in the treatment of RA; modern-day treatment paradigm for RA
Modern-day treatment paradigm for RA
Newer therapies for RA
Early, aggressive DMARD treatment for RA: DMARD monotherapy or DMARD-combinations? Position of glucocorticoids in the treatment of RA
Can standard-DMARDs or DMARD-combinations halt or retard joint erosions/damage? Remission RA without the use of biologicals: A clinical reality or an elusive goal?
Is drug-free remission possible in RA?
What is the evidence-base of such a treatment of RA from India?
Personal experience of the author
135:
Seronegative Spondyloarthropathies: Novel Treatment Modalities
Clinical characteristics of spondyloarthropathies (SSA)
Diagnosis of SSA
Treatment
NSAIDs, DMARDs, and corticosteroids1
Non-pharmacologic therapy
Surgery and AS
Newer therapy
Role of biologic agents3
Rationale for use of anti-TNF-α therapy
Infliximab5
Adverse effects
Contraindications
Etanercept8
Contraindications
Precautions
Special warning
Adalimumab9
Golimumab10
Anakinra11
Abatacept12
Rituximab13
Author's experience
Summary
136:
Rituximab in Rheumatoid Arthritis and Lupus
CD-20 targeting
Rituximab in RA
REFLEX trial
DANCER study
Rituximab in SLE
Toxicity and side effects of rituximab therapy
Future direction
Summary
Conclusion
Abbreviations used
137:
Biologic Agents in Rheumatic Diseases
Indications for all TNF-α blockers
Rheumatoid arthritis
Psoriatic arthritis
The TNF-α blockers
Infliximab
Dose in ankylosing spondylitis
Adalimumab
Dose
Etanercept
Dose
Ankylosing spondylitis
Psoriatic arthritis
No TNF-α blocker is more effective than the other
Switch therapy
Long-term follow-up
Warnings and adverse effects
Other adverse events
Rituximab
Indications
Exclusion criteria
Screening before rituximab
Doses
Evaluation of response
Consideration for repeated treatment
Contraindications
Adverse events
IL-1 blocking agents
Indications
Clinical use
Adverse effects
Warning
Precautionary statements
Abatacept
Indications
Caution
Clinical use
Other uses are
Warning
Precautionary statements
Biologic agents and vasculitides
Biological agents in SLE
Conclusion
Key points
138:
Role of DEXA in Diagnosis and Follow-up in Patients with Osteoporosis
Definition of osteoporosis
Bone mineral density
Techniques for measurement of BMD
Dual energy X-ray absorptiometry (DEXA)
Principles of DEXA
BMD measurements by dual energy X-ray absorptiometry (DEXA)
Indications for DEXA
DEXA results
Uses of DEXA
Follow-up DEXA
139:
RANK Ligands: Emerging Therapeutic Target in Osteoporosis
Pathogenesis of bone loss
Preclinical studies
Clinical studies in humans
Osteoprotegerin
Anti-RANKL antibody
Potential side effects with denosumab therapy
Frozen bone
Immunosuppression
Osteonecrosis of the jaw
Conclusion
140:
Biosimilars: Are they really ‘Similar’?
Biopharmaceuticals
Biosimilars
‘Marvel insulins’ episode
Quality aspects
Biosimilarity
Drug substance
Drug product
Non-clinical aspects
Clinical aspects
141:
Nutritional Strategies in Diabetes and Cardiovascular Diseases
What happens with excessive ingestion of calorie-dense food ?
Post-prandial hyperglycaemia and post-prandial hyperlipaemia
Carbohydrate: In what amount, of what type?
Protein as cardioprotective diet
Nuts: The health benefits
Light to moderate alcohol consumption
Fruits: The more the better
Fish: Cardioprotection with omega-3-fatty acids
Different diets–What to follow?
Some points to ponder
142:
Safety of Statins in Clinical Practice
Adverse effects of statins and their interaction with other drugs
Factors associated with an increased risk of myopathy
Pharmacokinetic mechanism by which combination of statin with other drugs induces myopathy
Combination with gemfibrozil (commonest cause of statin-induced myopathy)
Combination of other drugs which interfere with statin metabolism
The myopathy syndrome
Use of statins during pregnancy
Use of statins with warfarin
Use of statins in children
Statins in the elderly
Statins in alcoholics
Statins in renal failure
Statins in heart failure
Other possible hazards of statins
Management of myopathy
Management of raised transaminase level
Conclusion
143:
Hyperkalaemia: Causes, Electrocardiographic Changes, and Management
Causes
ECG manifestations
Treatment
Injection calcium gluconate
II Non-emergency treatment
Summary
144:
Therapeutic Apheresis: A Clinical Spectrum
Classification of apheresis
Principle and methodology of apheresis
Mechanism of action of therapeutic apheresis
Therapeutic plasmapheresis (TPE)
Category I: Diseases in which plasmapheresis is a standard or a valuable first-line therapy
Category II: Diseases in which there is sufficient evidence for use of TA as adjunctive therapy
Category III: Diseases in which there is a suggestion of benefit but existing evidence is insufficient.
Therapeutic cytapheresis
Therapeutic leukapheresis
Complications of apheresis
145:
Performance-enhancing Drugs in Sports
History
The target population
Efficacy of performance enhancing drugs (PEDS)
The undesirable effects
Need for physicians to know
Androgenic-anabolic steroids (AAS)
Therapeutic use exemption
Human growth hormone (hGH)
Erythropoietin (EPO)
Other drugs
Supplements
Myostatin inhibitors
Conclusions
146:
E-learning in Medicine
Tools for E-learning
Web 2.0
Wikis
Blogs
A list of some medical blogs
Podcasts and M-learning (Mobile-learning)
A list of some medical podcasts
Nature
New England Journal of Medicine
Medicine-net
RSS (Real simple syndication) newsfeeds
Content management systems
Goals of E-learning
Role of internet in medical research
Internet resources for clinical trials
Bibliographic databases
Funding information
Clinical trial registries
Internet randomisation services
Online analysis and sample size calculation
147:
Gene Therapy: An Update
History
The basic procedure of gene therapy
A. Viral vectors
Adenovirus (AV)
Adeno-associated virus (AAV)
Retrovirus
Lentivirus
Modified viral vectors
B. Methods of gene transfer without using viral vectors
Naked DNA
Lipoplexes/polyplexes
Oligonucleotides
C. Combination methods
Classification of gene therapy
Various methods of gene therapy
Use of gene therapy
Gene therapy for cancer
Gene therapy for SCID
Gene therapy for globin disorders
Gene therapy for bleeding disorders
Gene therapy for cystic fibrosis
Gene therapy for AIDS
Gene therapy for diabetes mellitus
Gene therapy for cardiovascular disorders
Challenges, limitations and problems
Ethical issues
Gene therapy in India
Recent advances in gene therapy
Fast forward to the future
148:
Adherence to Medication
Background
What is adherence to medication?
Extent of non-adherence
Types of non-adherence with medication
Barriers to adherence
Dimension or Barrier 1: social and economic factors
Dimension or Barrier 2: health care system-related factors
Dimension or Barrier 3: condition-related factors
Dimension or Barrier 4: therapy-related factors
Dimension or Barrier 5: patient-related dactors
Measures of adherence
Predictors of poor adherence to medication
Prerequisites for adherence to medication regimens
Strategies to improve adherence
1. Strategies to improve social and economic factors
2. Strategies to improve health care system-related factors
3. Strategies to improve condition-related factors
4. Strategies to improve therapy-related factors
5. Strategies to improve patient-related factors
Consequences of medication non-adherence
Conclusion
149:
Functional Foods
Functional food
Characterisation of functional food
Health claims of certain functional foods
Biomarkers
The benefits of whole grain foods, and fruits and vegetables
Some Indian functional foods
Fenugreek
Turmeric
Garlic
Ginger
Role of functional foods in various metabolic diseases
Functional foods for cardiovascular disease
Functional foods and cancer
Function foods for diabetes
Functional foods for satiety
Functional foods and immune enhancement
Safety of functional foods
Conclusion
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