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Category : All ; Cycle : November 2017
Medical Articles
Fellowship in clinical cardiology
PGDHSC (Ultrasonography)
PGDHSc (Echocardiogram)
FCGP., MCCP (cardiology)
230/12 Chandralok colony
NH-2 Goverdhan chauraha
Mathura – 281004
Uttar Pradesh

Pulmonary tuberculosis is a sub acute respiratory infection with acid fast bacilli Mycobacterium tuberculosis. The most frequent symptoms are cough, fever, night sweats and malaise. Cough in pulmonary tuberculosis is initially non-productive, but often progress to sputum production and in some cases Haemoptysis. The sputum is generally yellow and is neither malodorous nor thick. Extremely advanced cases may also present with bloody sputum. Rarely, the bleeding is massive leading to shock, asphyxia and death.
Tuberculosis (TB) is one of the top 10 causes of death worldwide. In 2016, 10.4 million people fell ill with TB, and 1.7 million died from the disease (including 0.4 million among people with HIV). Over 95% of TB deaths occur in low- and middle-income countries. Seven countries account for 64% of the total, with India leading the count, followed by Indonesia, China, Philippines, Pakistan, Nigeria, and South Africa. In 2016, an estimated 1 million children became ill with TB and 250 000 children died of TB (including children with HIV associated TB).

The management of active pulmonary tuberculosis starts with proper classification, such as drug susceptible tuberculosis, Drug resistant tuberculosis and HIV-PTB by advising following investigations
• Sputum smear (AFB) examination: • atlest two samples of sputum should be examined. Early morning sputum specimens tend to have a higher yield than specimens collected at either times and overnight sputum collection have provided even greater sensitivity. Presence of AFB confirms the diagnosis that the patient is suffering from active pulmonary tuberculosis. This investigation does not confirm that this active PTB is whether DSPTB or DRPTB or HIV-PTB
• X-ray chest PA view: this is not a confirmatory investigation unless confirmed by sputum microscopy. X-ray chest will be helpful in knowing the extent of damage of lung.
• CB NAAT or Gene xpert of sputum AFB: this is latest weapon which delivers very fast results within 2 hours. This rule out drug susceptibility PTB from Drug resistance PTB. It also rules out Rifampicin Resistance.
• Card test for HIV: It is essential to rule out HIV-PTB. Many TB patients were being treated without knowledge of the presence or absence of concurrent HIV infection. Detection of HIV antibodies among TB patients is crucial to the holistic management.
• The other tests Interferon gamma release essay (TB Gold, TB spot), ADA, PCR Blood and Mantoux test were not helpful in diagnosis of Active Pulmonary Tuberculosis and should not be prescribed.
DST TB: it is assumed 85% of pulmonary TB cases were drug susceptible and curable. They include new cases, Retreatment and default cases.
DIAGNOSIS: Diagnosis of Drug susceptible tuberculosis requires clinical history plus three investigations such as
• LED microscopy AFB Sputum smear examination
• X-ray chest PA view
• CB NAAT or Gene xpert sputum of AFB: this test is strongly recommended is retreatment and default cases
Management and treatment:
Two months RHEZ and four months RHE if your area is high risk
Rule and treat other comorbidities such diabetes, COPD, anaemia, immunodeficiency etc.
Monitor the therapy using AFB sputum smear examination and X-ray chest every 2 months
Case cured: previous sputum positive TB becomes sputum negative on two occasions of 2 months gap.
Drug Resistant TB: An estimated prevalence of 3% in new cases and 12-15% in retreatment cases. Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. WHO estimates that there were 600 000 new cases with resistance to rifampicin – the most effective first-line drug, of which 490 000 had MDR-TB. Drug resistance tuberculosis is divided in to two categories; primary resistance, which is the presence of drug resistance in someone who has never had treatment from tuberculosis and secondary resistance, which is the presence of resistance in a patient who has previously been treated for tuberculosis. Primary resistance results from acquiring an infection that is already drug resistance, while secondary resistance is the result of inappropriate therapy which may be either due to patient attitude towards treatment or empirical prescription of drugs by physicians without following fixed guidelines of WHO or serial DST reports. MDRPTB is defined as resistance to at least rifampicin and isoniazid. The treatment of MDRPTB is extremely difficult, since the drugs used are less effective, more costly and poorly tolerated due to drug related side effects. Failure to control drug resistance tuberculosis has led to outbreak of PRE XDRPTB, XDRPTB and XXDRPTB.
PRE XDR-PTB: defined as resistance to Rifampicin, isoniazid plus resistance to fluoroquinolones or second line injectable (3 drugs).
XDR-PTB: defined as resistance to rifampicin, isoniazid plus resistance fluoroquinolones and at least one second line injectables (capreomycin, amikacin, or kanamycin) (four drugs)
XXDR-PTB: resistance to more than four drugs.
DIAGNOSIS: initial diagnosis of drug resistance PTB requires clinical history (such as previous prescriptions) and 3 investigations such as
• LED microscopy AFB sputum smear examination
• X-ray chest PA view
• CB NAAT (Cartridge Based Nucleic acid amplification test) or Gene Xpert: this is initial test in treatment failures.
For Management we require one more test such
• Serial Liquid cultures: liquid culture gives fast results with in three weeks in comparison of solid cultures. The management and treatment of MDRPTB is complex and if family physician has expertise in managing MDRPTB cases, then manage the cases according to serial DST reports. Management of XDRPTB cases were definitely beyond the reach of family physicians and should be referred to specialized Government sectors where such services available.
HIV-PTB: Tuberculosis is a major opportunistic infection of HIV patients’ worldwide and is a leading killer of HIV-positive people: in 2016, 40% of HIV deaths were due to TB. The management again starts with identification and proper classification of TB such as Drug sensitive and Drug resistance, as drug resistance TB has been responsible for high rates of mortality in HIV infected individuals.
DIAGNSOSIS: investigations required for drug susceptible HIV-PTB
• Sputum for AFB
• X-ray chest PA view
• Gene Xpert of sputum
• Rapid card test for HIV : Out of three cards at least two cards of different companies and confirmed by ELISA
For drug resistance HIV-PTB
• Liquid cultures for AFB sputum
Investigations for Management and follow-up:
• CD4 cell count:
• Viral load
• Haemogram
• Liver profile
• Identification and management of Comorbities eg. Diabetes, malnutrition
The investigations and treatment of HIV-TB is expensive and this services were available to patients at free of cost nearest Government ART centre. Beside ATT it requires lifelong ART (antiretroviral therapy) which should be initiated within 2 weeks of starting ATT.

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ACNE..... Rosy Buds
From a naturopathic viewpoint, acne is an external manifestation of an internal imbalance. As with many naturopathic treatments, nutrition is key to treating acne. The body makes the oil (sebum) secreted by the sebaceous glands from the fats that are eaten. If poor quality fats (saturated fats, trans fatty acids) are eaten, the body produces poor quality oil. If good quality fats (olive oil, fish oil, flaxseed oil) are eaten, the body produces good quality oil. Poor quality oil does not flow adequately, so it clogs pores and attracts bacteria. Good quality oil flows well and nourishes the skin.
• Eat a high-protein, low-carbohydrate diet. Include vegetables, seaweeds, fish (cold-water fish like salmon, sardines, trout, and haddock), whole grains, sprouts, and fruits in the diet.
• Avoid fried foods, dairy products, processed foods, junk food, sugar, margarine, nut butters, citrus (except lemon juice), caffeine, food that aggravates the acne, and food sensitivities. Determine food sensitivities through the elimination and challenge diet.
• Fasting can be an effective method of treating acne but should not be undertaken for more than 2–3 days without a physician's supervision.
• Drink 50% of body weight in ounces of water daily (e.g., a 150 lb person would drink 75 oz of water).
• Brewer's yeast—Take 1 tbsp 3 times daily.
• Chromium—Take 400 mcg daily.
• Flaxseed oil—Take 1�2 tbsp daily.
• Selenium—Take 200 mcg daily.
• Vitamin A—Take 100,000 IUs daily. Toxicity to Vitamin A can occur at doses of 20,000 IU daily; therefore, use vitamin A only with a physician's supervision. It is possible that the acne may return several months after discontinuing vitamin A.
• Vitamin B-6—Take 50 mg 3 times daily.
• Vitamin C—Take 1000 mg daily.
• Vitamin E—Take 400 IUs daily.
• Zinc—Take 50 mg daily (particularly for males).

Herbal Medicine
Herbs are used to treat acne by cleansing the blood. When toxins accumulate in the blood, the liver works less efficiently and cannot metabolize hormones effectively, which leads to skin eruptions (i.e., an external manifestation of an internal imbalance).
• Burdock (Arctium lappa)—Used as a blood purifier when taken internally and as an antibacterial when applied topically.
• Dandelion (Taraxacum officinale)—Used as a liver purifier. The leaves may be applied topically in a poultice.
• Chaste tree berry (Vitex agnus)—Indicated for acne associated with the menstrual period.
• Milk thistle (Silybum marianum)—Used as a liver cleanser.
• Red clover (Trifolium pratense)—Used as a blood purifier.
• Tea tree (Melaleuca alternifolia)—Used as a skin disinfectant; it kills many organisms and penetrates the skin layer. Tea tree oil may be applied directly (sparingly) to the pimple. If irritation occurs, which is uncommon, use diluted tea tree oil. Tea tree oil has a very strong, medicinal odor.
• Alternate hot and cold compresses with to the affected area.
• Apply a hot washcloth to the affected area for 45 seconds then apply a cold washcloth for 15 seconds. Do this three times in succession always ending with the cold. Repeat several times during the day.
• Apply a poultice to the affected area.

Prevention Tips
• Use a honey mask on a weekly basis. Honey is considered as a disinfectant and a great way for healing pimples. It can also kill bacteria found in your skin.
• Cut your hair short if it’s long. Hair has oil. When you are moving, dust particles often culminate in your hair, and as your hair touches your face, neck, or forehead, it can provoke acne or worsen an affected area.
• Take a powerful multi-vitamin twice every day; the biggest organ—your skin—requires proper nutrients to stay healthy.
• Take vitamin A daily. It both protects your skin and prevents acne. Plus, vitamin A reduces sebum production.
• Avoid over washing and rubbing or scrubbing your skin excessively. Acne is not caused by not washing or by having dirty skin.
• Some people, especially students, have claimed that their acne grows worse when experiencing stressful situations. Advise: if it’s in your power, cut down on stress.
• Drink 8 glasses of water everyday. Water helps to clean and hydrate the skin.
• Avoid alcohol-based creams and lotions.
• Either change or wash your pillowcase everyday.
• Eat food rich in zinc. A deficiency in zinc may cause acne breakouts.
• Add a lot of fresh fruits and vegetables to your daily diet.
• When you are undergoing much stress, breathe deeply. Because there is a direct connection between acne and stress.

Other Recommendations
• Avoid exposure to oils and greases.
• Avoid medications that contain bromides or iodides.
• Avoid touching the face. Hands can transmit oil and bacteria. Do not pick or pop pimples.
• Avoid the use of greasy face creams or cosmetics.
• Do not smoke.
• Do not wash the affected area with soap. Use warm water to rinse off. If a cleansing agent is needed, use only a gentle non-soap product

Dr Wilkhoo HS

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Arthritis Reversed # 2..... Arthritis Types and Risk Factors
The term arthritis means “joint inflammation,” and the most common types are known as Osteoarthritis (OA) and Rheumatoid arthritis (RA).
Arthritis is a complex family of musculoskeletal disorders consisting of more than 100 different conditions that destroy joints, bones, muscles, cartilage and other connective tissues, hampering or halting physical movement and causing pain.
While arthritis is not a single disease, its symptoms are often universal and are largely experienced as stiffness, soreness, inflammation and pain. Over time, the cartilage between the joints can begin to wear down, exposing the joint to friction. When two bones rub together, inflammation and pain can take place. Redness and swelling of the joints and loss of joint function soon follow.
While the most common form, osteoarthritis, is a result of external factors like physical injury or wear and tear of joints through overuse, this is not the case with rheumatoid arthritis. In fact, despite advances in science, the exact causes of RA are unknown … but certain risk factors have been identified:- genetics, age, weight, injury, occupational hazards, sports, illness or infection, stress, etc.

Now we will go through two most common types of arthritis: osteoarthritis (OA), rheumatoid arthritis (RA).
Osteoarthritis most commonly type of arthritis which is caused by poor lifestyle. It is degeneration of the cartilage that cushions the area where two bones meet to form a joint. When the cushion wears out or cracks, the bones rub together, causing intense pain. In severe cases, the joints can develop calcifications. This means that calcium builds up on the bones and soft tissues, making them stiff and painful to move. The pain of osteoarthritis gradually worsens with use over the course of the day.
This type of arthritis occurs slowly over time and is the type that many runners, martial artists and construction workers begin to feel by middle age due to over-extreme use of joints.
Prevention is always the best medicine. However, reversing damage already done is also essential.
Rheumatoid Arthritis
Rheumatoid arthritis, on the other hand, is a chronic disease of the autoimmune system that causes inflammation of the synovial membrane (joint lining). This causes destruction and deformity of bone, cartilage, ligaments and muscle tissue.
RA commonly called “crippling arthritis” is a “systemic” disease. Besides the tissues around the joints, other areas RA affects include the glands of the eyes and mouth, the lining of the lungs and the pericardium. When inflamed, the tissue lining between the joints becomes red, painful and swollen. The frequency and duration of these “flare-ups” vary widely. After repeated episodes, chronic inflammation begins to cause damage to the surrounding tissue, cartilage and bone. Eventually this damage can lead to loss of cartilage and weakening of bones, resulting in painful and permanent destruction and deformities.
The second study offers even more hope as to the healing power of green tea for RA sufferers. Green tea, supplementation and relaxation techniques are powerful solutions for this disease.
Juvenile Arthritis
The autoimmune trigger of RA also affects children causing Juvenile arthritis (JA). Actually, JA is a term used to group the various autoimmune disorders affecting children 16 and under. While JA affects the joints, it also can affect the eyes, skin and gastrointestinal (GI) tract as well.
JA, while similar to RA, is more easily diagnosed. Again, this autoimmune disease is not precise in how, or whom, it affects, but inherited genes and external factors can trigger it in a child. If you have a family history of RA and your child shows red inflammatory joints.
The natural solutions and plan for JA are the same as for RA. The difference is that usually a parent or adult will have to manage the lifestyle changes in the home and keep the child on course with the plan.

There Is Hope!
People think that because they experience excruciating pain today, they will experience it tomorrow and keep experiencing it for the rest of their life. It is as if the trajectory of arthritis, to them, is inevitable, and therefore there is no hope. This does not have to be the case. Nothing about arthritis is “inevitable” if you understand the condition and take steps to control it.
People suffering with arthritis do not believe anything can be done to help ease their pain. Why? Because the drug-based therapies they have been following are not useful in providing a change to the condition – only symptomatic relief. Yes, immediate relief of pain or stiffness or inflammation is a good thing and drugs are the fastest means for that relief. However, there are two problems with relying on synthetic drug therapies over the long term.
Problem 1: The drugs and cortisone injections are toxic to the system, causing in some cases damage to the liver and stomach lining, weakening of the joint cartilage and the immune system, and GI tract issues.
Problem 2: Drugs do not change the course of the condition and thus, as the arthritis worsens over time, drugs that are more potent are needed, causing more toxicity and potentially damaging side effects.
The good news is that a multi-pronged approach to arthritis can do wonders, and even feel like a miracle to those suffering its nasty symptoms. Because there is no cure, it is extremely important to become proactive in managing, treating and slowing down the condition

Dr Wilkhoo H S

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Arthritis Reversed #1 ... Biggest Myths on Arthritis
Now medical fraternity is applying a holistic and complimentary system to treat & manage chronic ailments such as arthritis, diabetes, cardiopathy, etc. For any wellness action plan to work there must be a clear understanding of the various aspects involved in so called Arthritis, which also involves clearing up the myths and setting forth the facts of the situation.
Generally the line between fact and fiction is very thin. Myths in healthcare take shape when a sound bite or piece of information is spread and made public, which may be personal experiences or individual concomitants. All these type of information are made available in web globally, making the context so called facts.
When it comes to diseases and conditions like arthritis, the pain, symptoms and joint involved can wreak havoc on a life. If left unchecked, the quality of life of the one suffering arthritis can be destroyed.
After all, a firm belief based in facts goes a long way toward beginning and maintaining a wellness program, especially when one is facing daily pain and physical and emotional debilitation. Let’s look at those myths.
MYTH #1: Rheumatoid Arthritis (RA) and Osteoarthritis (OA) are the Same
Perhaps the most pervasive myth of all is the notion that there is only one type of arthritis and it just happens to have different symptoms for different people. Arthritis for a fact is an inflammatory condition of the joint. In fact, there are over 100 different types of arthritis; the three most common being osteoarthritis (OA), rheumatoid arthritis (RA) and juvenile arthritis (JA).
While rheumatoid and juvenile arthritis are autoimmune diseases, to be precise – osteoarthritis (OA) is not a disease at all. It is a symptom of joint degeneration.
Autoimmune diseases, like rheumatoid and juvenile arthritis (and type I diabetes, lupus, multiple sclerosis, etc.), are progressive and associated with a systemic autoimmune disorder. That means the body makes antibodies that attack its own tissues and joints when triggered by some unknown event. Such triggers are known to include a reaction to a virus, the flu shot and stress. In the case of RA and JA, the joints are affected from the internal imbalance.
On the other hand, osteoarthritis is the result of any combination of several external factors, including traumatic physical injury and excessive sports or physical activities over the course of decades. This causes wear and tear of the joints, as well as of the cartilage separating the joints and the surrounding tissues (tendon and muscle).
MYTH #2: Arthritis Is a Normal Part of Aging and Only Affects the Elderly
If you look around it is easy to see how this myth formed and took hold. There are plenty of elderly afflicted with arthritic conditions with visible signs such as misshapen hands, walkers and wheelchairs, etc.
To begin correcting this myth it is important to know that rheumatoid and juvenile arthritis are autoimmune diseases and, therefore, have nothing to do with aging. Osteoarthritis, on the other hand, is a result of joint wear and tear based in injury and/or overuse, which can come on at any time – or not at all. As such, OA also is not a “normal” part of the aging process.
By keeping the immune system strong and stable, eating right, exercising right and taking care of bone and joint health, the onset and debilitating effects of arthritis need not be part of your aging process. And with better diagnosis and natural treatment remedies and therapies available, when you find you have the condition you can stop it and reduce or even reverse its symptoms, so they will not progress into your later years.
MYTH #3: If You Don’t Look “Sick,” You Don’t Have Rheumatoid Arthritis
If one is only looking to the outward signs and symptoms of RA to know if they have it, they will be amiss. Even when people do not have the visible outward signs of rheumatoid arthritis, such as red swollen joints and deformed fingers, they can still suffer symptoms, like joint pain, fatigue and a general sense of feeling unwell.
The best way to know if you have, or are at risk for, RA is speak to your primary care physician, look into family history and do some blood work.
MYTH #4: If You Have Arthritis, You Should not Exercise
This is a myth most believed by those suffering the symptoms of arthritic pain and inflammation. Decades ago patients were told not to exercise because it would rub the joints and make things worse. This is incorrect. While it is true that depending on your arthritis type and conditions certain exercises should be avoided, this is not a blanket statement about all forms of exercise. In fact certain amount and types of exercise can greatly help reduce the symptoms of arthritis. Most often, those with arthritis in the hips and hands feel pain in the joints and inflammation and/or contraction in the muscles and tissues around those joints. However, part of what is contributing to the pain and stiffness is the limited range of motion within the joint structure that has happened as a result of not exercising.
The first step is to begin exercising slowly, lightly and with limits so as not to worsen or aggravate the conditions. Moving each joint slowly at first helps lubricate the joints and stretch the muscles. Strengthening exercises can help stabilize the arthritis joint structures. This in turn helps bring fresh blood, and thus oxygen and nutrients, to the area, which decreases inflammation, stiffness and pain.
Thus the myth that one suffering arthritis must rest and not exercise, no longer holds water.
MYTH #5: Different Climates Have No Effect on Arthritis
It is necessary to understand that there is truth within the myth. There is no scientific evidence to support the notion that cold weather or environments cause arthritis or alter its course, or that warm weather can reverse or cure arthritis.
Climate does play an important role in how one experiences the symptoms of their arthritis. Say for an example, cold weather constricts muscles, tendons and blood vessels, causing constriction around the joints, and thus increased pain and restricted range of motion (ROM) and whereas, heat allows muscles to expand and blood to flow, and so relieves compression around joints and helps move fresh blood into the arthritis area. This reduces pain and stiffness and increases range of motion (ROM). And as well, damp environments (whether warm or cold) cause inflammation around joints, and thus restrict movement and cause pain.
MYTH #6: Arthritis Will Lead to Disability, Wheelchair and the Nursing Home
This myth is a hard one to bust, especially varies with the experiences one has with arthritic symptoms. As a result of our history of poor arthritis diagnosis, treatment and prevention methods, many who contracted arthritis did end up with a walker, in a wheelchair and living in assisted environments.
The first thing to understand is that arthritis is a continuum; it is not one size fits all. Rheumatoid arthritis is the more difficult of the two most common types to control, as it is an autoimmune disease. But early detection and stabilization of the immune system can help keep it from progressing too rapidly. Supplementation and change of diet and various therapies can reduce its symptoms while strengthening the affected and surrounding joint areas.
Osteoarthritis is easier to account for, stop and manage symptoms as they are mostly related to lifestyle and activity choices, bone and joint health and weight.
MYTH #7: Arthritis Sufferers Have To Live In Pain
This is a huge myth which is widely believed. This is because many arthritis sufferers do live in pain, with daily stiffness and inflammation.
By engaging in mind/body exercises to reduce stress, eating an anti-inflammatory diet, stretching, exercising, taking proper supplementation, using therapeutic lifestyle changes prescribed by health-wellness coaches, you can greatly reduce the discomfort. Inflammation decreases, blood flow increases, joint pressure reduces, joint support strengthens and pain slips away.
Even with the best treatment plan, the best healthcare providers, the best supplements and diet there are so many things to control. These include sleep patterns, stress levels, genetic makeup, health habits (smoking/alcohol) and potential slips and falls that can increase your pain.
MYTH #8: Arthritis Can’t Be Reversed
The notion that the damage done by arthritis cannot be reversed is perhaps the biggest myth of all. This view believes nothing can be done to reverse damage, and so patients need to manage their condition as best they can. In other words, symptomatic relief only. However, traditional and holistic medicines have natural methods for increasing bone density, rebuilding bone and regenerating soft tissue. In other words, a natural approach to reversing damage done by arthritis based on using supplements, topical creams and energy medicine.

Dr Wilkhoo H S

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