ACUTE CORONARY SYNDROME
Dr.S.ABBAS ALI
MD, DFM, DNB, MNAMS
FCGP, MCCP (Cardiology)
PGDHSc(Ultrasonography)
PGDHSc(Echocardiogram)
DEFINITION
ACS includes Unstable angina and evolving MI which share a common underlying pathology – plague rupture, thrombosis and inflammation. It results from reduction of flow through the affected epicardidal coronary artery. The flow reduction may be caused by completely occlusive thrombus or sub totally occlusive thrombus. A totally occlusive thrombus results in STEMI and a sub totally occlusive thrombus results in NSTEMI. Management of ACS is beyond the limit of Family physician and during evolution history and all risk factors should noted and diagnosed confidently and then refer to tertiary health care.
RISK FACTORS
NON MODIFIABLE MODIFIABLE Controversial risk factors
Age
Gender
Family history of IHD or premature death or MI in first degree relative Smoking
Hypertension
Diabetes
Hyperlipidemia
Obesity
Sedentary life styles
Poor oral hygiene
Cocaine use
Stress
Type A personality Raised Apolipoprotein
Raised homocysteine
Raised fibrinogen
Hyperinsulinemia
ACE genotype
TYPES
• STEMI (ST segment elevation MI)- results from totally occlusive thrombus of epicardial coronary artery.
• NSTEMI (non ST segment elevation MI) – results from subtotal occlusion of epicardial coronary artery.
ST SEGEMENT ELEVATION MYOCARDIAL INFARCTION
PATHOPHYSIOLOGY
1. There is total occlusion of the epicardial coronary
artery
2. The thrombus is fibrin rich hence called red
thrombus. Fibrinolytics are drug of choice
3. there is macro-infarction and time bound necrosis
of myocardium
4. Early reperfusion is the key to treatment
CLINICAL FEATURES
• Sudden onset of chest pain – substernal may radiate, pain lost for 30 minutes and it is not relieved by rest or sublingual nitrates. There may be associated dyspnoea, sweating, weakness, vomiting along with clinical features of cardiac failure.
• ECG FEATURES: patients with STEMI present with ST segment elevation. Many may ultimately develop a Q wave on the ECG. Those who undergo a successful fibrinolysis or primary PCI may not develop a Q wave on the ECG. A new onset LBBB with classical chest pain is also considered STEMI Fibrinolysis or primary PCI is the treatment of choice.
TREATMENT – immediate in the first 30 minutes
• If the chest pain is typical ACS give 325 mg of aspirin (not enteric coated) to be chewed (if there is no aspirin allergy)
• Clopidogrel 300 mg stat
• Sub lingual nitrates if HR >50 and <100/minute ; SBP >90 or if there is no BP fall of > 30 from base line (b) no prior sildenefil intake for 24 hours or Tadalafit for 48 hours © No RV infarction
• Sedation IV morphine 5-10mg +metoclopramide 10mg iv (not IM because of risk of bleeding with thrombolysis)
• Arrange emergency ambulance
• Re-assurance
• O2 inhalation – in icu
• Firbrinolytics or primary PCI
NON ST SEGMENT ELEVATION MYOCARDIAL INFARCTION
PATHOPHYSIOLOGY
• It results from sub-total critical occlusion of the epicardial coronary artery
• The thrombus is platelet rich hence called white thrombus. Hence fibrinolytics are contraindicated. Anticoagulants (UFH/LMWH), antiplatelets and other cardiac medications are treatment of choice
• The distinction between USA/NSTEMI is made by the presence or absence of serum cardiac marker such as Treponin
• There is a micro-infarction, hence treponin is done.
• The myocardium is still viable with high possiblity of developing necrosis, if the occlusion becomes total
• The risk determines intervention
CLINICAL FEATURES:
• PAIN is similar to anginal pain but may be more severe usually lasting upto 20 minutes. Pain is present at rest, there may be decreasing tolerance for exertion,
• clinical signs may be unremarkable. If some patients with large area of myocardial ischaemia or a large NSTEMI the physical findings can include diaphoresis, pale cool skin, tachycardia, S3,S4 or murmur of papillary dysfunction, basal rales and some time hypotension resembling large STEMI
DIAGNOSIS
For diagnosis at least three of four diagnostic tool required for general physician.
• Clinical history
• ECG
• Cardiac biomarkers
• Stress testing or angiography (optional)
ECG: In UA, ST-segment depression, transient ST-segment elevation, and/or T-wave inversion occur in 30 to 50% of patients. These patients do not develop Q waves. Both are differentiated by presence of treponin in blood. If Treponin levels are high then it is called NSTEMI and If treponin levels were normal then it is called Unstable angina. In patients with the clinical features of UA, the presence of new ST-segment deviation, even of only 0.05 mV, is an important predictor of adverse outcome. T-wave changes are sensitive for ischemia but less specific, unless they are new, deep T-wave inversions ( 0.3 mV).
CARDIAC ENZYMES OR CARDIAC BIOMARKERS
• Treponin T and I: cardiac Treponin T and I are the most sensitive and specific markers of myocardial necrosis. Serum levels increase within 3-12 hours from the onset of chest pain. If normal after 6 hours and ECG normal the risk of missing MI is very tiny.
• CK-MB: the levels raise with in 3-12 hours.
• Myoglobin: the levels raise with 1-4 hours from the onset of chest pain. They highly sensitive but not specific.
OTHER INVESTIGATIONS REQUIRED
x-ray chest PAview
haemogram
lipid profiles
liver profiles
serum electrolytes
blood sugar fasting and pp
HBA1c
Serum calcium Serum uric acid
FT4 FT3 TSH
Blood urea@serum creatinine
Serum Vitamin D
Serum B12
Serum testosterone
Prothrombin time and APTT
TREATMENT – IMMEDIATE WITH IN 30 MINUTES
• If the chest pain is typical ACS give 325 mg of aspirin (not enteric coated) to be chewed (if there is no aspirin allergy)
• Clopidogrel 300 mg stat
• Sub lingual nitrates if HR >50 and <100/minute ; SBP >90 or if there is no BP fall of > 30 from base line (b) no prior sildenefil intake for 24 hours or Tadalafit for 48 hours © No RV infarction
• Sedation IV morphine
• Re-assurance
• Firbrinolytics should not be given. LMWH or UFH or Fondaprinax can be given
• Conservative or invasive tretment depends upon risk stratification (TIMI score)
TIMI SCORE: TIMI risk score is simple tool composed of 7 (1 point) risk indicators rated on presentation
• Age 65 years or above
• At least 3 risk factors of CAD
• Prior coronary stenosis of 50% or more
• ST Segment deviation on ECG presentation
• At least 2 anginal events in prior 24 hours
• Use of aspirin in prior 7 days
• Elevated serum cardiac biomarkers

Repetitive Strain Injury (R.S.I):
Repetitive Strain Injury is an umbrella term for physical pain in Neck, Shoulder, Arm, Wrist, Hand, Back and Leg. It’s a disorder of muscle, tendon and nerves.

R.S.I is also known as Work Related Musculoskeletal Disorders (WRMSD), cumulative Trauma disorder (CTD), Occupational Overuse Syndrome (OOS).

The question is "Do you feel" your :-
• Muscles are sensitive to pressure.
• Stiff and tight feeling.
• Headache.
• Dull, aching, burning pain in muscles.
• Pain going down to arms and legs.
• Numbness or tingling.
• Muscle weakness.
• Unpredictable, erratic symptoms.
• Heat eases the pain.

If you checked many of this then you most likely have some R.S.I problems.
Consult with a R.S.I specialist.

RSI injuries are coupled with:-
1.Inflammation
2.Pain
3.Redness
4.Eventually limited movement

R.S.I is a progressive disorder; the longer you wait for the treatment the longer the recovery will take.
When don’t you treat the R.S.I complained then the complained continue in three stages
The three stages are –

Phase 1:- Pain is easy to locate During work you suffer pain that disappear quickly after you stopped working. After sometime you move into the second phase

Phase 2:- Pain is less easy to locate.Pain radiates to other part of the body.Appear quickly and disappears more slowly.

Phase 3:- Pain is almost present all the time and more extensive in nature.Pain is very demobilizing.

Example of RSI is
Carpal Tunnel Syndrome (pain in wrist joint and radiate up to fingers)
Tennis Elbow (pain in the elbow ).
Thoracic outlet syndrome ( T.O.S ).
Temporo mandibular Disorders etc.


Avoiding R.S.I complains = Avoiding Strain

• Reading, watching TV, using computer for prolong time without taking any break put a lot of pressure on muscles.
• Tense muscle has very low blood circulation so they are not providing enough oxygen (O2), nutrition, and metabolic waste is not removed.
This results are: – weary muscles, cramps, cold hands and pain.

To prevent R.S.I:-

1.Take some micro break regularly, take 20-30 sec break after 30 min or 45 min. that’s give enough time to the muscle for recovery (remove the static loading)
2.Do some stretch of the hands, arms, shoulder and neck regularly that help to

Increase blood circulation Prevent shortening of the muscle fibres Reduce stiffness


The cause of RSI (Repetitive Strain Injury):
1.Repetitive activity.
2.Awkward posture or poor working posture.
3.Working continuously without taking break.
4.Impaired sleep.
5.Nutritional inadequacies.

Treatment for R.S.I :Physiotherapy/physical therapy, Chiropractic ,Myofascial Release Therapy,Alexander technique,Feldenkrais,Manual therapy,Taping.

The successful and failed therapy depends on perpetuating factors which are commonly overlooked and neglected.Perpetuating factors are numerous and often require a special knowledge to recognize their injury to RSI (Repetitive Strain Injury ) .

PREVALENCE OF HIV INFECTION AND IT’S AMONG TUBERCULOSIS PATIENTS AND NON-TUBERCULOSIS PATIENTS – CASE CONTROL STUDY
DR.S.ABBAS ALI
MD, DFM, DNB, MNAMS
FCGP, MCCP (CARDIOLOGY)
PGDHSc (Ultrasonography)
PGDHSc (Echocardiogram)
M : 9412178773
Email: dr_s_abbas20@yahoo.co.in


Abstract
Objectives: To determine the prevalence of HIV infection and its clinical profile among tuberculosis patients (Cases) and Non-TB patients (Controls)
Methods: A case-control study study was conducted at District Hospital, Mathura, Uttar Pradesh during the period September 2009 to February 2011. 252 proven Tuberculosis patients as cases and 252 non-tuberculosis patients (having similar clinical features like TB) as controls selected stratified random sampling method
Results: Out of 252 tuberculosis patients 26 were HIV seropositive and none was positive in Non-TB patients. The percentage of prevalence in TB patients was 10.3%. The prevalence in males 13.2% (19/143) and in females, 6.4% (7/252), 12 (46.15%) were married and 14 (53.85%) were singles, 17 (65.38%) patients were Hindus and 9 (34.62%) were Muslims. 14 (53.85%) patients were from rural areas and 12 (46.15%) patients were from urban areas. 96.2% HIV –TB patients has income below 10000/Rs and all most all HIV – TB patients has heterosexual sexual behavior and not used protective measures during unprotected extramarital sex. The most peculiar clinical features of HIV seropositive TB patients of this study were chronic diarrhea (73%) aphthous ulceration (92.3%), pain in abdomen (38.4%) oral candidiasis (26%) lymphadenopathy (39.8%).
Conclusions: HIV seroprevalence was higher among TB patients and calls for routine HIV screening and counseling of TB suspects for holistic management.


INTRODUCTION
Tuberculosis is a major opportunistic infection of HIV patients’ world wide and despite the synergy between the human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics; the public health responses have largely been separate. Detection of HIV among TB patients is crucial to the holistic management of HIV-TB co-infected patients. The joint statement by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America recommends that all patients with tuberculosis (TB) undergo testing for human immunodeficiency virus (HIV) infection after Counseling (Blumberg et al 2003).
As per NATIONAL AIDS CONTROL ORGANIZATION, HIV/AIDS epidemiological surveillance and estimation report for the year 2005. (Available from: http:// www.nacoonline.org/fnlapil06rprt.pdf [Last accessed on 2010 Sep 20]) an estimated 5% TB patients were HIV infected. Routine HIV testing in tubercular patients is NOT the national policy. Many patients were being treated for tuberculosis under programme conditions without knowledge of the presence or absence of concurrent HIV infection. Relapse rate is high in HIV-TB, which may be due to re-infections rather than true relapse of TB. This thesis finding stresses the importance of HIV screening of high risk TB patients such as drivers, labors, businessmen at least, to avoid confusion during management and treatment of Tuberculosis patients.
OBJECTIVES:
To determine the prevalence of HIV infection and its clinical profile among tuberculosis patients (Cases) and Non-TB patients (Controls). The parameters evolved were socio-demographic factors, habits, sexual behavior, clinical and radiological features.
Methods
Setting: DISTRICT HOSPITAL, MATHURA, UTTAR PRADESH
Duration: September 2009 to February 2011
Study design: Retrospective case control study
ESTIMATION OF SAMPLE SIZE: Sample size estimated on 50% power, 95% of confidence level 10% exposure in TB patients (Cases) and 5% exposure in non-ill group (controls) by statistician calculator (Epi Info version 6 November 1993). This had given a sample size of 252 patients for each group such as cases and controls. Services of Eminent Statistician utilized in estimation of sample size.
Method of sampling: Stratified systematic Random sampling system
Identification of cases and controls: From OPD register, 252 Tuberculosis patients (all three categories) were drawn. Stratified random sampling technique was used in the selection of cases. Only proven TB patients whose HIV status was not known at the time of TB diagnosis were included in the analysis to draw the true prevalence of HIV infection among TB patients. TB diagnosis was done on the basis of smear microscopy, chest radiography, and clinical signs/symptoms as per the Revised National Tuberculosis Control Programme (RNTCP).
The controls are free from disease under study but have similar symptomatology. From OPD register controls were drawn from diagnosed cases of acute bronchitis, allergic bronchitis, and acute exacerbation of chronic bronchitis, bronchiectasis, chronic bronchitis, emphysema and malignant pleural effusion. I selected one control for each case (252) from the eligible source population, matched on age, gender and calendar year. Stratified Random sampling technique was used in the selection of controls.
DATA COLLECTION:
The study was clinic based and data collected by me. The study protocol includes the information regarding life style and socio-demographic factors ( patient age, gender, religion, occupation, marital status, income, place of residence, education, habits), detailed history of the disease and physical examination of each patient (both cases and controls) included in the study was done and following information such as clinical features, radiological features, category TB, Sputum AFB status, type of TB, Risk factors responsible for the spread of HIV, HIV Virus subtype responsible for HIV infection and CD4 cell count of HIV patients were recorded. A chest X-ray was taken from all patients to study the radiological pattern. Information collected about them was treated as confidential and the study did not interfere with the normal management of the patients
Data were collected between September 2009 and February 2011, and a total of 504 (252 cases and 252 controls) participants were recruited as study subjects. Informed consent in their own language was obtained from the patients prior to enrolment. For those below 20 years, permission was sought from their parents/guardians.
HIV DETECTION:
During a regular follow-up visit and after pretest counseling, blood samples were collected for HIV antibodies screening and were tested initially by the three Rapid card tests as per the guidelines laid down by NACO (Testing strategy III) and positive test result was disclosed to the patients by post test. The results were again confirmed by ELISA test for HIV antibodies was done on all patients (cases and controls) included in the study. A patient was said to be positive for HIV when tested for positive by two different HIV test kits done on different occasions. Western Blot was not done due to lack of availability. All the ethical issues were observed during data collection. The HIV positive TB patients referred to nearest ART centre (convenient to patients) either Delhi or Agra and they are carefully and patiently followed and their CD4 cell count collected and studied during the follow up of ATT treatment at DOTS centre and the response with ART observed.
STATISTICAL ANALYSIS:
The data of cases and controls were analyzed using EPI info software version 6 (1993) and SPSS soft ware version 17. The socio-demographic variable differences in prevalence of HIV infection between cases and controls was statistically assessed using Chi-square test. Qualitative data was compared and analyzed in terms of percentages. Results of the two groups were compared using appropriate statistical technique. The statistical significance of the values was expressed through p – values, where ever the p – values are not significant, the odds ratio was expressed. A two-tailed p-value of <0.05 was considered as statistically significant results.
Results:
252 confirmed and microbiologically proven TB patients (cases) and 252 non TB patients having similar clinical features like cases, aged between 18 – 57 years were screened for HIV-1/2 antibodies by ELISA method. Of these, 26 cases were found to be HIV-positive in TB patients and none was found in controls. Seroprevalence of HIV infection among TB patients was 10.3% (26/252). HIV seropositivity observed 10.9% (6) were in the age group of 18-27 ( 4 females and 2 males), 14.7% patients (11 males and 3 females) were in the 28-37 age group, 10% (6 males) were in the age group of 38 – 47 and none was found in the age group of 48 – 57. The mean age of prevalence of HIV infection was 34.5 years. Out of 252 controls no HIV seropositive were found in any age group.
The HIV infection was found to be more in males i.e. 13.2% (19/143) than in females, 6.4% (7/252), 12 (46.15%) were married and 14 (53.85%) were singles, 17 (65.38%) patients were Hindus and 9 (34.62%) were Muslims. 14 (53.85%) patients were from rural areas and 12 (46.15%) patients were from urban areas. 25 (96.2%) HIV-TB patients income was below Rs.10000/month and majority were transport drivers 8 (30.8%) labors 5 (19.3%), businessmen, farmers and house wives of these occupations and they have low literacy levels.
All the 26 (100%) HIV-TB patients had given heterosexual sexual behavior, and all are not using condoms and practicing unsafe sex. 77% (20) patients had given extra-marital unsafe sex with sex worker and multiple partners. None gave homosexual history, blood transfusion, and IV drug abuse or using unsterilized needles. 19.2 %( 5) patients had given history of migration. Six (23.9%) female patients had acquired the infection probably by heterosexual contact with infected spouse. past history of unprotected extra-marital sex was revealed in 77% (20) of HIV seropositive tuberculosis patients and it will be major risk factor for transmission of HIV infection and Alcoholism 73% (19/26), migration to cities or metros for work, low literacy, and poverty were the other factors fuelling the spread of HIV infection according to this study.
The most peculiar clinical features of HIV seropositive TB patients of this study were chronic diarrhea (73%) aphthous ulceration (92.3%), pain in abdomen (38.4%) oral candidiasis (26%) lymphadenopathy (39.8%). The fever, loss of weight, loss of appetite, cough were common to both TB and HIV-TB. The difference in signs and symptoms among the HIV positive and HIV negative TB patients was found to be statistically significant. 17 (65.4%) HIV seropositive TB patients had sputum AFB negative and 9 (34.6%) had sputum AFB positive.
. In this study extensive cavitatory lesions were common in Tuberculosis patients but in Co-infected (HIV-TB) patients’ ill-defined fibrotic lesions on upper lobe were more common and HIV-1 was the predominant viral subtype. Out of 26 HIV seropositive TB patients, 16 (61.5%) had Pulmonary tuberculosis patients, 6 (20.1%) had extra-pulmonary tuberculosis and 4 (15.4%) had combined variety. The main site of extra-pulmonary involvement was mesenteric lymphadenopathy and abdomen (8 patients) followed by pleural (1) and cervical lymphadenopathy (1) and brain (1). In this study we found 69.2% of cases (18 patients) were found in Category I, 27% of cases (7 patients) found in Category 2, and 3.8% of cases (1 patient) found in category 3. Maximum number of cases observed in category 1
In this study of CD4 cell count, 7 (26.9%) patients were found in the category range of 51 – 100 which includes 5 (21.3%) males and 2(28.6%) females. In this range we found 3 (18.8%) pulmonary, 2 (33.3%) extra pulmonary and 2(50%) combined tuberculosis patients. In the range 101 – 200, we found 12 (46.2%) (10 (52.6%) males and 2 (28.6%) females) cases, in which 9 (56.2%) were pulmonary, 2 (50%) combined and 1 (16.7%) extra-pulmonary. In the range 201 – 300 we found 7 (26.9%) (4 (21.1%) males and 3 (42.8%) females) cases, of which 4 pulmonary and 3 extra-pulmonary. The mean CD4 cell count was 182.
Discussion:
The present study demonstrated prevalence of HIV infection among tuberculosis patients was 10.3%. No HIV infection found in controls. Mohanty et al. (Ind.j.tub 1994) reported 5.89% of HIV infection in tuberculosis patients from Mumbai. Vasudevaiah et al. (Indian j.tub 1997) reported HIV seropositivity in tuberculosis patients attending the Govt.Hospital for chest diseases, Gorimedu, Pondicherry was 4% in 1994, 3.5% in 1995 and 4.9in 1996. The HIV/AIDS epidemiological and surveillance project 2005 conducted by National AIDS control organization, Ministry of health and family welfare, Govt. of India, estimated 9% of HIV infection among tuberculosis patients. The findings of above studies are very much agreement of this project and indicating that the risk of HIV infection among tuberculosis patients was increasing. The HIV seroprevalence of 10.3% among TB patients in our study is a cause for alarm, especially in view of the fact that HIV seroprevalence among TB patients is a good indicator of the spread of HIV infection in the general population.
The prevalence of HIV seropositivity in tuberculosis patients in the present study was 10.3%, which is higher than the HIV prevalence found in other studies in India. In the twin studies from Pondicherry, Siva Raman et al (1992) and Arora et al (1993) reported HIV seroprevalence of 2.7% and 3.4% respectively in tubercular patients. Mohanty et al (1994) reported a seroprevalence of 5.89% from Mumbai. The high prevalence of HIV infection in tubercular patients in these two places, Mumbai and Pondicherry is because of prevalence of HIV infection there. Mumbai is a metropolitan city and prostitution is rampant there. Immigrant populations who come here in search of work were easy target to the prostitutes, from whom they contact the HIV infection. Infact, the prostitutes in Mumbai have been reported to have a very high sero prevalence of HIV infection up to 51% (Lal et al 1994). Though, Mathura is less industrialized and the higher seropositivity (10.3%) in tuberculosis is causing concern. In this study, the most of the HIV-TB patients were drivers, labors, and cattle businessmen. These people do not have proper sex and health education, and most of the time they were away from their families and homes, befalls easy prey to the prostitution, which may be the cause of significantly higher HIV seropositivity. As compared to previous reports from Delhi of 4.4% in 1995-1999, 9.4% in 2000-2002, and 8.3% in 2003-2005. Ramachandran et al (Indian J Med Res 2003) have reported a seroprevalence of 4.7% in Tamil Nadu in 1997-1998. The trend observed over the years highlights the importance of continuous surveillance and in-time appropriate preventive measures.
In this study, 252 controls of unknown HIV status having similar symptomatology to cases had screened for HIV antibodies. No HIV infection was identified in controls. The percentage of diseases collected as controls were allergic bronchitis 22.3%, acute exerbations of chronic bronchitis 10.3%, COPD 26.2%, emphysema 12.6%, acute bronchitis 17.9%, malignant lung disease 5.5%, malignant pleural effusion 5.2% and bronchiectasis 4.8%. Few authors like J cadranel, D Garfield et al (2010) reported lung cancers were reported in higher frequency in HIV patients. These study findings were contrary to the findings of above author. It may be possible; we screened lung cancer patients of unknown HIV status and not in confirmed HIV patients.
SOCIODEMOGRAPHIC CHARACTERISTICS
AGE AND SEX
The study population comprised of 252 confirmed TB patients as cases, who were screened for presence of HIV antibodies. Of these, 143 (56.7%) were males and 109 (43.7%) were females. The HIV prevalence in relation to gender in TB patients was 13.2% (19) in males and 6.4% (7) in females. The overall male: female ratio was 2.7:1. The overall prevalence of HIV infection in TB patients was 10.3%. No HIV infection was found in controls. In control group the distribution of males 59.2% (149) and females 40.8% (103). The mean age of prevalence of HIV infection was 34.5 years and the main age group affected was 18 – 47 which is the sexually active age and is also the most productive in one's life. In Mumbai, Mohanty et al. (Ind.j.tub 1993) reported highest seroprevalence (71.7%) in the 21 – 40 year age group. Talib et al (Journal of infectious diseases, 1993) also reported maximum HIV cases in the age group of 20 – 39 years. So the findings of this project were very much agreement of the above studies. The HIV prevalence in relation to gender in TB patients was 13.2% (19) in males and 6.4% (7) in females. The overall male: female ratio was 2.7:1. NACO epidemiological report – 2005, reported 39% were females and 61% were males. The striking male predominance noted in the present study has also been reported by other authors. Such as Deivanayagam CN et al, (Ind.J.Tuberculosis:2001) Bhagyabati DS et al (Journal, Indian Academy of Clinical Medicine 2005), and Swaminathan S et al (2002). So the findings of this study were very much in agreement of the above studies.
MARITAL STATUS
Out of the 26 tubercular patients with HIV seropositive TB patients 14 (53.85%) were singles and 12 (46.15%) were married which includes unmarried singles and married singles due to divorce and separation. Prevalence was significantly high among singles. This finding is also consistent with previous reports, which found single, unmarried persons more vulnerable to HIV infection. Single unmarried persons are more likely to maintain multiple sex partners or be involved in high risk sexual behaviors (homosexuality, commercial sex work, alcohol use and intravenous drug abuse) that make them vulnerable to infection with HIV.
RELIGION
Out of 26 HIV seropositive tubercular patients, 17 (65.38%) patients were Hindus and 9 (34.62%) were Muslims. In 226 HIV seronegative tubercular patients 125 (55.31%) were Hindus, 76 (33.63%) were Muslims and 25 (11.06%) were others which includes Christians and Punjabis. No HIV seropositives were identified in controls. Dermal et al. (Indian J Community Med 2002) reported HIV positivity was seen equally among all religions and both sexes.
PLACE OF RESIDENCE
Out of 26 HIV seropositive tubercular patients, 14 (53.85%) patients were from rural areas and 12 (46.15%) patients were from urban areas. It signifies that prevalence was higher in rural areas. It may be due to change in life styles, behavior, migration and effective ways of communication like transport, travel including tourism. The epidemiological report of NACO – 2005, reported HIV infection in rural areas was 58.7% and in urban areas was 41.3%. These findings were very much in agreement with the findings of this study.
INCOME
Out of 26 HIV seropositive tubercular patients, 14 (53.85%) patients were found their income below 3000/-Rs and nil, 8 (30.76%) patients were found their income below 5000/-Rs/month, 3 (11.54%) were found their income below 10000Rs/month and 1 (3.85%) was identified income below Rs20000/month. The majority of HIV patients were found low income groups. Theur et al. (J.infectious diseases 1990) from California and Prasad et al (2003) from India reported HIV infection was more common in poor socio-economic status.
LITERACY
Out of 26 HIV seropositive TB patients 7 (26.92) were illiterates, 9 (34.62%) were studied up primary level, 5 (19.23%) were studied up to upper primary level, 4 (15.38%) were completed secondary education and 1 (3.85%) was found graduate. In this study we observed majority of HIV-TB patients were having low levels of literacy.
OCCUPATION
Out of 26 HIV seropositive TB patients 7.7% (2) were businessmen, farmers 7.7% (2) drivers were 30.8% (8), labors 19.3 (5) housewives 26.8% (7) professionals 7.7 (2). The occupational profile of our patients revealed that a majority of them were transport drivers, laborers, businessmen and house wives of these occupations. Mohanty et al. (Ind.j.tub 1993) reported 36.8% patients working as manual laborers while Rajsekaran et al. found majority (55.6) of patients working as farm labors. Jenkins et al. (Clin Infect Dis 2000) reported high prevalence of HIV infection in occupations involving mobility. Other authors have found seropositivity rate was highest among those who were unemployed (40%) followed by the business professionals (35%). The percentage of the professions is thus seen to vary in different studies, largely due to the differences in the occupational patterns and the source from where the patients were selected.
LIFE STYLES AND RISK FACTORS
HABITS
Out of 26 HIV-TB patients, 69.3% (18) of patients were alcoholics 73% (19) were smokers, 100% (26) patients had given history of tobacco chewing and substance abuse was not seen in seropostive TB patients. In comparison of cases and controls the percentage of prevalence of bad habits was more in HIV seropositives. In this study alcoholism was found to be contributing factor for visiting commercial sex workers and thus seems to the risk factor. Similar observations reported by Katarina et al. (Med J Armed Forces India 2000)
RISK FACTORS
Heterosexual route and extra-marital sex and unsafe sex with single/multiple partners and commercial sex workers were most important risk factors of this thesis study. Arora et al (Indian chest diseases, Allied science 1993) reported a history of heterosexual promiscuity in 75% of the HIV seropositive cases. Mohanty et al (Ind.j.tub 1993) reported 95%, and Talib et al (1999) reported 100% of heterosexual promiscuity. All these were in concordance with the findings of this project. The heterosexual transmission (100%) remains the commonest mode of transmission in this study since other sexual practices being very uncommon in my area. Six females seemed to have acquired infection from their infected husbands. More than 77% had extra-marital relations. There was however no case of transmission that could be attributed to blood transfusion or IV drug abuse, contrary to several studies reported from other parts of India and abroad.
CLINICAL FEATURES
In this study, General weakness or asthenia was common in both TB and HIV-TB patients (100%) but General weakness is observed in higher degree in HIV-TB patients. Asthenia observed 41.7% in controls. Fever was observed (100%) both in TB and HIV-TB patients but in controls it was observed in 11.9%. Cough, dyspnoea and chest pain observed in more or less same proportion in controls, TB and HIV-TB patients. Haemoptysis was present in 34% of TB patients which was massive in some patients, 19.2% in HIV-TB patients and 8% in controls. Loss of appetite was observed in equal proportions (100%) both in TB and HIV-TB patients but it was observed in 49% of controls. Loss of weight more than 10% was observed in equal proportions (100%) in TB and HIV-TB patients. Ascitis and herpes zoster was observed in equal proportions in TB and HIV-TB patients. The most peculiar clinical features of HIV-TB in this study were recurrent fever (100%), chronic diarrhea (73%) aphthous ulceration (92.3%), pain in abdomen (38.4%) oral candidiasis (26%) lymphadenopathy (39.8%). The fever, loss of weight, loss of appetite, cough were common to both TB and HIV-TB. The mean duration of the most common presenting symptom (cough) was 12 weeks while fever and weight loss had mean duration of about 14 and 12 weeks, respectively, at the time of presentation. Mean duration of anorexia was 15 weeks and for dyspnoea it was about 8 weeks. The average (mean) duration of symptoms at the time of presentation was 12.2 weeks, which is in overall suggestive of late presentation and contributing to the delay in the diagnosis of TB. The duration of illness in the present study ranged from 2 weeks to 2 years. In controls the mean duration of cough and dyspnoea ranged from 2 weeks to 5 years. General weakness or asthenia was more intense in HIV seropositive TB patients in comparison of Controls and cases. Kenya medical research institute, cohort study in 1990, reported cough, fever, dyspnoea, loose motions, loss of weight, loss of appetite, candidiasis, and itchy rash were common symptoms in HIV-TB patients. Saumya Swaminathan et al in their study reported haemoptysis 18%, oral candidiasis 38% of HIV-TB patients. Bissue F et al (J.Inter.med.1994) in their study quoted fever in91%, cough 84%, and weight loss > 10kg in 70% in HIV-TB patients. Similar observations were reported by K.C.Mohanty. (Ind.j.tub 1993)These findings were very much in agreement with the results of this study. The average duration of symptoms was 12.2 weeks, indicating that there was a delay in diagnosing tuberculosis and starting treatment. Whether the delay was at the patient or provider level needs further investigation. The duration of illness in our patients ranged from 2 weeks to 2 years. Swaminathan et al. found that the duration of illness in their cases before seeking treatment was 12 weeks. Fever, weight loss, cough, and lymphadenopathy which were consistent with studies by Kumar et al (2002) and by Putong et al.(2002) But Dey et al (2003) found rapid weight loss was most common presentation in seropositive patients, and cough was the most common symptom of TB in immunocompetent subjects. In the series reported by Mohanty et al. fever was the most common complaint, while Deivanayagam et al. (Ind.J.Tuberculosis:2001) reported cough with expectoration in majority of their patients.
TYPE OF HIV VIRUS
In this study all the 26 HIV-TB patients were found HIV-1 infection (100%). Migliori et al. (1992) found 59 (18.3%) out of 323 tuberculosis patients seropositive for HIV-1 antibody. Similar reports observed by Bonney EY et al (2008). The screening of 200 blood samples at National Institute of Virology, Pune by Indian council of medical research in 1992, identified HIV-1 infection was more frequent as compared to HIV-2 infection was very much similar to the findings of this project.
SPUTUM AFB
Out of 26 HIV seropositive tubercular patients, 17 (65.4%) patients had sputum AFB negative and 9 (34.6%) had sputum AFB positive. Beauliev et al (1993) reported sputum smear positivity in 22.8% of HIV-TB patients and in 56.2% of patients sputum AFB negative. Elliot et al (1993) similarly reported 76% sputum negative in comparison with 24% of sputum positive. Similar observations made by Kiel et al, (Chest:1989:95) Col. A K Praharaj et al (MJAFI 2004) and Levy R et al (Am.J.of Public health 1991) in their study. These studies findings were very much in agreement of findings of this project. The reason could be attributed to predominance of non-cavitatory lesions and extra-pulmonary tuberculosis in HIV patients
RADIOLOGICAL FEATURES
In this study, out of 26 seropositive TB patients 6 (23.1%) patients had normal x-ray, 12 (46.2%) patients had unilateral lesions on upper lobe, and 8 (30.7%) patients had bilateral lesions on upper lobe. 4 (15.3%) patients had cavitatory, 13(50%) patients had ill defined fibrotic lesion, 1(3.8%) patient had mililary and 2 (7.6%) patients had pleural thickening. In seronegative TB patients 29 (12.8%) had normal x-ray, 86 (38.1%) patients had unilateral lesions on upper lobe, and 111 (49.1%) patients had bilateral lesions on upper lobe. 149 (65.9%) patients had cavitatory, 35 (19.02%) patients had ill defined fibrotic lesion, 11(4.7%) patient had mililary and 16 (7.9%) patients had pleural thickening and 22 (8.7%) had hydropneumothorax. In this study we observed extensive cavitatory lesions were common in Tuberculosis patients but in Co-infected (HIV-TB) patients’ ill-defined fibrotic lesion on upper lobe were more common. The results were similar to the study published by K C Mohanty et al. (Ind.j.tub 1993). Many other studies have also reported a lower prevalence of radiological presentations in HIV-TB patients. According to Park text book of S.P.M. 16th edition, chest radiography may be less useful in people with HIV because they have less cavitations. Cavities usually develop because the immune response to tubercular bacilli leads to some destruction of lung tissue. In people with HIV, who do not have a fully functioning immune system, there is less tissue destruction and hence less cavitations was very much agreement of findings this study. The pattern of pulmonary involvement and the frequency of extra pulmonary involvement in this study were not different from other Indian reports.
DISEASES CLASSIFICATION
Out of 26 HIV seropositive TB patients, 16 (61.5%) had Pulmonary tuberculosis patients, 6 (20.1%) had extra-pulmonary tuberculosis and 4 (15.4%) had combined variety. The main site of extra-pulmonary involvement was mesenteric lymphadenopathy and abdomen (8 patients) followed by pleural (1) and cervical lymphadenopathy (1) and brain (1). ). Anuradha et al (1993) reported pleuro-pulmonary tuberculosis is more common. Houston et al (1994) reported extra-pulmonary tuberculosis more common than pulmonary tuberculosis. NACO, Govt. of India has reported in 200, TB as the commonest opportunistic infection (62.3%) in the HIV infected persons. The incidence of combined pulmonary and extra pulmonary TB infection was significantly higher in the seropositive patients, a finding that is consistent with a study by Jones et al. (Am Rev Respir Dis 1993) The findings of this thesis were very much agreement of the above studies.
CATEGORY OF TB
In this study we found 69.2% of cases (18 patients) were found in Category I, 27% of cases (7 patients) found in Category 2, and 3.8% of cases (1 patient) found in category 3. Maximum number of cases found in category I. Range et al (1996) reported an increase of HIV reactivity in newly registered tuberculosis patients 33% to 46%. Mohanty et al. (Ind.j.tub 1993) reported 5.89% of new cases of pulmonary tuberculosis HIV infection. Anastasias et al (International journal of tuberculosis and lung diseases 1997) made a retrospective study of 295 patients from 1991 to 1994 in Durban among the group of highest risk for HIV infection and reported the prevalence of HIV infection was 13.1% in patients with drug resistant tuberculosis and 14.9% in patients with drug sensitive tuberculosis. The above finding were very much agreement of findings of dissertation.
CD4 CELL COUNT
In this study of CD4 cell count, 7 (26.9%) patients were found in the category range of 51 – 100 which includes 5 (21.3%) males and 2(28.6%) females. In this range we found 3 (18.8%) pulmonary, 2 (33.3%) extra pulmonary and 2(50%) combined tuberculosis patients. In the range 101 – 200, we found 12 (46.2%) (10 (52.6%) males and 2 (28.6%) females) cases, in which 9 (56.2%) were pulmonary, 2 (50%) combined and 1 (16.7%) extra-pulmonary. In the range 201 – 300 we found 7 (26.9%) (4 (21.1%) males and 3 (42.8%) females) cases, of which 4 pulmonary and 3 extra-pulmonary. The mean CD4 cell count was 182. In this study we observed, CD4 Cell count was lowest less than 100/cmm in those patients with combined (pulmonary and extra pulmonary) lesions and all 26 our patients presented with an initial CD4 count of less than 300/µl consistent with many studies such as Sharma sk et al ((2004). Badri et al from South Africa reported most of the TB affected patients (67%) had CD4 level of more than 200/cmm. This could be attributed to late presentation primarily due to patient ignorance and lack of suspicion at primary health care level.
CONCLUSIONS
The present study has shown that the prevalence of HIV infection among tuberculosis patients was very high in compare of non-tuberculosis patients having similar clinical features. The extent of prevalence was 10.3% in tuberculosis patients. This is of great concern especially as it might affect both patient management and public health prospective.
Despite the synergy between the human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics, the public health responses have largely been separate. Intensive efforts and early diagnosis of HIV infection among tuberculosis patients was crucial for holistic management of HIV-TB patients. With this study screening of HIV antibodies in TB patients adds one more classification, which will be more helpful in predicting prognosis of disease.
Classification
TB: it is assumed all TB cases (pulmonary and extra-pulmonary) were curable. It can be easily diagnosed by AFB sputum and x-ray chest PA View
Resistant TB: it includes MDR-TB and XDR-TB, which can be easily predicted with the help of previous prescriptions. Management of Resistant TB was beyond the reach of family physician and can be referred higher centre.
HIV-TB: Can be easily diagnosed in TB patients by rapid card tests. Beside ATT it requires services of nearest ART centre.
Knowledge of HIV status in a TB patient is critical from both patient and public health perspectives. In those patients who test seropositive for HIV, better care can be provided in the form of effective combined antitubercular (ATT) therapy and antiretroviral treatment. ATT was alone insufficient for the treatment of HIV seropositive TB and it was observed during this study that curative outcome was more with addition of antiretroviral therapy. If a HIV-positive TB patient on ATT worsens or fails to improve with therapy, the possibility of other co-existing opportunistic infections or immune reconstitution syndrome should be considered. Knowledge of a person's HIV serostatus also provides the opportunity to administer prophylaxis for opportunistic infections and thereby reduces morbidity and mortality. The spouse and relatives of HIV-seropositve patients may also be counseled on HIV infection and its modes of transmission and prognosis, preventing the spread of infection. Spouses may be educated on safe sex practices and may be offered testing themselves.




What is already known on the topic?
Tuberculosis is the commonest opportunistic infection of HIV infection or AIDS
What this study adds
HIV – TB was on the rise. So routine screening of TB suspects were necessary for Holistic management of TB and HIV-TB patients.

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Assisted reproduction technology is a safe and effective way to build a family. Having a multiple birth (twins, triplets or more) is the single greatest health risk associated with assisted reproductive fertility treatment. Females are delaying their motherhood nowadays. The number of women giving birth after turning 40 has risen steadily in recent years, with multiple births most likely amongst the over-45s. As per the office of the National Statistics, the number of multiple births to women over 40 has risen sharply in the last 30 years. These change is because of the fact that more and more women are becoming carrier oriented, they want to be emotionally and financially strong, have not found their perfect partner or are facing treatments for cancer or ovarian failure.

The aging of the egg supply has a powerful effect on the chances that an assisted reproductive technology (ART) procedure will result in pregnancy and a healthy baby. Women aged 40 or older may face problems in conceiving for the first time or after their previous delivery. Obvious reason is the quality of the egg and the number of eggs. As women gets older the number and quality of egg cells that are produced by the ovaries declines. As women wait longer to have children, more couples have fertility problems due to declining egg quality, and other issues that are more common in older women. Many couples end up needing advanced treatments such as IVF, in vitro fertilization to overcome this age related decline. Age related infertility and difficulty in conceiving can cause great emotional distress to couples.

In Vitro Fertilization treatment an option Available for Age Related Fertility Problems

IVF comes to the rescue of infertile couples facing age related problems. Many fertility doctors recommend that women over about the age of 38 that are infertile should have aggressive fertility treatments and proceed to in vitro fertilization sooner before fertility potential in her is lost. Older women often prefer to move on to IVF after a few IUI (Intra Uterine Insemination)s have failed.
Age Limit for In Vitro Fertilization

All clinics have an upper age limit after which they will not do IVF with the woman's own eggs. Most IVF centers will attempt IVF using the female partner's eggs until about age 43-45. There is not a substantial decline in success by age of the recipient woman with donor egg IVF. Donor Egg IVF in women’s up to 48 years is successful.

To know more about impact of age on motherhood, age related infertility treatments and the possibility of multiple pregnancies and its side effects on mother read the whole article at http://indiraivf.wordpress.com/2015/01/02/fertility-treatment-pregnancy-after-40/

Assisted reproduction can only partly compensate for age and age-related decline in fertility, thus a good fertility education and monitoring program would facilitate the early referral of people seeking help to conceive to fertility specialists. Indira Infertility Clinic based in Udaipur and Pune has helped countless couples navigate the often complicated journey of infertility and ultimately realize their dream of parenthood. We provide a wide range of assisted reproduction services to help people build families, including drug treatments to induce or regulate ovulation, surgery to clear blocked tubes or remove fibroids from the uterus, intrauterine insemination, in vitro fertilization, technologies like egg retrieval that help people preserve their fertility and counseling for infertility treatment. The team of infertility specialist at Indira IVf including young talented and aspiring Gynaecologist, Sonologist, Embryologist and Clinical staff is highly trained in all aspects of Reproductive technology. Our team believes in providing fertility education to infertile couples before starting the treatment. We educate and inform all pregnant women and those planning pregnancy, regardless of age, about the treatment and pros and cons of delaying motherhood. Doctors at Indira IVf take care that patients receive optimal care and support and the appropriate medical attention required to meet any needs that arise from becoming a mother.

You can contact the team of doctors for any help in conceiving with the help of assisted reproductive technology especially in vitro fertilisation (IVF) at http://www.indiraivf.com or at http://www.indiraivf.com/services2.html#ac

J of IIndian Society of Period ontology 01/2009 13 :1:1.5