Introduction
When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be �mom� and �dad�, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a �full life�.
What is needed for pregnancy?
In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.
In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.
It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.
Thus, to summarise, pregnancy requires
1.Production of healthy (�Normal Morphology�) and movable (�Normal Motility�) sperms in adequate number (�Normal Count�) in the testes
2.Transport of these sperms through the sperm conducting ducts from testes to penis
3.Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
4.Transport of these sperms from vagina through cervix to the uterus and the tubes
5.Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
6.Pick up of the eggs by the tubes
7.Approximation of eggs and the sperms to form the embryo
8.Transport of embryo from the tubes into the uterus
9.Acceptance of the embryo by the uterus and its growth
What is Infertility?
Literally, the word �Infertility� means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called �Absolutely Infertile�. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.
It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word �Regular� and �Frequent� are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.
The word, �Subfertility� seems better and more scientific than �Infertility�, to describe the couples who have reduced chance of conception, due to any cause. However, the word �Infertility�, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.
What causes Infertility?
Please look at the point �Thus, to summarise, pregnancy requires� where 9 points have been mentioned.
Thus the common causes may be
1.Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
2.Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examles include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
3.Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called �Unexplained Infertility�. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out.
Treatment of Infertility
To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it�s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It�s quite natural that you might be in stress.
In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.
Semen Analysis
Semen analysis is an indispensable part of evaluation of an infertile couple. It is accepted that if semen analysis report is normal, male factor is usually said to be normal. However, a single abnormal semen analysis does not always mean that there is any abnormality in the man. This is, because, semen consists of 2 parts- the sperms and the fluid ("seminal plasma"). In a man, sperm production requires 3 months and it needs cool temperature than rest of the body. This is why, men have their testes hanging outside the body in the scrotum.Thus, today's semen analysis reflects a man's health 3 months before. If, for any reason (for example, high fever, tight underwear, hot tub bath etc), man's health was abnormal 3 months ago, the semen analysis may become abnormal. Again, the results can vary from one laboratory to another.
How semen collection and analysis is done?
The easiest and the most commonly used method is masturbation. But remember, you have to do it in awkward environment, where privacy will be maintained, but the mental pressure, that you have to give semen, may be harmful. So, stay relaxed. It's preferable to collect semen in the laboratory. But if its not possible, you can collect it at home, carry it in the pocket of your trousers and must reach the laboratory within 30 minutes of collection. Please inform the laboratory about the timing of collection.
Please maintain abstinence for 3 to 5 days (not more than 5, not less than 5). That means you should avoid intercourse and masturbation for 3-5 days prior to the test. It's important to collect all the semen in the collection pot and not to spill a portion outside.
Then it's tested in the laboratory for certain parameters like- volume (amount of semen), liquefaction (time needed for semen to become liquid), total sperm count, motility (ability of the sperms to move), morphology (the appearance of the sperms), vitality (whether sperms are living or not) etc. Please make sure that your laboratory is following WHO 2010 criteria for semen analysis (not the older criteria like 1992). Sometimes, some special tests may be done on the semen depending on your scenario.
What happens if a man cannot collect semen?
Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor, especially if you are not accustomed to masturbation or had difficulty earlier.. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like vibro-ejaculator, can help to solve this problem. This is a small device applied on the front part of the penis ("Glans Penis") to stimulate the organ to discharge the semen. The other options include rubbing the penis against a special Non-Toxic Condom (Not ordinary condom) or intercourse with that condom. Some men feel comfortable to practise coitus interruptus.
In few men, when no semen comes out, the problem may be retrograde ejaculation (Semen going into bladder instead of moving forward). In that case, sperms can be collected from the urine immediately after masturbation. If it fails, options include some medicines, electroejaculation (Putting current in prostate gland by a small probe inserted through the anus under general anaesthesia), prostatic message and sometimes collecting sperms from testes with a small fine needle.

What happens if the report is abnormal?
If a single report is abnormal, as mentioned above, it may not be conclusive. So, we usually advise repeating the test after few days, preferably from a second laboratory. At the same time, its important to diagnose the cause of this abnormality. To find out the cause, you may need physical examination of your genital organs. Your doctor may ask you some questions and with your permission, may check your body areas (hair growth, breast development), penis, scrotum, testicular size etc. Doctor can advise you some tests like ultrasound of your testes, or sometimes of your prostate gland. I severe cases, doctor can advise you some hormonal tests (blood tests- LH, FSH, Testosterone etc) and in some occasions, karyotyping (chromosomal analysis)
So, whenever we find abnormality, we have to detect the cause. Treatment without detecting thee cause is more likely to fail. So, first thing is- whether sperms are produced or not.
One important thing is to remember, sperm production has nothing to do with manliness. You may feel absolutely normal with normal sex life but sperm production may be defective. So, first thing is not to feel depressed when the report comes abnormal.

What treatment can be done?
Every attempt is made to find out the cause and treat the cause so that you can father your baby using your own sperm by natural means. Treatment includes some life-style advice, some medicines (antioxidants etc). But if the problem is severe, medicines may not act. The only conditions, where medicines act very well, is when the sperms are not produced because of hormonal problems in the pituitary gland.
What lifestyle changes are advised?
Remember, life style changes can improve your sperm count to some extent. You should avoid smoking, alcohol, taking drugs like anabolic steroids etc. You should try avoiding heat exposure to your scrotum. This can be done by avoiding tight underwear, avoiding prolonged sitting, avoiding prolonged driving, avoiding hot bath tub etc. Try keeping laptop and mobile phone away from your lap or thighs.
What is the next action?
If the sperm count improves, then natural conception is possible. In other cases, we may not be able to improve the sperm count, but pregnancy is possible. If the problem is mild, intrauterine insemination (IUI) can be done, with the success rate 20-25% per cycle. This means, every 100 women undergoing IUI, 25 can conceive in the 1st cycle. In other cases, up to 3-4 cycles of IUI can be done. If IUI fails, then the option remains IVF with success rate 40%. Remember, in all these cases, your sperms will be used.
IUI can be successful if sperm count is minimum more than 5 million per ml and there is reasonably good morphology and motility. If not, IVF or ICSI would be the better option. But IUI can serve as trial also. That means before putting the semen, the prepared sperms can be examined and it can be predicted what is the success rate of IUI in this particular case and whether IVF or ICSI would be needed. In rare occasions, where sperm count is extremely low but the couple do not wish for IVF or ICSI, pooled semen IUI can help- where the semen is collected in number of occasions and is preserved and the final pool is used for insemination, to give a reasonable success rate.
What is insemination?
Insemination literally means putting semen in a particular place. Various forms of insemination exist in fertility treatment. First one is �Intravaginal Insemination (IVI)�, where the raw semen, collected by the husband can be put inside the vagina, taking precautions (to prevent infection) by the husband himself or by the wife. Rarely, it needs medical assistance from a doctor. It�s usually advised to couples having sexual disorders where full penetrative intercourse is not possible (erectile dysfunction of the husband or very painful intercourse experienced by the wife) or where ejaculation cannot happen during intercourse (a very unusual problem). Thus, the success rate of IVI is no better than natural intercourse (success rate 15% per cycle), for those couples who can manage successful intercourse.
�Intrauterine Insemination (IUI)� is the treatment where �prepared� semen is put inside the cavity of the uterus, near the Fallopian tubes. Thus, IUI bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs. Thus it increases the success rate compared to natural intercourse or IVI.
However, to achieve pregnancy after IUI, the female partner must have open tubes, adequate number of eggs produced by ovaries, eggs must be released by the ovaries and sperms must meet the eggs. And, thus nature plays important role, as in natural intercourse.
Please note, we used the word �prepared� semen. In natural intercourse, as mentioned earlier, the dead sperms and bacteria cannot enter the uterus, because cervix prevents their entry. If they are put artificially by IUI inside the uterus, severe reaction can happen. So, after collection, the husband�s semen is processed in the laboratory to remove all those impurities and to select only the best number of healthy and movable sperms and it definitely increases success rates of IUI
What can be done if there is no or very few sperms?
In such cases, we have to find out the exact problem. If the problem is due to adequate sperm production but blockage in the sperm conducting duct, some surgery can be done. However, such surgery is not widely available and may fail. So, most of the men usually opt for special type of IVF (In Vitro Fertilization) using the technique called ICSI (Intracytoplasmic sperm injection). Here sperms are collected from semen (is some sperms are there), or urine (in retrograde ejaculation) or by putting needle inside your scrotum (usually under anaesthesia). In case of block, the chance that we can collect your sperm from your body is 80-100%. That means, out of 100 such men, in more than 80 cases, sperms can be obtained from his testes. The procedures include TESA (Testicular Sperm Aspiration), TESE (Testicular Sperm Extraction), MESE (Microsyurgical Epididymal Sperm Extraction) and PESA (Percutaneous Epididymal Sperm Aspiration).
If it appears that the sperms are not produced well, still sometimes some sperms can be seen inside the testis. However, the chance of getting your sperms is 50%. So, if you agree, we can try collecting the sperms from your testes using TESA or TESE. Before that, we need to be sure that there is adequate chance of getting sperms from your body and so, you may need further investigations.
What is ICSI?
ICSI is a type of IVF. In standard IVF, your wife will be given some injections to mature her eggs, which will be collected under anaesthesia through the vagina using ultrasound. These eggs are then mixed with the sperms in the laboratory and the embryos, thus produced, are either directly put inside your wife's uterus or some may be frozen and kept for future use, if the 1st cycle fails.
In ICSI, the best single sperm is chosen and is inserted directly inside the egg to produce the embryo.
When donor sperm is used and how?
If a man does not have any sperms or too few sperms to do IUI, IVF or ICSI is not affordable, donor IUI is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like STD, HIV, Hepatitis B or C. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it�s only given after discussion and written consent by the couple.
How Abnormal Sperm Count is Treated at clinics of Dr Sujoy Dasgupta?
We believe in patient�s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.
We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.
We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.
We advise only those investigations that are needed and then find out the cause, if possible. We give the ouples all the options like medicines, IUI, ICSI, surgery, donor sperms etc and given them adequate time to consider their decision, Once, they decide, we respect their decision and proceed according to their wishes. The privacy and confidentiality are maintained strictly throughout
Conclusion
Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the mean time, they conceive naturally. That means even without treatment, there is some chance of pregnancy. Of course, it�s stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed stress can affect the hormone levels in females and affects sexual performances in males. It�s easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.

An allergy is the hyper immune reaction of a person to many substances which are though safe for others but harmful to an allergic people. Those substances are called allergen or antigen
there are various types allergens or antigens present in the environment such as dust mites, pollens, various foods, many drugs, cold air, strong smells of various substances like perfumes, petrol, paints.
Those antigens or allergens when enters inside body our immune cells recognize them and eliminate them out. Our immune cells like T cells (T lymphocyte) and B cells (B lymphocytes) play the major role to perform this task. In a normal person when those antigen or allergen enter inside the body the immune system eliminate them without reacting anyway, but an allergic person of hypersensitive immune system reacts to those substances vigorously. A person of hypersensitive immune system, the B cells induces the inflammatory tissue reaction called allergic reaction when comes in contact to those antigens or allergens. The B cells of a sensitized immune system when detect any such foreign protein or antigen produce certain substances called IgE antibody. In our body there are some cells called mast cells. Those mast cells contain some granules called histamine and heparin. Around the surface of mast cells numerous receptor are found called FC receptors to which the IgE antibody binds. When any allergen invade the body the B cell identifies the invader and produces the IgE antibodies that flows and attach with the FC receptor of mast cell surface.
The antigen or allergen further binds with those IgE antibodies over mast cell surface. This way of antigen and antibody fixation stimulate the mast cell to releases the histamine content around the tissues. Those histamines when comes in contact to the surrounding tissue binds to the histamine receptors (H1 receptor) present over the tissue surface and starts developing allergic reactions.
The symptoms of sneezing, runny nose, redness and itching of eyes nose are nothing but the outcomes result of histamine and tissue reaction.
So for a long term curative prospect, it is required to rectify the hypersensitivity nature of the immune system of the allergic person so that when he get exposed to the same allergens does not react adversely which he was reacting earlier. Conventional treatment helps to check the allergic symptoms by histamine receptor antagonist or leukotriene receptor antagonist method. Similarly the steroid preparation helps to minimize the inflammation of the respiratory and nasal mucous surface hence reduces the symptoms. It helps to check the allergic reaction in a short term period. Again when the person exposes to the same allergens produce same symptoms and need the same medication to stop the reaction. Therefore it becomes essential to take those medications for regular basis to check allergic reaction. As we have to live in the same environment so it is quite difficult to keep away us from those allergens at all.
Scope of Homeopathy Treatment
Constitutional Homeopathy treatment helps to rectify or modify the sensitive nature of the immune system of an allergic persons so gives a long term cure
If one person�s immune system has become hypersensitive, so under the back ground there must be something that has made it such like. So what are the things that have made the immune system so hypersensitive?
Staying always in a stressful condition for weeks or even months produces cortisol, the body's stress-induced hormone. When cortisol becomes elevated and remains so for awhile, it affects the cells that comprise your immune system. So prolonged stress condition can affect your immune system to become hypersensitive. When anybody is in stressful situation he/she may react differently to the stress. Some people feels hopeless,desperate from the stress. Some people feels frustrated, anger or vexed by the situation. Some people feel to cry out loudly or even cry while sharing their mater. A homeopathy physician searches out the exact reaction what the person express or feel out of a stress and accordingly choose the medicine. This is just a single example of selection of remedy. Similarly there are many factors needed to be considered to choose a suitable remedy for that patient.
There are different types of emotions like sadness, anger, frustration, fear, apprehension. Some people constantly suppress their natural emotions due to some unavoidable circumstance and that suppression directly affect on the immune system. so here a homeopathy physician try to find out what is the exact emotional factor has been suppressed and select accordingly one constitutional remedy which helps to modify his immune system to work normally.
The constitutional homeopathy treatment offers a long term cure to the allergic patient.Besides that there are many remedies which are given to manage the acute symptoms of allergic disease.
At the time of acute crises of allergic problem there are various medicines specifically used for a specific symptoms can be given to manage the acute condition.

MANAEMENT OF ACTIVE PULMONARY TUBERCULOSIS IN GENERAL PRACTICE
DR.S.ABBAS ALI
MD DNB MNAMS
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.
Classification
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.

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
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 www.wellnessdrwilkhoo.com

Dr Vipin Chaurasiya
Public
Oct 31, 7:29 PM
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Psoriasis and ayurveda

Psoriasis is a long lasting autoimmune diseases which is characterised by an abnormally excessive growth of the epidermal layer of the skin. Abnormal production of skin cells and overabundance of skin cells result from the sequence of pathological events in the psoriasis.
Skin cells are replaced every 3 to 5 day's in psoriasis rather than the usual 28 to 30 day's. These changes are believed to stem from the premature maturation of keratinocytes induced by an inflammatory cascade in the dermis,involving macrophages and t cells. These immune cells move from dermis to the epidermis and secret inflammatory chemical signals i.e. interleukins
These inflammatory signals are believed to stimulate keratinocyte to proliferate.
Where ayurveda is work::
the ayurveda treatment is focus to moved out the dosha ( vaat pitta kapha...in this condition these are inflammatory cascade or inflammatory chemical signals) from the body by various panchkarma procedure. After this panchkarma procedures internal medication is used to correct autoimmune response by which disease is completely managed by ayurveda medication
So patient should select ayurveda treatment in psoriasis rather than allopathic treatment.