Advancing in medical science

 INTRAVENOUS IMMUNE GLOBIN (IVIG) ADMINISTRATION IN NEONATES:

Patient population:

Neonates with isoimmune hemolytic disease of the newborn due to Rh or ABO incompatibility. Although data are limited, IVIG may be helpful in other types of Rh hemolytic disease such as anti-C and anti-E. It may be considered for non-isoimmune causes of hemolytic anemia such as G6PD deficiency.

Other indications for IVIG in neonates include immune thrombocytopenia and overwhelming sepsis.

Criteria for Use in Isoimmune Hemolytic Disease:

In Rh or ABO hemolytic disease, if the total serum bilirubin is rising despite intensive phototherapy or the total serum bilirubin level is within 2 to 3 mg/dL (34-51 μmol/L) of the exchange level.

Suggest guidelines from Hammerman 2000

Total Serum Billirubin (TSB) Levels for IVIG Administration in Term Healthy ABO-incompatible Coombs-positive Neonates.

AGE	TSB level despite 4 hours of phototherapy
<12 hours	204 mcmol/L (12 mg/dL)
12-24 hours	272 mcmol/L (16 mg/dL)
25-72 hours	306 mcmol/dL (18/dL)

 Additional Criteria: Hb<130 g/L

Consider administration as early as possible when active hemolytic disease of newborn is diagnosed and exchange transfusion is a possibility.

Intravenous gammaglobulin has been shown to reduce the need for exchange transfusion, repeat exchange transfusions, the duration of hospital stay, and phototherapy in Rh and ABO hemolytic disease. The mechanism of action appears to be related to blockage of Fc receptors in the neonatal reticuloendothelial system.

Contraindications

Neonates with IgA deficiency or hypogammaglobunemia (with IgA antibodies in the patient's serum)-risk of hypersensitivity or anaphylactic reactions .

Dosage and Administration:

Use Gamunex (10% Immune Globulin Intravenous (Human)), a ready-to-use sterile solution of human immune protein for intravenous administration.

Dose of 0.5 g-1.0 g/kg IVIG should be infused over 2 hours. If necessary, the dose can be repeated in 12 hours.

Sample Calculation

Gamunex is supplied in 2.5 g and 5g vials. To minimize wastage, choose the nearest vial size according to the patient's weight to administer within the range of 0.5-1.0 g/kg.

For 3 kg infant:

Dose of IVIG= 3kg x 1.0 g/kg= 3g (round to 2.5 g)

10% Solution has 1.0 g in 10 mL or 2.5 g in 25 mL

Infuse at 1.5 mL/hr (0.5 mL/kg/hr) x 30 minutes 

If tolerated, increase  to 12 mL/hr (4 mL/kg/hr) to infuse total volume approximately 2-2.5 hours.

For Gamunex, the maximum allowed rate of infusion is 8.4 mL/kg/hr

Spring Season Heading Off

 Nepal is, undoubtedly , a naturally country that enjoys pleasant weather round the year. Its geographical diversity has divided the Seasons in Nepal into five weather zones-tropical, temperate zone, cold zone, sub artic zone and the artic zone.

The country enjoys different seasons of spring, summer, monsoons, autumn, and winter. However, the spring and autumn season offer the ideal time to visit the country when it is neither too hot, nor too cold.

Spring season in Nepal:

Spring season in Nepal continues from March till May. It also offers the best time to visit the beautiful country of Nepal. In this particular season, the country attracts large number  of tourists. The months of March-April are considered the second best season for marketing, the best time being October-November.

Summer In Nepal:

The month of June heralds arrival of summers which lasts till August. During the summer months, the average temperature lingers around 28 C. However, the terai and hilly areas experience much higher temperature due to scorching sun.

Monsoon in Nepal:

Nepal receives monsoons from June that continues till September, with 2,500 millimeters of rain every year. After monsoons, starts the dry season from October till November which offers enjoyable weather, as countryside gets lush green after the rains.

Autumn in Nepal:

As the natives get a little relief from scorching summers and heavy rains, then comes autumn which lasts from September to November. This is certainly the best time to visit Nepal, as the surrounds get clear by summer monsoons. During autumn months, the weather remains pleasant, not much affected by cold. 

Winter season in Nepal:

Nepal enjoys winter season during December-February . The temperature reaches almost the freezing point during these months, while hilly regions experience rough weather and heavy snowfall.

Locally, seasons in Nepal is also categorized into 6 divides. Each lasting 2 months.

Gene X-pert system are slowly presenting in developing countries

 

GeneXpert MTB/RIF assay is a rapid diagnosis test of Tuberculosis (TB) and drug resistance. It is revolutionizing TB control with aids in prompt diagnosis and treatment (selection of appropriate TB regimen).

GeneXpert MTB/RIF assay is a nucleic acid amplification (NAA) test which simultaneously detects DNA of Mycobacterium tuberculosis complex (MTBC) and resistance to rifampin (RIF) (i.e. mutation of the rpoB gene) in less than 2 to 6 weeks for MTBC to grow and conventional drug resistance tests can add 3 more weeks.

This system integrates and automates sample processing, nucleic acid amplification, and detection of the target sequences.The primers in the XpertMTB/RIF assay amplify a portion of the rpoB gene containing the 81 base pair"core" region. The probes are able to differentiate between the conserved wild-type sequence and mutations in the core region that are associated with rifampicin resistance.The Centres for Disease and Prevention (CDC) recommends that NAA testing be performed on at least one respiratory specimen from patients who have a moderate or high suspicion of having pulmonary TB.

Background: Due to the emergence of Mycobacterium tuberculosis(M.tb) clinical isolates resistant to most potent first-line drugs (FLD), second-line drugs (SLD) are being prescribed more frequently. We explore the genetic characteristics and molecular mechanisms of M.tb isolates phenotypically resistant to SLD, including pre-extensively drug-resistant (pre-XDR) and extensively drug-resistant (XDR) isolates.

Methods : Drug-resistant (DR) M.tb isolates collected from 2012 to 2017 were tested using sequencing and phenotypic drug susceptibility testing. Genotypes were determined to explore their links with SLD resistance patterns.

Results: Of the 272 DR M.tb isolates, 6 non-multidrug resistant (non-MDR) isolates were fluroquinolones (FQ)-resistant, 3 were XDR and 16 were pre-XDR (14 resistant to FQ and 2 to second-line injectable drugs). The most frequent mutations in FQ-resistant and second-line injectable drugs resistant isolates harbored mutations conferring resistance to pyrazinamide. All XDR isolates belonged  to the Beijing genotype, of which one, named XDR+, was resistant to all drugs tested. One cluster including pre-XDR and XDR isolates was observed.

Conclusion: This is the first description of SLD resistance in Cambodia. The data suggest that the proportion of XDR and pre-XDR isolates remains low but is on the rise compared to previous reports. The characterization of the XDR+ isolate in a patient who refused treatment underlines the risk of transmission in the population. In addition, genotypic results show, as expected, that the Beijing family is the main involved in pre-XDR and XDR isolates and that the spread of the Beijing pre-XDR strain is capable of evolving into XDR strain. This study strongly indicates the need for rapid interventions in terms of diagnostic and treatment to prevent the spread of the pre-XDR and XDR strains and the emergence of more resistant one.

Slum

 Slum : A densely populated usually urban area marked by crowding, run-down housing, poverty, and social disorganization. Although slums, specially in Birgunj , are usually located in urban areas, in other countries they can be located in suburban areas where housing quality is low and living conditions are poor. While slums differ in size and other characteristics, most lack reliable sanitation services, supply of clean water, reliable electricity, law enforcement, and other basic services. Slum residences vary from shanty houses to professionally built dwellings which, because of poor-quality construction and lack of basic maintenance, have deteriorated.

Due to increasing urbanization of the general populace, slums became common in the 18th to late 20th centuries in the Birgunj and other Cities. Slums are still predominantly found in urban regions of developing countries, but are also still found in developing countries, but are also still found in developed economies. The world's largest slum city is found in the Neza-Chalco-Ixtapaluca area, located in the State of Mexico.

Birgunj City is believed to have created the Nepal's well recognized first slum, named Jhopar Basti, as it evolved into a large urban settlement. Jhopar Basti was named for a Poor place .Which, by the late 1982, was surrounded by slaughterhouse and tanneries which emptied their waste directly into its waters. Trash piled up as well and by the early 2000s the lake was filled up and dry. On this foundation was occupied by successive waves of free slaves. It housed the poor, rural people leaving farms for opportunity. Politicians and social elite discussed it with derision. Slums like Jhopar Basti triggered discussions of affordable housing and slum removal. As of the start of the 21st century, Jhopar Basti slum had been transformed into the Little basti and Chinatown neighborhoods of Birgunj, through that city's campaign of massive urban renewal.

Slums sprout and continue for a combination of demographic, social, economic, and political reasons. Common causes include rapid rural-to-urban migration, poor planning, economic stagnation and depression , poverty, high unemployment, informal economy, colonialism and segregation, politics, natural disasters and social conflicts.

Rural-urban migration is one of the causes attributed to the formation and expansion of slums. Since 1950, world population has increased at a far greater rate than the total amount of arable land, even as agriculture contributes a much smaller percentage of the total economy.

Many people move to urban areas primarily because cities promise more jobs, better schools for poor's children, and diverse income opportunities than subsistence farming in rural areas.