{Recent changes in ADA guidelines 2017}
1. Emphasis on role of psychosocial care in Diabetes management.
2.Staging of Type 1 diabetes mellitus
Grade 1 - Presymptomatic with Normoglycemia
Grade 2 - Presymptomatic with dysglycemia
Grade 3 - Symptomatic with new onset hyperglycemia
3. New validated screening tool has been added. Its a 7 questions set based on age, sex, weight, family history, gestational dm and h/o hypertension. Score more than 5 signifies increased risk of diabetes.
4. Delivery baby more than 9lb is no longer an independent risk for diabetes.
5. Recommendation to test GDM patient postpartum for persistent diabetes has been changed from 6-12 weeks to 4-12 weeks.
6.In view of emerging evidence on sleep duration and quality on glycemic control, assessment of sleep duration and pattern has been included in comprehensive medical evaluation.
7. Diabetes comorbidities list has been updated with inclusion of autoimmune diseases, HIV, anxiety disorders, depression, disorderedeatingbehavior, andseriousmental illness.
8. In nutrition apart from carbohydrates counting protein and fat counting has been added.
9. Need to interrupt prolonged sitting of more than 30 minutes with physical activity.
10. Long term networking leads to B12 deficiency, requires monitoring and supplementation.
11.Bariatic surgery now referred to as metabolic surgery reinforcing it's role in T2DM management.
BMI cut off has been updated.
12. Pharmacological approach to glycemic control updated:
Empaglifozin and liraglutide recommended reduces CVS mortality in established cardiovascular disease.
Non inferiority of basal plus glp1 agonist versus basal plus 2 rapid acting versus 2 premixed insulin
13. Any of 4 antihypertensives (ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers) may be used in patients without albuminuria.
14. Beneficial effect of specialised therapeutic footwear for patients with high risk of foot problems.
15. there are concern regarding concentration of metformin on the fetal side of the placenta and glyburide levels in cord blood. Insulin remains treatment of choice.
16. In pregnancy target HbA1c is 6-6.5% but optimal is less than 6%.
Targets for T1DM,T2DM,GDM
Fasting - less than or equal to 95 mg/dL
1hr PP - less than or equal to 140mg/dl
2hr PP - less than or equal to 120mg/dl
17. In hospital setting, sole use of sliding scale should be discouraged. Basal insulin or Basal plus bolus should be given, Target 140-180mg/dl.
18.Classification of hypoglycemia
Level 3 - Severe hypoglycemia - severe cognitive impairment requiring external assistance for recovery
Level 2 - clinically significant hypoglycemia is now defined as glucose ,<=54 mg/dL (3.0 mmol/L)
Level 1- glucose alert value is defined as less than or equal <=70mg/dL(3.9mmol/L)

Public health system developed over past few years in state of Rio de Janeiro, Brazil  is definitely one of the better models of primary health care available anywhere. It was indeed a great opportunity to visit family health clinic in urban area and also in slums which is being known as favelas in Rio.

                   

The first thing which you will notice is their commitment towards providing a hygienic environment, well cleaned clinic without much noise and chaos even in the health centre locate in favelas which is the most congested and densely populated area of Rio de Janeiro.







 These health clinics have HIS which stores all the data of patient electronically. 
These clinics are equipped with X ray machine, USG and laboratory which collects all the samples and sends it to a central laboratory.



At the entry you will find a health worker with “may I help” sign. Their duty is to guide everyone towards appropriate place of their need.
As some people only come to collect report, others for investigations, dressing, vaccination or for taking drugs. For these purposes they don't need consultation with doctors and are being managed efficiently at entrance itself. It reduces time and crowd in the clinic.
Next you will find a big map which is google map snapshot of the catchment area of that clinic. This is equally divided based on total number of families in 7-12 groups. Each group is being taken care by team which consists of 1 doctor mostly family physician, 1 nurse, 1 technical nurse, and 5 community health workers. Out of 5 community workers 3 goes out to community and remaining 2 works in clinic daily and they rotate among themselves. Each community Worker has been assigned families out of their area for which they are responsible. Doctor has to spent 40 hrs per week in the clinic and out of this 4 hrs in the community. During the visit, doctor has to see those patients who couldn't come to hospital for various reasons.

Public health care is completely free. All the investigations, drugs, consultation are free. Every 2-3months dental kit with tooth brush and paste are provided free of cost.


For every 2 team 1 dentist is there to look after oral hygiene.
Consultation with specialists from ENT, Ophthalmology, Paediatrics etc are also provided only on reference of their family physicians. These specialist visit these hospital on a weekly schedule.
Each patient has got their health book where all the consultation made are written. They have also got a health app in their mobile to schedule their consultation etc. Whenever they visit the clinic they have to go to their respective team registration area from where they will be given necessary directions.
Each team has got their own team office and consultation area. In the team office you will find data of individuals assigned to each community worker. On an average each team has to look after 2000 individuals. On a big chart You will find picture of Doctor, nurses and technical nurses and below there are 6 groups with picture of respective community worker. In each group there is space for 296 families. By the side of each Family there are 6 Colour coded boxes which is To be filled by community worker. Important data which is to be entered according to colour code in the boxes are age less than 1 year, age 1-5 year, tuberculosis, pregnancy, HTN/DM, HA.


These all details are also available electronically through their HIS. Same goes for vaccination they track all the children in their area electronically and monitor them for vaccination.

 This not only eliminates any form of error but makes healthcare more accessible to the population. Community participation is also there as they are receiving good quality service at affordable price. Affordable because they have to only pay taxes to the govt and in turn get free healthcare.
There are so many things we can learn from their health system, First is the politival commitment of health secretary of Rio towards building a strong public health system which is entirely based on principles of primary health care that are affordable, available, accessible and appropriate. Hygiene and cleanliness can never be achieved only by good administration but also requires community participation and commitment towards keeping it clean.
I would also like to mention few things which are different there like abortion which is illegal, although they promote contraception and condoms are available for free from their health centres. Have a look at this graffiti (anyway in Rio u will find lots and lots of graffiti all around). "FAÇA SEXO SEGURO USE CAMISINHA" which means make safe sex use condoms.
There are many cases reported of early pregnancy in age group of 11-15 years. Only in cases of anencephaly or intrauterine death abortion is recommended.
So would like to thank the health secretary and his team for explaining us everything.

 Let me clear conflict of interest first. I am Dr. Pratyush and have done my DNB family medicine from Sir Ganga Ram Hospital, New Delhi. I took family medicine at my DNB CET  rank 1725, where during councelling i had options of other clinical specialities like medicine, peds etc at periphery centres. Since i have thought of doing my own “start up” ..to setup my own clinic near to our village, Family medicine was the best option for me.
Every one of us (postgraduate aspirant) may not have decided their plan post their pg courses. Some decide based on their rank, some are clear about their choice and they wait till they get their dream branch. But most of them finally end up doing postgraduate courses and with time everything settles. Life moves on.
Family medicine is not a new branch, in fact its into existence for past so many years. Family medicine is that speciality which finds its place most of govt health reforms plan. But beyond that there is still need of more political committment.
Family medicine is a broad speciality which is designed for specific purpose and that is primary care. Need for primary health care is huge in country like India with over a billion population. Family medicine deals with all age groups and all body systems, its a concept of generalism. There is huge potential for this specialty in terms of job, affordable and quality health care. Only thing we need is more structures health care with defined role of family physicians.
Training in family medicine covers various specialty like internal medicine –  9 months, obs – 3 months, peds 3 months, surgery 3 months, ICU and emergency medicine – 3 month, ent,ophthal, psychiatry, dermatology postings. It also include posting in primary health care. Duration of these postings is not uniform across all institutes. But over all, major posting is medicine then peds, surgery and obs gynae.
Rest all other rules are similar, you have to submit a thesis for which your guide and co -  guides can be from any speciality belased on your thesis topic. At the end you have to give exam which consists of 4 papers. Paper 4 is mcq based only from community medicine. Rest all subjects are asked in other 3 papers. Theory exam is not that tough as it seems because you are expected only the basics.
In practical exam you get 2 cases of medicine, 2 cases of peds and 1 case of surgery or obs/gynae. There will be a separate medicine viva, peds viva and community medicine viva.
Frequently asked questions.
1. I want to do only medicine posting/surgery posting during my tenure as i am intrested only in surgery/medicine.

No, its not possible.

2. Can i extend my posting in few specialities of my choice?

Look, generally u have to follow the set pattern which your institute have made it for its DNB trainees and is also based on NBE guidelines.

3. Can i do superspeciality/subspeciality courses in neurology, cardiology, gastroenterology?

No, if you are interested, u should only take general medicine not family medicine.

4. Any other courses available after family medicine?

Yes, u can do geriatrics, palliative care and various other skill based courses.

5. Are family residents being treated equally in departments being posted?

Mostly yes, you will be treated at par with other residents of department and will be given opportunities in various academic programs of that department. But it also depends on your sincerity and dedication.

6. Is it similar to community medicine?

No, Both are different and their curriculum is different. Family medicine is a clinical speciality where you are going to practice as family physician.

7. Is it a approved/recognised course?

There should be no confusion regarding it. Its approved by MCI and after completing your training you can update it in your MCI and state medical council registration.

8. Is their any postgraduation MD family medicine courses?

Yes, it has been started. New AIIMS which have been set up have also got Department of community and family medicine.

9. What about research opportunities ?

There are lots of research opportunities in this field. We have many journals like journal of family medicine and primary care, rural and remote health etc. If you are interested in research, family medicine and primary care will never disappoint you.

10. What about family medicine conferences?

There are many conferences which takes place at national and international level. WONCA which stands for world organisation of family doctors conducts various confernces on various themes in association with regional groups. Details you can check it on website wonca.net .
In India we have Academy of family physicians of India which supports and promotes family medicine. AFPI has got a journal jfmpc.com . AFPI has got various state chapter which conducts regular CMEs and orientation programs. AFPI conducts national level family medicine and primary care conference. Next conference is at Kochi from 26 jan 2017. There are various bursaries and awards to support you for your travel in many international conferences.

Every resident joining any postgraduate course must have faced it. This is probably the first hurdle you will find after joining any postgraduate course.Mostly in hospital its all on you to find a thesis topic and prepare protocol.
Through this post i wanted to simplify the things and clear common errors and give you some basic ideas how to find a best topic for your thesis.
1. Finding a suitable topic for your thesis protocol
A. Choose a topic based on your interest eg, Diabetes, Hypertension, Infectious Disease, Critical care,depression etc.
B. There should not be any scarcity of cases in your hospital as your thesis is a time bound study.
C. Your thesis methodology should not have very costly investigations which is not standard of care for the disease. As you will find it difficult to get it approved from ethics committee.
D. Your thesis topic should be new and unique. Unique in the sense that there is something  new which have not been done before. In reality its very difficult to find a really unique topic, then you can search for topic which have been done else where, which has got different population characteristics but not in your region.

2 Thesis topics ideas.

You can search on pubmed.com or google scholar or www.cochranelibrary.com to read various published research papers . You can look for thesis topic through these search engines.

Diabetes
1. Assessment of neuropathy through various scale (eg mnsi) and correlation with glyceamic control
2. Assessment of retinopathy and its correlation
3 Assessment of nephropathy
4. Assessment of microvascular complications and correlation with glyceamic control
5 Assessment of depression among t2dm using various depression scale
6. Assessment of well being among t2dm using who 5 point well being score and correlation with glyceamic control
7. Assessment of sexual health among t2dm and its correlation with duration and glyceamic control
8. Assessment of drug compliance among patients of t2dm
9. Knowledge attitude and practice about dietary modifications in t2dm
10. Correlation of vit d
11.correlation of serum magnesium
12. Correlation of serum zinc, chromium
And prevalence of microvascular complications
13. Correlation of above glyceamic control
14. Study on Metformin and B12 level
15. Study on peripheral macrovascular disease and glyceamic control using Doppler
16. Prevalence of osa among diabetic using scales for OSA and its correlation with glyceamic control
Similar studies can be done using various scale for depression, anxiety, drug compliance and well being.

Infectious disease
1. Drug compliance study, psychiatric scales on tuberculosis.
2. Knowledge attitude and practice study among health care providers and general public about
A. Tuberculosis
B. Hiv
C. Dengue
D. Chikungunya
E. Hepatitis b
3. Drug resistance pattern and radiological pattern in tb
4. Clinico laboratory profile of
A. Scrub typhus
B. Leptospirosis
C. Tiberculosis
D. Dengue
E. Chikungunya
F. H1N1
5.Radiological pattern and its correlation with severity and outcome among pulmonary kochs
6. Study using various psychiatric scales in tubercuslos to look for depression anxiety etc
7. study on Discrimnation and stigma among people living with hiv aids
8. Clinical profile, cd4 count and other lab parameters in hiv
9. Osteoporosis in hiv compared to general population using BMD.
10. Study on prevalence of tb and hiv
11. Drug resistance pattern, treatment outcome, in tb/hiv
12. Study on newer modalities like line probe assay cb naat gen probe and comparison with conventional tests like sputum for AFB and chest xray

Critical care
1. KAP study on palliative care
2. Study on hospital acquired infection, drug resistance pattern among icu patients.
3.Prevalence of Icu psychosis
4. Prevalence of critical care neuropathy and its correlation with severity and duration
5. Prevalence of dyselectrolytemia and its correlation with infection and mortality
6. Study using sofa score, apache score and other scores and its correlation with lab parameters and duration of hospital stay
Methodology.
You need to calculate sample size which is usually based on previous studies. Try to keep a achievable sample size.
Observational studies are easier to do.

References.
Its the most important thing. Keep all the references in Vancouver style. You can use this website citethisforme.com

This is most common cause of rejection of your thesis protocol.
You must define everything including various scale and values used, its reference range etc in protocol. Inclusion and exclusion criteria should be clearly defined.

Thesis protocol
Please follow guidelines as per national board examination strictly. Dont change the heading by yourself. Keep it as given in the guideline In the same order  otherwise its going to be rejected.

http://www.natboard.edu.in/pdoof/thesis/NBE%20Guideline%20for%20thesis%20protocol-2013%20_NEW_.pdf

Common mistakes
1. References not in correct order as cited in protocol and numbered in reference column.
2. Reference dont match with the topic.
3. Citing old references
4. Avoid writing “incidence” in observation studies as its a prevalence study
5. Headings should be according to NBE guidelines and in the same order.

P.S. If your research topic is good it will be easier to get your work published later. So choose it wisely.

We celebrate today birth anniversary of Mahatma Gandhi who spread the message of truth,peace, self restraint and non violence; Lal bahadur shastri who epitomized simplicity and honesty.

Mahatma Gandhi wrote a book "KEY TO HEALTH" during his confinement in Aga khan palace in pune during 1942-1944.
Lets read this book today on his birth anniversary and understand the philosophy of health.
He made beautiful remarks on ill effects of alcohol, tobacco, opium and other intoxicants. He also defined health in this book and wrote about several determinants of health like air, water, food, condiments and 'brahmcharya' (self restraint).
He considered human body as a miniature universe within and stresses on understanding of our inner human machinery.
In the 2nd part of this book he dealt with natural therapeutics using earth, water, akash, air and sunlight. Most of these like sitz bath, phototherapy, breathing exercises are still being practiced.
He also made it a point to the readers our limitation which despite so much of progress and research is still not enough to understand our human body and brain.

So lets pray for peace, good health and love for everyone.

PDF file link - http://www.gandhiashramsevagram.org/pdf-books/key-to-health.pdf

Based on RNTCP guidelines 2016.

1. 3 new goals – cure, prevent resistance and break chain of transmission.
2. Introduction of daily regime
3. Definition and treatment of mono and polyresistance apart from MDR and XDR Tuberculosis
4. Treatment in CAT 1 – 2(HRZE) + 4 (HRE) : Continue ethambutol in continuation phase too 
5. Treatment in CAT 2 – 2(HRZES) + 1(HRZE) + 5 (HRE)
6. Introduction of Bedaquiline as a new drug. ATP synthase inhibitor specifically targets myc. Tb. Indicated in age more than 18 years. Contraindicatef in pregnancy and those taking hormonal OCP. It may be given in patients with stable arrythmia.
7. Definition of presumptive tuberculosis. Duration > 2 weeks etc
8. New algorithm to diagnose Tuberculosis – pulmonary, extrapulmonary, drug resistant.
9. Introduction of Newer molecular methods like CBNAAT and line probe assay in diagnostic algorithm apart from smear microscopy and chest Xray.
10. Diagnosis of tuberculosis based on X-ray will be called as Clinically diagnosed tuberculosis
11. Sputum should be around 2ml and preferably be mucopurulent.
12. Follow up – New and previously treated Drug sensitive pulmonary tuberculosis – No need to extend Intensive phase, sputum microscopy at end of IP and end of treatment, weight monthly, chest x-ray if required.
13. Follow up – MDR tuberculosis – sputum smear monthly 3,4,5,6,7 months in intensive phase and at 3 months interval in continuation phase 9,12,15..., extend ip phase by maximum 3 months total of 9 months.

Download WHO - HIV guidelines- 2016

Treatment guidelines can be downloaded from the links given below.
Chapter 1
Chapter 2

It’s a viral infection caused by flavivirus and transmitted by aedes mosquito.

Aedes mosquito usually bites during day time and breeds in stagnant water. Since dengue virus has four antigens so there is risk of getting dengue again for maximum 4 times.

Usually it’s a self limiting illness but it may progress to Dengue hemorrhagic fever and Dengue shock syndrome.

Thrombocytopenia is usually seen on 3-4 day of fever and decreasing trend till 6th day and again increases from 7th day.

If there is pain abdomen, breathlessness, bleeding, hypotension or low blood pressure, hospitalization is recommended.

Rule of 20 for Doctors - Rise in hematocrit (pcv) more than 20% and fall by 20% after fluid replenishment, 20 petechiae in tourniquet test, pulse pressure less than 20mm of hg

Treatment remains supportive... paracetamol for fever and plenty of fluids. For inpatients if platelet is less than 10000 platelet transfusion is done. Avoid drugs which may cause thrombocytopenia...

Ramadan, a holy month of Islam varies between 29 and 30 days. Muslims who fast abstain from eating drinking smoking and use of oral medications.
Patients of diabetes mellitus who fast are at greater risk of complications which are hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), Diabetic ketoacidosis, dehydration and thrombosis.
Medical recommendation most often for the patients is to not undertake fasting. But if they insist on fasting they must make such decision in consultation with their doctors understanding risks associated with it.
Management is individual centric.
General considerations
1. There should be frequent monitoring of blood glucose level.
2. Nutrition should be adequate enough to maintain a constant body mass. Avoid taking heavy sunset meals rich in carbohydrate and fats. Take plenty of fluids during non fasting hours and food containing complex carbohydrates at the predawn meal is advised.
3. Normal level of exercise. Avoid excessive exercise as it may cause hypoglycemia.
4. Breaking the fast. If blood sugar is less than 60mg/dl anytime or less than 70mg/dl within few hours of fast, or if blood sugar is in excess of 300mg/dl.



Management of Type 2 Diabetes mellitus


1. Patients controlled with lifestyle modification alone may distribute calories over 2 to 3 smaller meals to avoid hyperglycemia.
2. Patients on oral drugs- insulin sensitizers like metformin are preferred.
Those treated with metformin can safely fast. Dose needs to be modified - 2/3 of total dose should be given with sunset meal and 1/3 before predawn meal.
Pioglitazones are not independently associated with hypoglycemia but they can’t be substituted for any other OHA as it takes 2-4 weeks to exert its effects.
Sulfonylureas like glimepride, glyburide, glipizide are not recommended in view of hypoglycemia risk.
Glinides may be taken twice daily as it is short acting.
DPP 4 inhibitors (gliptins) are best tolerated drugs and can be taken. Alpha glucosidase inhibitors like acarbose miglitol and voglibose can be taken.



Patients treated with insulins :


One long or intermediate acting insulin injection along with short acting insulin before meal can be used. Use of 50:50 premixed insulin in evening and 30:70 insulin at early morning was also found useful.
Insulin pump is better option.



References :- ADA guidelines