Updates to RNTCP Guidelines

Recent changes in Tuberculosis 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.

Some more additions to it, adding here which might help to pg students.

1)monitoring health status of Tb treated patients (for recurrence of tb) for 24 months after treatment
2) online monitoring of treatment adherence through 99dots programme (currently it is on pilot basis running for tb-hiv patients)
3) intensified tb case finding in clinically, socially and geographically vulnerable population. It's a provider initiated activity.
4) now 'tb suspect' term is replaced by 'presumptive Tb case'.
5) in diagnostic algorithm sputum examination along with chest x-ray is recommended.
6) 'NSP' term is replaced by 'microbiologically confirmed case'
7) NSN and others r called now onwards 'clinically diagnosed tb' case. (terms replaced)
8) definitions of cured, defaulted, treatment completed, failure, failure to respond, loss to follow up are somwhat changed.
9) cat I, cat II, cat IV terminologies r obsolete n replaced by drug sensitive (new or previously treated) and drug resistant tb categories.

Disclaimer:
I had received this message on WhatsApp. I haven't compiled this.

Acute or chronic?

No matter how much clear today's evidence based medicine gets, one thing will be always hazy.

Acute, subacute and chronic are concepts related to time. Thus they relative to each other.

A bout of vomiting that began 1 minute ago is acute, and so is acute chest pain since 1 hour. But when a young man complains of back ache since yesterday, will it cease to be acute?

A look at the dictionary will tell you "acute" can be used in two different ways :
1.
(of an unpleasant or unwelcome situation or phenomenon) present or experienced to a severe or intense degree.
Example-
"an acute housing shortage"

2.
(of a disease or its symptoms) severe but of short duration.
Example-
"acute appendicitis"

Acute is derived from the Latin word "acus" which means"needle", thus auguring well the above two meanings.

Similarly, the meaning of chronic on Google is

- (of an illness) persisting for a long time or constantly recurring.
Example-
"chronic bronchitis"

Chronic is derived from Greek "Khronos" which means "time", again matching with the meaning.

Subacute is vaguely defined as something that is between acute and chronic.

Point to be noted is that - all these three words are "adjectives" and not "adverbs". Thus they describe the noun ie the patient or the disease and not the "verb" or the action that the disease is causing.

Acute Appendicitis tells you that the patient suffered from SEVERE Appendicitis FOR A SHORT TIME. And not that "it progressed quickly".

Similarly Chronic Bronchitis tells you the patient has Bronchitis that recurred many times over a period of time or is present since a long time. It doesn't mean that "there was an episode of bronchitis 1 year ago".

Many doctors use a simple Funda -
Acute - minutes to hours
Subacute - hours to days
Chronic - days to weeks.

However this "minutes to hours to days to weeks" stands for progression of disease and not "how many hours or weeks ago he had that episode".

I hope this clarifies the long standing confusion on this topic.

# whenever in doubt, refer to the etymology of the words #

Second opinion OPD

The OPD naming has evolved over the years to reflect the need of the patients.

For layman, OPD is the out patient department, where doctor examines the patients and prescribes medicines. Most OPDs don't have special names. Some can be broadly divided into new patient opd, where taking detailed history takes a lot of time and follow up patient opd where usually the patient is well controlled on treatment and keeps following with the doctor just to screen and pick up any new disease early or sometimes for dosage adjustments.

But you can also find other OPDs like usual (read 'rich') OPD and poor patients OPD.

But looking at the knowledge explosion, patients consider themselves as "i-know-all". Thus they don't trust the doctor.
Also, increasing mistrust leads to erosion of doctor- patient relationship.

The breed of Family doctors is soon become extinct and everyone wants to rush to specialists and super specialists. Thus, patients End up consulting more than one doctor.

Also with rising affluence, the average Indian wants the best health care to be provided for which he is ready to loosen his strings.

The day isn't far, when doctors will keep separate time slots for second opinion, for unsatisfied patients coming after talking to another doctor - the future of second opinion OPDs!

Does repeated case presentation help a medical student?

My friend in postings, had presented the same case 4 times to various professors during our medicine postings, because other students hadn't prepared their cases. Did he became better each time presenting the same case?
That, the teacher will decide, but he almost learnt the entire case by heart eventually. Ml

So, if someone has presented lots of cases during the years of MBBS clinical postings, does that student become better at case presentations / better clinician or it just doesn't matter??

I think it's a sigmoid curve with a plateau. Initially you'll become better and better at presentation but eventually it will saturate. Then only the right lobe of brain and the flow of thoughts in a person's mind will be helpful in marginally increasing the presentation skills.

UG vs PG medical student

UG : Undergraduate medical student, ergo is doing his MBBS

PG : completed MBBS and now doing MS or MD

The difference is that, UG sees patients horizontally and PG sees patients both horizontally and vertically.

UG sees ample number of patients but he usually makes contact with a particular patient only once during the patients treatment course.
Thus, he can decipher the clinical signs seen in the present.

When a PG gets to follow up a patient, he knows what was his history. Many a times, you many even get to hear an anecdote about that patient
( woh patient jo file bhul Gaya tha pichale Baar..... Or ... One who had troubled a lot).
The PG knows the course of the disease better by following up with patients. And this also gives him a sense of worthiness that he is actually making a difference in someone's life when he sees patients getting better and go home.

The PG who also has empathy develops a third dimension of connect with the patient and gets totally immersed in the 3D world of health care around himself which is full of heart warming stories of doctor-patient relations.