NAMAVIJAY 21: DR. SHRINIWAS KASHALIKAR

Practice of NAMASMARAN is actually a training of doing an activity where you may not get any tangible or demonstrable “benefit”!

NAMASMARAN actually transforms us to our original omnipotent, omnipresent and omniscient state, which is totally devoid of any desires! This is because; this is a state from where everything (including the desires) originates! This is an immortal state. But having said this on the basis of the glimpse of this state; actual realization of it may require decades or even more!

When we are told that don’t expect anything; we think that we should not expect money, name, fame, power etc.

So we stop expecting these things and start expecting satisfaction; because we think it is assured by Guru! But this concept of “getting” itself traps us! We mistakenly take the position of a seeker! We think (erroneously) that the “satisfaction” referred to by our Guru, is some kind of gratification or complacence; and keep waiting for it; and are eventually disappointed.

But from time to time; Guru pulls us out of this abyss of disappointment and shows us that the satisfaction or fulfillment is already there; though inaccessibly deep inside! We have simply to go on practicing NAMASMARAN to reach and merge in it!

This empowering nurturing of us; from our innate core; amidst apparently unbearable agonies and terrifying turbulences; is the victory (VIJAY) of our Guru (NAMA)! Hence this is NAMAVIJAY!

NAMAVIJAY23: DR SHRINIWAS KASHALIKAR

The advantage of writing about NAMASMARAN is that we face adoration, admiration, compliments, criticism, opposition and even humiliation.
But in general; we feel disheartened as people do not accept, practice and promote this panacea of global benevolence with the zeal and zest we expected.

This is of great advantage to gradually understand ourselves more realistically; in terms of our own commitment to NAMASMARAN; because as the time passes; we begin to realize four things; with increasing clarity and conviction!

1. We ourselves; are far from being lovingly and buoyantly involved in NAMASMARAN
2. It is really difficult to accept, practice, promote and get involved in NAMASMARAN
3. We as well as the people at large; are sure to appreciate, accept, practice, promote and get involved in NAMASMARAN; at appropriate time
4. This process of cosmic homeostasis as per the divine plan is not our personal victory; but it is the fulfilling victory (VIJAY) of our innate core, NAMA (our Guru)!

FAMILY MEDICINE
DR.S.ABBAS ALI
MBBS, DFM, MD, DNB, MNAMS
PGDHSc(Echocardiogram)
PGDHSc(ultrasonography)
FCGP, MCCP
If we look at the history of medicine during last 100 years, it has moved from organism to organ, from organ to cell and from cell to molecular properties. The vast increase of medical knowledge during the 20th century has contributed to increasing complexity of specialization with in the medical profession. There are at present 20 recognized specialties and many more subspecialties. Some specialties have emerged based on clearly defined skills such as surgery, radiology, and anesthesia, some based on parts of the body such as ENT ophthalmology, cardiology and gynecology and some based on particular age group such as pediatrics, geriatrics and obstetrics. Again in each speciality, there has been a growth of subspecialties as for example, neonatology, perinatology, pediatric cardiology, pediatric neurology, and pediatric surgery – all in pediatrics. A super specialist or sub specialist is one who learns more about less and less. He is concerned with particular organ or part of the body. The specialization and micro specialization contributed the mushrooming growth of large luxurious super speciality hospital. No doubt, specialization raised the standards of medical care but it favors high cost, low coverage, and elite oriented health services.
Despite spectacular advances in medical advances and massive expenditure, the death rates and life expectancy in the developed countries have remained unchanged. So the developed and developing countries needed a specialization which focuses on organism or specialization in general practice which give comprehensive and personalized health care. In 1966 two reports namely Mills commission report, Willard committee reporting United States made similar recommendations. In 1971 the American academy of general practice which began in 1947 changed its name to American academy of Family physicians. The emergence of new speciality family medicine has been hailed as a rediscovery of the human, social and cultural aspects of health and disease.
The American Academy of Family Practice (AAFP) defines family medicine as a “medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.” Family medicine aims to provide initial, continuing and comprehensive care, while centering this process on the patient-physician relationship in the context of the family. These physicians emphasize disease prevention and health promotion, and when referral is indicated, the physician remains the coordinator of patient care.
In Family medicine referral system is not just sending patients to super speciality hospital or sub specialists but they consider it as two way exchange of information by referring to particular sub specialist and follow-up care of those who referred in consultation with sub specialist. It will ensure continuity of care and inspire confidence of the patients. The family doctor serves as a patient advocate in dealings with sub-specialists, third-party payers, employers and others. Ideally, this leads to decreased disintegration of patient care in inpatient settings, higher patient satisfaction, and increased cost-effectiveness.
Family medicine is different from Community medicine. Community medicine specialists deals with populations and try to measure the needs of populations both sick and well and engaged in services to meet those needs. They do not provide comprehensive health services to individuals or Family. Family medicine is horizontal speciality like internal medicine and pediatrics, shares of large areas of content with other clinical disciplines. Family medicine is different from Internal medicine. The specialty of internal medicine is comprised of physicians trained in adult medicine who provide the majority of health care to adults in the hospital or clinic. The internist do not trained in maternity and child care and they do not treat children and neonates. The family medicine specialist trained in adult medicine, paediatrics and neonatology, obs&gyanaecology, surgery including minor orthopedics and community medicine. So A single post graduate in family medicine can meet the requirements of physician, surgeon, paediatrician, obstetrician and gynaecologist and community medicine specialist of PHCs, CHCs and district hospitals. No doubt we need specialists and subspecialists at the level of tertiary health care services but at the same same we need more and more Family Physicians at the level of primary and secondary health care services.

APPROACH TO ABNORMAL LIVER FUNCTION TESTS IN FAMILY PRACTICE


Dr.S.ABBAS ALI
MD, DFM, DNB(FAM.MED)
MNAMS (Family Medicine)
FCGP, MCCP (Cardiology)
PGDHSc(Ultrasonography)
PGDHSc(Echocardiogram)


Abnormal LFTs are common observation in family practice. It can be present in majority of patients with no symptoms and in some patients with minor symptoms like lethargy, pruritis, abdominal pain, low grade fever. An expert family physician with the help of detailed history and physical examination can suspect potentially fatal diseases like cirrhosis, primary biliary cirrhosis, primary sclerosing cholangitis, and liver tumors and by following cardinal principles of family practice like referral, sharing of responsibility and continued follow up may save patients lives with liver problems.
I. TEST FOR HEPATOCELLULAR INJURY
Aminotransferases: Alanine aminotransferase (ALT) and Aspartate Aminotransferase (AST) are released in blood stream after hepatocellular injury. Increased ALT activity reflects hepatic damage more specific.
II. TEST FOR CHOLESTASIS
Serum alkaline phosphatase: this enzyme situated in the canicular and sinusoidal membrane of liver cells. A greatly increased alkaline phosphatase activity is main biochemical indicator of biliary obstruction.
Gamma glutamyl transferase: increased plasma GGT occur in biliary obstruction and acute parenchymal damage from any cause

III. TEST FOR HEPATIC FUNCTION
They help in predicting prognosis
Serum albumin: decreasing levels indicate poor prognosis
Serum Bilirubin: increasing levels indicate poor prognosis
Prothrombin time (PT): increasing levels indicate poor prognosis
IV.CHOLESTASIS PREDOMINANT LIVER INJURY
ALT and AST levels are mildly elevated. Serum alkaline phosphatase and GGT levels are high.
Primary biliary cirrhosis: suspect if middle aged women of 50 years with autoimmune disorder like hypothyroidism, Rheumatoid arthritis etc with complaints of lethargy, pruritis, abdominal pain, low grade fever and increased serum alkaline phosphatase. Antimitochondrial antibody (AMA) positive. These patients should be referred to particular subspeciality for further evolution without delay. The definitive treatment was Liver transplantation. It should be considered as early as possible to minimize morbity and mortality. In PBC interlobular bile ducts are damaged by chronic granulomatous inflammation causing progressive cholestasis, cirrhosis and portal hypertension.
Primary sclerosing cholangitis: PSC is a disorder of unknown cause characterized by non malignant non bacterial inflammation, fibrosis and stricture of the intra and extra hepatic bile ducts.
Suspect if middle aged men with autoimmune disorder especially ulcerative colitis with elevated serum bilirubin and serum alkaline phosphatase with no symptoms or with fluctuating symptoms like lethargy, pruritis, abdominal pain and jaundice. P-ANCA is positive. There is no curative medical therapy and liver transplantation is the only option for survival and it should be considered early to minimize morbidity and mortality.
Secondary biliary cirrhosis:this develops after prolonged large duct biliary obstruction due to gall stones, bile duct strictures and sclerosing cholangitis.
Liver tumors: ultrasound of abdomen and abdominal CT are helpful. Alpha feto protein levels are increased in hepatocellular carcinoma.
Screening tests for chronic liver disease
HBV & HCV serology
Haemogram and iron studies for haemochromatosis: in Haemochromatosis ↑ferritin ↑iron ↓total iron binding capacity
Alpha 1 antitrypsin deficiency
Wilson diseases: serum copper low, serum ceruloplasmin low and urinary copper ↑
PBC: ↑AMA ( anti mitochondrial antibody)
PSC: ↑P-ANCA ↑ANA ↑AMA
AIH: ↑ANA ↑ASMA (anti smooth muscle antibody) ↑IgG
Immunoglobulins: ↑IgA in alcoholic liver disease ↑IgM in PBM and ↑IgG in autoimmune hepatitis (AIH)
Hepatocellular carcinoma: increased alpha fetoprotein
V.HEPATOCELLULAR PREDOMINANT LIVER INJURY
High levels of AST and ALT usually observed. If levels are high evaluate further by advising viral markers.
Acute viral hepatitis: AST and ALT raised. Serum bilirubin may be normal. Viral markers positive.
Chronic viral hepatitis: Hepatitis B & C are most common causes of abnormal LFT
Alcoholic liver disease: AST /ALT ratio is typically 2:1 or more. When the history is not reliable, normal serum alkaline phosphatase, ↑↑GGT and macrocytosis suggest this condition.
Fatty liver: is the most common cause mild abnormality of LFT in general population. Risk factors of nonalcoholic fatty liver include obesity, DM and ↑Lipids (triglycerides)
Autoimmune hepatitis: AIH occurs mainly in young and middle aged females with concomitant autoimmune disorders (eg. Rheumatological disorders, autoimmune thyroiditis)
Ischaemic hepatitis: can be seen in condition when effective circulatory volume is low (eg. MI, Hypotension, haemorrhage) AST, ALT and LDH raised.
Toxic hepatitis: paracetamol overdose is the main cause. History is vital.
Management and follow up
Manage according to specific diagnosis: If patient is asymptomatic and all the initial evaluation are negative then features of opportunistic health promotion and prevention are followed eg. life style modification, give help for reducing weight, alcohol, smoking, control DM, control hyperlipidaemia, and stop potentially hepatotoxic medication. Repeat test after 3 months, if abnormalities persists do an Ultrasound, abdominal CT has role. If the diagnosis is not apparent or the suspected diagnosis is beyond the reach of family practice then further testing is needed. In this cases cardinal principles of family practice like timely referral, sharing of responsibility, continued follow up are followed. This type of attitude may save patients lives with liver problems.

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