AFPI Karnataka Newsletter

Vol 8 Issue 1 - 15 Jan 2025

President's Letter

Season's Greetings from AFPI Karnataka Chapter! As we approach the end of the year, I am delighted to share the accomplishments of the AFPI Karnataka chapter over the past quarter. Our new committee has hit the ground running, and we have had a fantastic three months.

Recent Initiatives:

Community Outreach:

As the president of the AFPI Karnataka chapter, I am proud of our accomplishments and grateful for the enthusiasm and dedication of our members. I wish you all a joyous festive season and look forward to a productive, healthy, and happy new year.

Stay Connected: For updates on our activities, conferences, and certification programs, please visit our website or follow us on social media.

Regards,
Dr. Sowmya B Ramesh
President, AFPI Karnataka
drsowvivek@gmail.com

Secretary's Note

Warm greetings to all of you! As we embark on another promising year together, I take this opportunity to thank each one of you for your active participation and support in the various events and initiatives organized by the Academy of Family Physicians, Karnataka Chapter. Your enthusiastic involvement, particularly in large numbers, has been the cornerstone of our success, enabling us to further our mission of advancing the family medicine specialty.

The strength of any organization lies in the collective efforts of its members. I urge all of you to continue this momentum by actively participating in our academic activities, workshops, and conferences. Together, we can elevate the standards of family medicine and make a meaningful impact on healthcare in our community.

I also encourage you to bring your friends and colleagues into our fold, increasing our membership and expanding our reach. A larger, more diverse membership will help us pool ideas, share experiences, and amplify our voice as advocates of family medicine.

As members of this esteemed association, I invite you to take up more responsibilities, contribute your expertise, and play an active role in shaping the future of our profession. Whether it is through leadership roles, mentorship, or volunteering, your contributions can strengthen our association and advance the family medicine specialty.

Additionally, your ideas and feedback are invaluable to us. We welcome your suggestions to improve our initiatives, enhance our events, and strengthen our association further. Please feel free to share your thoughts and recommendations – every voice matters in our collective journey toward growth and excellence.

Let us continue to work together to foster a culture of excellence, learning, and collaboration within our association.

With warm regards,
Dr. Hemavathi D
Hon Gen Secretary, AFPIKA

Editor's Note

A major conference is coming up in the city [WONCA South Asia Region Family Medicine] from 4/4/25 to 6/4/25. It is necessary that all family physicians participate in this conference because it is going to focus on the future of family medicine and all aspects from training to empowerment and how best to lobby and get the government to strengthen the discipline of family medicine and thus improve health care delivery. It will also discuss the ways and means of getting more young doctors to take up this specialty as a career option.

This first issue of the new year carries many features of interest. A leading article on Hyperthyroidism, a critical appraisal of asymptomatic stones, and educative and interesting case stories and updates. I am happy that the new office bearers are taking a lot of interest in the academic and social activities of the association.

B.C Rao
badakere.rao@gmail.com
Chief Editor

AFPI News

AFPI Karnataka’s new executive committee consists of a team of young passionate and wise experienced members.

Events:

Miscellany

What is new

PIPAC

Pressurized intraperitoneal aerosol chemotherapy, or PIPAC, is a new treatment technique that gives chemotherapy in the form of a pressurized aerosol, or spray, directly into the abdominal cavity. PIPAC is safe, and most people handle it well. It has fewer side effects than regular chemotherapy. Complications....

PIPAC is most often used for end-stage peritoneal carcinomatosis. It may be an option if one has stomach cancer; platinum-resistant, recurrent ovarian cancer (a type that comes back 6 months after treatment with platinum-based chemotherapy); or colorectal cancer, and surgery isn’t an option.

Figure 19 PIPAC

It may also help if tumours in stomach, pancreas, liver, or appendix that have spread to the abdomen.

PIPAC is a simple procedure that takes less than an hour. It is known as a minimally invasive surgery as it involves making small cuts. These are used to place a trocar inside your belly. It will help to guide a camera, or laparoscope, and other surgical tools for the procedure.

During PIPAC, the doctor injects the medication into the belly through a nebulizer, a machine that turns liquid medicine into a fine mist. That helps it go more deeply into the body. Once the drug is inside, 30 minutes wait as it goes to work.

Doctors are studying a new, faster system with a shorter wait time of 2-3 minutes. It may be offered in the future.

While it is still new, PIPAC’s results are promising. In a recent study, more than half the people who had PIPAC reported smaller tumours and relief of symptoms.

We need more research to understand what happens with different tumours. Experts should know more about PIPAC after randomized clinical trials and large studies comparing PIPAC’s results with regular chemotherapy for specific tumours.

Benefits of PIPAC

Improved Efficacy: By directly targeting cancer cells in the abdomen, PIPAC has shown potential for better tumor response rates compared to conventional chemotherapy.

Reduced Side Effects: Since the chemotherapy is confined to the abdomen, patients may experience fewer systemic side effects often associated with traditional chemotherapy. PIPAC is a promising treatment option for patients with peritoneal surface cancers. These are aggressive cancers that have spread to the lining of the abdomen and are often resistant to traditional chemotherapy.

Improved Efficacy: By directly targeting cancer cells in the abdomen, PIPAC has shown potential for better tumor response rates compared to conventional chemotherapy.

Reduced Side Effects: Since the chemotherapy is confined to the abdomen, patients may experience fewer systemic side effects often associated with traditional chemotherapy.

Combination Therapy: PIPAC can be used in conjunction with other treatments, such as surgery, to enhance overall treatment outcomes.

While PIPAC shows promise, it is essential to consult with a qualified medical professional to determine if it is a suitable treatment option for individual patients.

The greater omentum

A vibrant and enigmatic immunologic organ involved in injury and infection resolution.

Figure 20 Greater Omentum

Once thought of as an inert fatty tissue present only to provide insulation for the peritoneal cavity, the omentum is currently recognized as a vibrant immunologic organ with a complex structure uniquely suited for defence against pathogens and injury. The omentum is a source of resident inflammatory and stem cells available to participate in the local control of infection, wound healing, and tissue regeneration. It is intimately connected with the systemic vasculature and communicates with the central nervous system and the hypothalamic pituitary adrenal axis. Furthermore, the omentum has the ability to transit the peritoneal cavity and sequester areas of inflammation and injury. It contains functional, immunologic units commonly referred to as “milky spots” that contribute to the organ’s immune response. These milky spots are complex nodules consisting of macrophages and interspersed lymphocytes, which are gateways for the infiltration of inflammatory cells into the peritoneal cavity in response to infection and injury. The omentum contains far greater complexity than is currently conceptualized in clinical practice and investigations directed at unlocking its beneficial potential may reveal new mechanisms underlying its vital functions and the secondary impact of omentectomy for the staging and treatment of a variety of diseases.

In summary, the omentum is an enigmatic immunologic organ uniquely suited for defence against pathogens and injury within the peritoneal cavity. The microscopic functional unit of the organ, the milky spot, is rich in macrophages and lymphocytes organized around a specialized postcapillary venule allowing for the rapid influx of inflammatory mediators into the peritoneal cavity in response to injury and infection. These functional units are widely distributed throughout the adipose-rich regions of the organ and, along with a population of resident stem cells, are largely responsible for the remarkable properties of infection control, wound healing, and tissue regeneration that are widely appreciated and applied clinically. Thus, the omentum is much more than visceral fat and peritoneal insulation. It is a versatile Shock.

Further reading: https://www.ncbi.nlm.nih.gov/books/NBK448192/

Meet the microbiome's 'dance partner': The hidden kingdom of viruses living in your gut

Amber Dance

Figure 21

Human innards are teeming with viruses that infect bacteria. What are they up to?

You have probably heard of the microbiome – the hordes of bacteria and other tiny life forms that live in our guts. Well, it turns out those bacteria have viruses that exist in and around them – with important consequences for both them and us.

Meet the phageome.

There are billions, perhaps even trillions of these viruses, known as bacteriophages ("bacteria eaters" in Greek) or just "phages" to their friends, inside the human digestive system. Phageome science has skyrocketed recently, says Breck Duerkop, a bacteriologist at the University of Colorado Anschutz School of Medicine, and researchers are struggling to come to grips with their enormous diversity. Researchers suspect that if physicians could harness or target the right phages, they might be able to improve human health.

"There will turn out to be good phages as well as bad phages," says Paul Bollyky, an infectious disease physician and researcher at Stanford Medicine. But for now, it is still not clear how many phages occupy the gut – perhaps one for each bacterial cell, or even fewer. There are also bacteria that contain phage genes but are not actively producing viruses – the bacteria are just living their lives with phage DNA tagging along in their genomes.

And there are lots of phages still unidentified. Scientists call these the "dark matter" of the phageome. A big part of current phage research is to identify these viruses and their host bacteria. The Gut Phage Database contains more than 140,000 phages, but that is surely an underestimate. "Their variety is just extraordinary," says Colin Hill, a microbiologist at University College Cork in Ireland.

Scientists find phages by sifting through genetic sequences culled from human faecal samples. That is where researchers found the most common gut phage group, called crAssphage. (Named for the "cross-assembly" technique that plucked their genes out of the genetic mishmash.) In a recent study, Hill and colleagues detailed a light-bulb shape for crAssphages, with a 20-sided body and a stalk to inject DNA into host bacteria.

The gut is an ecosystem, like the woods, and phages are bacteria predators, like wolves are deer predators. The gut needs phages like the woods needs wolves.

It is not clear whether crAssphages make a difference to human health, but given that they infect one of the most common groups of gut bacteria, Bacteroides, Hill would not be surprised if they did. Other common groups, which also infect Bacteroides, include the Gubaphage (gut bacteroidales phage) and the LoVEphage (lots of viral genetic elements).

Phageomes vary widely from person to person. They also change depending on age, sex, diet and lifestyle, as Hill and colleagues described in the 2023 Annual Review of Microbiology.

Though phages infect bacteria and sometimes kill them, the relationship is more complicated than that. "We used to think that phage and bacteria are fighting," says Hill, "but now we know that they're actually dancing; they're partners."

Phages can benefit bacteria by bringing in new genes. When a phage particle is assembling inside an infected bacterium, it can sometimes stuff bacterial genes into its protein shell along with its own genetic material. Later, it squirts those genes into a new host, and those accidentally transferred genes could be helpful, says Duerkop. They might provide resistance to antibiotics or the ability to digest a new substance.

Figure 22

Phages keep bacterial populations fit by constantly nipping at their heels, says Hill. Bacteroides bacteria can display up to a dozen types of sugary coats on their outer surfaces. Different coats have different advantages: to evade the immune system, say, or to occupy a different corner of the digestive system. But when crAssphages are around, Hill says, the Bacteroides must constantly change coats to evade the phages that recognize one coat or another. The result: at any given time, there are Bacteroides with different coat types present, enabling the population as a whole to occupy a variety of niches or handle new challenges.

We each have a unique phageome constantly interacting with our microbiome (Credit: Getty Images)

Phages also keep bacterial populations from getting out of hand. The gut is an ecosystem, like the woods, and phages are bacteria predators, like wolves are deer predators. The gut needs phages like the woods needs wolves. When those predator-prey relationships are altered, disease can result: researchers have observed phageome changes in inflammatory bowel syndrome (IBS), irritable bowel disease and colorectal cancer – the viral ecosystem of someone with IBS is often low in diversity, for example.

People try to re-balance the gut microbiome with diets or, in extreme medical cases, faecal transplants. Tackling phages might provide a more fine-tuned approach, Hill says. As a case in point, scientists are seeking phages that could be used therapeutically to infect the bacteria that cause stomach ulcers.

Perhaps we should be grateful for the trillions of phages managing the gut's ecosystem. Without them, Hill suggests, a few kinds of bacteria might quickly come to dominate – potentially leaving you unable to digest some foods and subject to gas and bloating.

The wild and wondrous phageome is a dance partner for bacteria and humans alike.

Magic Cure

Miscellany

Magic cure

Late Dr. K. S. Hande was a general practitioner like me and like me, has gone through difficult times in the early years of his practice. When patients are few and far between, one has lots of idle time. This time sadly must be spent in the clinic, as one cannot afford to be elsewhere for the fear of losing even that occasional patient.

While my pass time was reading, his was to stand outside his clinic and watch the humanity go by. One day, some 35 years ago, when he was indulging in this favorite pastime, to his surprise he saw one of his patients who had visited him a few days earlier pass by cheerfully waving a greeting.

This patient really had no business to be walking around so cheerfully because when he had visited the doctor, he was a very sick person with X-ray confirmed pneumonia. How then he got so well? Why did he not turn up the next day as advised? Did he go to another doctor and get better? Did I do anything wrong? Was my fee too much that drove this man away from me? These were the worrisome thoughts that Dr. Hande had.

He got the patient to come in and asked him,

Figure 23

‘What had happened, why you did not turn up the next day?’

‘What saar[sir], you gave magic injection that day, next day my fever went, second day my cough went and yesterday I ate well and felt fit and now I am on my way to work. I did not come because your one injection of that magic medicine cured me,’ the patient said. A quick examination revealed complete clearance of his lungs! Dr. Hande had given the patient 400,000 units of procaine penicillin. That was how the drug acted in those days!

One cannot think of such cures now. We have now made a mess of the treatment of infections by indiscriminate use of antibiotics and the germs have developed resistance to most antibiotics and society is paying a heavy price for the physician’s folly! A dreaded time may soon arrive when we see patients dying due to these multidrug resistant infections.

Rashomon Effect

The 40-year-old gentleman was in deep distress. His wife was caressing his left shoulder in a bid to alleviate his pain. Within the last 48 hours, he has met three doctors (specialists to be precise) and underwent an ECG, ECHO, MRIs of shoulder and neck bone, and a battery of blood tests. The wife's hands were overflowing with the prescriptions, bills, and the lab reports. Being an IT professional, he has been suffering from neck pain often. Three days back, the pain started to shift to his left shoulder and arm. Naturally, he googled his symptoms which indicated the possibility of an imminent heart attack. The couple had rushed to a local doctor who performed blood tests and ECG and sent him to a cardiologist.

The cardiologist thought it could still be a myocardial ischemia and performed an echo test and Troponin. It turned out to be normal but to be on the safer side, he prescribed low dose blood thinners, cholesterol medications and advised him to get an orthopedic opinion.

The pain was excruciating and the orthopedician being a specialist in keyhole surgeries suggested that it could be a tear in the shoulder tendons since the patient was a diabetic. He performed an MRI of the shoulder which was equivocal. He gave him some more medications and suggested he meets a neurologist ‘just in case’ it could be a nerve problem. After examination, the neurologist too thought it could be a diabetic or viral neuropathy based on the high diabetes. He advised a few tests and an MRI of the cervical spine. Finally, it turned out to be a slipped disc in the neck bone and he landed in our net.

What we see here is a common healthcare situation of late. Every specialist sees the patient and his symptoms from his specialized narrow perspective. The clinical notes, investigations and management are tailored to the doctor's specialization. This is what I would state as Rashomon Effect.

Rashomon was a famous movie directed by the celebrated Japanese auteur, Akira Kurosawa. In this movie, a murder scene is described by the different witnesses in their own point of view. All their views are different from one another. But they all believed that they are speaking the truth because it is their own correct perspective.

Similarly, every medical specialist has their own approach towards the patient, typically focused on the system in which they have specialized. Upper stomach pain is seen as esophagitis by a gastroenterologist, angina by a cardiologist and costochondritis by the orthopaedician. If we look at their clinical notes and examination findings, it would match their diagnosis since their mind is blinkered. The specialized mind fills the gaps with his previous observations, knowledge about their organ system and myopic training.

With increasing super specialization, the patient is not seen as a whole but an affected organ system. The specialist of the organ system falls prey to the Rashomon effect and explains the patient's symptoms from his perspective. It is difficult to avoid this in the upcoming future since general practitioners are on the wane now. Unless the medical community talks about this, this could reach tremendously dangerous propositions.

[Source not clear as it came as a forwarded message to me]