Newborn Clinical Pathway: Fill & Download for Free

Short answer, exact mechanism for G6PD (glucose-6-phosphate dehydrogenase) deficiency predisposing to neonatal jaundice is as yet unclear. Exploring features of G6PD deficiency, neonatal jaundice and G6PD deficiency-associated neonatal jaundice reveal a likely but as-yet scientifically unproven hypothesis.G6PD deficiencyThe G6PD gene is on the X chromosome.So males can be G6PD normal/deficient and females G6PD normal/intermediate (heterozygous)/deficient (homozygous).G6PD is the most common human enzyme deficiency (enzymopathy), present in ~400 million people worldwide (1).Ethnic background plays a role with higher propensity in black, Asian and Mediterranean babies (2).Every year ~4,500,000 births worldwide with G6PD deficiency (3).Most people with this deficiency remain asymptomatic (illness-free) throughout life (4).So far, ~ 140 mutations of G6PD have been identified. Mostly point mutations, i.e., one amino acid difference from the normal/wild-type form of the protein. Physiological outcome?Different mutations variably decrease this enzyme's stability (5).Mutations can affect either how the enzyme catalyses its reaction or its affinity for its substrate.G6PD deficiency is an enzyme defect with important consequences for red blood cell (RBC, erythrocyte) metabolism.According to Klowak and Wong (6), red blood cell (RBC, erythrocyte) diseases are of 3 types:Hemoglobin: sickle cell disease, thalassemiaMembrane-cytoskeleton: hereditary spherocytosisMetabolism: G6PD deficiency, i.e., glucose-6-phosphate dehydrogenase deficiencyNeonatal jaundiceNeonatal jaundice is also known as neonatal hyperbilurbinemia .In other words, accumulation of unconjugated bilirubin in the blood.Neonatal jaundice is clinically evident by 1 to 4 days after birth.Certain key differences in basic physiology can predispose newborns to jaundice (physiologic jaundice).For one (4), in adults, colonic bacteria rapidly reduce conjugated bilirubin to urobilinogens so little of it reverts back to the liver through the gut-hepatic (enterohepatic) circulation .OTOH, in newborns, most of the conjugated bilirubin is converted back to unconjugated bilirubin by the intestinal mucosal enzyme, beta glucuronidase.Unconjugated bilirubin is reabsorbed into the blood by enterohepatic circulation.This increases the bilirubin load that needs to be cleared by the newborn's liver.For another (4, 7), newborn per se is already prone to hyperbilirubinemia (physiologic jaundice) because its liver now has to newly take on the task of clearing bilirubin that was being cleared by the placenta in utero.Third, newborns' bilirubin production is 2 to 3 times higher compared to adults.Newborns have more blood cells and fetal RBC lifespan is shorter (~85 days compared to 120 days).Increased newborn RBC turnover means more bilirubin production.Fourth, newborn clearance of bilirubin is much less efficient.Much lower newborn levels of the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT1A1), a key bilirubin metabolism enzyme.A 7-day old infant's liver has ~1% adult liver UGT activity and reaches adult levels only by ~14 weeks of age (8).Features of G6PD deficiency-associated neonatal jaundice~1/3rd of male newborns with neonatal jaundice have G6PD deficiency while rate is lower in female newborns (9, 10).Among G6PD deficient, it's also more frequent and severe in premature compared to normal births (11).G6PD-associated neonatal jaundice is rarely present at birth and peaks at days 2 to 3 post-birth (12).Why G6PD deficiency could predispose to neonatal jaundiceThough exact mechanism is as-yet undeciphered, a number of triggers have been identified:1. Medical literature suggests maternal/caregiving factors could increase a G6PD deficient baby's chance of getting neonatal jaundice (1).The mother taking certain drugs (13).Using naphthalene-camphor balls to store baby's clothes (14).2. G6PD deficiency-associated neonatal jaundice differs in key aspects from physiologic jaundice (1, 3, 7, 15).Increased hemolysis, i.e., breakdown of RBCs or anemia, isn't the most common observation in G6PD deficiency-associated neonatal jaundice.Rather than anemia, bilirubin clearance is the most common problem in G6PD deficiency-associated neonatal jaundice.This implicates the bilirubin pathway in G6PD deficiency-associated neonatal jaundice (3, 4, 7).Prevailing hypothesis is that bilirubin conjugates less efficiently with serum albumin.In turn, impaired blilrubin-albumin conjugation leads to impaired bilirubin clearance by liver.No direct scientific evidence yet that certain G6PD deficiencies have less efficient bilirubin-serum albumin conjugation (binding).BibliographyCappellini, Maria Domenica, and G. Fiorelli. "Glucose-6-phosphate dehydrogenase deficiency." The lancet 371.9606 (2008): 64-74. Page on david-bender.co.ukRatnavel, Nandiran, and N. Kevin Ives. "Investigation of prolonged neonatal jaundice." Current Paediatrics 15.2 (2005): 85-91.Maisels, M. Jeffrey. "Neonatal jaundice." Pediatrics in Review 27.12 (2006): 443. Page on yimg.comFrank, Jennifer E. "Diagnosis and management of G6PD deficiency." American family physician 72.7 (2005): 1277-1282.Gómez-Manzo, Saúl, et al. "The Stability of G6PD Is Affected by Mutations with Different Clinical Phenotypes." International journal of molecular sciences 15.11 (2014): 21179-21201. The Stability of G6PD Is Affected by Mutations with Different Clinical PhenotypesGlucose-6-phosphate dehydrogenase deficiencyMason, Philip J., José M. Bautista, and Florinda Gilsanz. "G6PD deficiency: the genotype-phenotype association." Blood reviews 21.5 (2007): 267-283. Page on researchgate.netKawade, Noboru, and S. Onishi. "The prenatal and postnatal development of UDP-glucuronyltransferase activity towards bilirubin and the effect of premature birth on this activity in the human liver." Biochem. J 196 (1981): 257-260. Page on nih.govMatthay, K. K., and W. C. Mentzer. "Erythrocyte enzymopathies in the newborn." Clinics in haematology 10.1 (1981): 31-55.Kaplan, Michael, et al. "Acute hemolysis and severe neonatal hyperbilirubinemia in glucose-6-phosphate dehydrogenase–deficient heterozygotes." The Journal of pediatrics 139.1 (2001): 137-140.Lopez, Rafael, and Jack M. Cooperman. "Glucose-6-phosphate dehydrogenase deficiency and hyperbilirubinemia in the newborn." American Journal of Diseases of Children 122.1 (1971): 66-70.Kaplan, Michael, and Cathy Hammerman. "Glucose-6-phosphate dehydrogenase deficiency: a hidden risk for kernicterus." Seminars in perinatology. Vol. 28. No. 5. WB Saunders, 2004.Perkins, Richard P. "Hydrops fetalis and stillbirth in a male glucose-6-phosphate dehydrogenase-deficient fetus possibly due to maternal ingestion of sulfisoxazole; a case report." American journal of obstetrics and gynecology 111.3 (1971): 379.Valaes, Timos, Spyros A. Doxiadis, and Phaedon Fessas. "Acute hemolysis due to naphthalene inhalation." The Journal of pediatrics 63.5 (1963): 904-915.Kaplan, Michael, et al. "Conjugated bilirubin in neonates with glucose-6-phosphate dehydrogenase deficiency." The Journal of pediatrics 128.5 (1996): 695-697.Thanks for the A2A, Anonymous.

How Do You Get Infected With HIV?The Human Immunodeficiency Virus (HIV) is not spread easily. You can only get HIV if you get infected blood or sexual fluids into your system. You can't get it from mosquito bites, coughing or sneezing, sharing household items, or swimming in the same pool as someone with HIV.Some people talk about "shared body fluids" being risky for HIV, but no documented cases of HIV have been caused by sweat, saliva or tears. However, even small amounts of blood in your mouth might transmit HIV during kissing or oral sex. Blood can come from flossing your teeth, or from sores caused by gum disease, or by eating very hot or sharp, pointed food.To infect someone, the virus has to get past the body's defenses. These include skin and saliva. If your skin is not broken or cut, it protects you against infection from blood or sexual fluids. Saliva can help kill HIV in your mouth.If HIV-infected blood or sexual fluid gets inside your body, you can get infected. This can happen through an open sore or wound, during sexual activity, or if you share equipment to inject drugs.HIV can also be spread from a mother to her child during pregnancy or delivery. This is called "vertical transmission." A baby can also be infected by drinking an infected woman's breast milk. Fact Sheet 611 has more information on pregnancy.Blood and any body fluid visibly contaminated with blood should be considered capable of transmitting hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Semen and vaginal secretions should also be considered potentially able to transmit these viruses. Similarly, cerebrospinal fluid, amniotic fluid, pleural fluid, synovial fluid, and peritoneal and pericardial fluids carry a significant risk of transmitting these viruses.In contrast, unless blood is visibly present, saliva, sputum, sweat, tears, feces, nasal secretions, urine, and vomitus carry a very low risk of transmission of HCV and HIV. It should be noted that saliva can also carry HBV.Occupational transmission of blood-borne infections may also occur through parenteral, mucous membrane, and non-intact skin exposure. The greatest risk for transdermal transmission is via a skin penetration injury that is fairly deep and sustained with a sharp hollow-bore needle that has visible blood on it that had recently been removed from a blood vessel of a patient with a high viral load.Although many infectious agents may be transmitted by such contact, the most consequential include HBV, HCV, and HIV. (See Pathophysiology and Prognosis.)In addition, skin and soft-tissue infection at the site of the inoculation, through introduction of staphylococcal species, is an issue of concern and must not be neglected. Tetanus prophylaxis is also an important issue of concern. Another important issue is the fact that many medical institutions adopt clinical pathways, algorithms, and plans for management of their own health care personnel but are woefully lacking when faced with the outside individual at significant risk for these diseases from needlesticks, mucous membrane splashes, or sexual encounters. (See Treatment and Medication.)Health care personnel include employees, volunteers, attending clinicians, students, contractors, and any public safety workers whose activities involve contact with patients and their environment such that exposure to blood or other body fluids can occur. Nurses, trainees, and students are at especially high risk for significant morbidity from these exposures.Non–health care personnel may be exposed by way of social interaction, sexual encounters (including sexual assault), trauma scenarios, intentional inoculations consistent with contemporary terrorist activity, or drug abuse. A flow chart for the management of body fluid exposure is shown below.Flowsheet for management of blood/body fluid exposures.Infection riskBody fluid exposures carry a risk of transmitting HIV, HBV, and HCV. The risk of developing HIV after a needlestick injury involving an HIV-infected patient is around 0.3%. Factors that increase the odds of HIV transmission after percutaneous exposure include a deep injury, the presence of visible blood on the instrument causing the exposure, injury via a needle that was placed in a vein or artery of the source patient, and terminal illness in the source patient.Wearing gloves may reduce (>50%) the volume of blood introduced through an injury. (See Prognosis.)Note that the risk of HIV transmission in health care workers from exposure of the mucosa to HIV-infected fluids was extremely low (0.09%) and that no cases of HIV conversion after exposure of intact skin to HIV-contaminated fluids or from bites (unless visible blood was present) were reported.How Can You Protect Yourself and Others?Unless you are 100% sure that you and the people you are with do not have HIV infection, you should take steps to prevent getting infected. People recently infected (within the past 2 or 3 months) are most likely to transmit HIV to others. This is when their viral load is the highest. In general, the risk of transmission is higher with higher viral loads.This fact sheet provides an overview of HIV prevention, and refers you to other fact sheets for more details on specific topics.Sexual ActivityYou can avoid any risk of HIV if you practice abstinence (not having sex). You also won't get infected if your penis, mouth, vagina or rectum doesn't touch anyone else's penis, mouth, vagina, or rectum. Safe activities include kissing, erotic massage, masturbation or hand jobs (mutual masturbation). There are no documented cases of HIV transmission through wet clothing.Having sex in a monogamous (faithful) relationship is safe if:Both of you are uninfected (HIV-negative);You both have sex only with your partner; andNeither one of you gets exposed to HIV through drug use or other activities.Oral sex has a lower risk of infection than anal or vaginal sex, especially if there are no open sores or blood in the mouth. See Fact Sheet 152 for information on the risks of various behaviors.You can reduce the risk of infection with HIV and other sexually transmitted diseases by using barriers like condoms. Traditional condoms go on the penis. The "female" condom goes in the vagina or in the rectum of receptive women or men. For more information on condoms, see Fact Sheet 153.Some chemicals called spermicides can prevent pregnancy but they don't prevent HIV. They might even increase your risk of getting infected if they cause irritation or swelling.For more information on safer sex, see Fact Sheet 151.Drug UseIf you're high on drugs, you might forget to use protection during sex. If you use someone else's equipment (needles, syringes, cookers, cotton or rinse water) you can get infected by tiny amounts of blood. The best way to avoid infection is to not use drugs.If you use drugs, you can prevent infection by not injecting them. If you do inject, don't share equipment. If you must share, clean equipment with bleach and water before every use. Fact Sheet 154 has more details on drug use and HIV prevention.Some communities have started exchange programs that give free, clean syringes to people so they won't need to share.Vertical TransmissionWith no treatment, up to 35% of the babies of HIV-infected women would be born infected. The risk drops to about 4% if a woman takes AZT during pregnancy and delivery, and then her newborn is given AZT. The risk is 2% or less if the mother is taking combination antiretroviral therapy (ART). Caesarean section deliveries probably don't reduce transmission risk if the mother's viral load is below 1000.Babies can get infected if they drink breast milk from an HIV-infected woman. Women with HIV should use baby formulas or breast milk from a woman who is not infected to feed their babies. Fact Sheet 611 has more information on HIV and pregnancy.Contact With BloodHIV is one of many diseases that can be transmitted by blood. Be careful if you are helping someone who is bleeding. If your work exposes you to blood, be sure to protect any cuts or open sores on your skin, as well as your eyes and mouth. Your employer should provide gloves, facemasks and other protective equipment, plus training about how to avoid diseases that are spread by blood.What If I've Been Exposed?If you think you have been exposed to HIV, talk to your health care provider or the public health department, and get tested. For more information on HIV testing, see Fact Sheet 102.If you are sure that you have been exposed, call your health care provider immediately to discuss whether you should start taking antiretroviral drugs (ARVs). This is called "post exposure prophylaxis" or PEP. You would take two or three medications for several weeks. These drugs can decrease the risk of infection, but they have some serious side effects. Fact Sheet 156 has more information on PEP.Treatment as PreventionIn 2011 two large studies showed that the use of antiretroviral medications by people not yet infected with HIV led to significant protection against infection. This is called Pre-exposure Prophylaxis (PrEP, see Fact Sheet 160.) Discuss PrEP with your health care provider.The Bottom LineHIV does not spread easily from person to person. To get infected with HIV, infected blood, sexual fluid, or mother's milk has to get into your body. HIV-infected pregnant women can pass the infection to their new babies.To decrease the risk of spreading HIV:Use condoms during sexual activity;Do not share drug injection equipment;If you are HIV-infected and pregnant, talk with your health care provider about taking ARVs;If you are an HIV-infected woman, don't breast feed any baby; andProtect cuts, open sores, and your eyes and mouth from contact with blood.If you think you've been exposed to HIV, get tested and ask your health care provider about taking ARVs.here are some link’s for referencehttps://www.cdc.gov/hai/pdfs/bbp/exp_to_blood.pdfChapter 5: AIDS Facts and Myths - Questions People Ask - AIDS Videohttps://www.cdc.gov/hai/pdfs/bbp/exp_to_blood.pdf

Paper-I1. Human Anatomy:Applied anatomy including blood and nerve supply of upper and lower limbs and joints of shoulder, hip and knee.Gross anatomy, blood supply and lymphatic drainage of tongue, thyroid, mammary gland, stomach, liver, prostate, gonads and uterusApplied anatomy of diaphragm, perineum and inguinal region.Clinical anatomy of kidney, urinary bladder, uterine tubes, vas deferens.Embryology: Placenta and placental barrier. Development of heart, gut, kidney, uterus, ovary, testis and their common congenital abnormalities.Central and peripheral autonomic nervous system: Gross and clinical anatomy of ventricles of brain, circulation of cerebrospinal fluid; Neural pathways and lesions of cutaneous sensations, hearing and vision; Cranial nerves, distribution and clinical significance; Components of autonomic nervous system.2. Human Physiology:Conduction and transmission of impulse, mechanism of contraction, neuromuscular transmission, reflexes, control of equilibrium, posture and muscle tone, descending pathways, functions of cerebellum, basal ganglia, Physiology of sleep and consciousness.Endocrine system: Mechanism of action of hormones, formation, secretion, transport, metabolism, function and regulation of secretion of pancreas and pituitary gland.Physiology of reproductive system: menstrual cycle, lactation, pregnancy.Blood: Development, regulation and fate of blood cells.Cardio-vascular, cardiac output, blood pressure, regulation of cardiovascular functions;3. Biochemistry:Organ function tests-liver, kidney, thyroidProtein synthesis.Vitamins and minerals.Restriction fragment length polymorphism (RFLP).Polymerase chain reaction (PCR).Radio - immunoassays (RIA).4. Pathology:Inflammation and repair, disturbances of growth and cancer, Pathogenesis and histopathology of rheumatic and ischemic heart disease and diabetes mellitus. Differentiation between benign, malignant, primary and metastatic malignancies, Pathogenesis and histopathology of bronchogenic carcinoma, carcinoma breast, oral cancer, cancer cervix, leukemia, Etiology, pathogenesis and histopathology of - cirrhosis liver, glomerulonephritis, tuberculosis, acute osteomyelitis.5. Microbiology:Humoral and cell mediated immunityDiseases caused by and laboratory diagnosis of-· Meningococcus, Salmonella· Shigella, Herpes, Dengue, Polio· HIV/AIDS, Malaria, E. Histolytica, Giardia· Candida, Cryptococcus, Aspergillus6. Pharmacology:Mechanism of action and side effects of the following drugs· Antipyretics and analgesics, Antibiotics, Antimalaria; Antikala-azar,Antidiabetics· Antihypertensive, Antidiuretics, General and cardiac vasodilators, Antiviral, Antiparasitic, Antifungal, Immunosuppressants· Anticancer7. Forensic Medicine and Toxicology:Forensic examination of injuries and wounds; Examination of blood and seminal stains; poisoning, sedative overdose, hanging, drowning, burns, DNA and finger print studyPaper-II1. General Medicine:Etiology, clinical features, diagnosis and principles of management (including prevention) of: - Tetanus, Rabies, AIDS, Dengue, Kala-azar, Japanese Encephalitis.Etiology, clinical features, diagnosis and principles of management of:Ischaemic heart disease, pulmonary embolism.Bronchial asthma.Pleural effusion, tuberculosis, Malabsorption syndromes, acid peptic diseases, Viral hepatitis and cirrhosis of liver.Glomerulonerphritis and pyelonephritis, renal failure, nephrotic syndrome, renovascular hypertension, complications of diabetes mellitus, coagulation disorders, leukemia, Hypo and hyper thyrodism, meningitis and encephalitis.Imaging in medical problems, ultrasound, echocardiogram, CT scan, MRI.Anxiety and Depressive Psychosis and schizophrenia and ECT.2. Pediatrics:Immunization, Baby friendly hospital, congenital cyanotic heart disease, respiratory distress syndrome, broncho - pneumonias, kernicterus. IMNCI classification and management, PEM grading and management. ARI and Diarrhea of under five and their management.3. Dermatology:Psoriasis, Allergic dermatitis, scabies, eczema, vitiligo, Stevan Johnson's syndrome, Lichen Planus.4. General Surgery:Clinical features, causes, diagnosis and principles of management of cleft palate, harelip.Laryngeal tumor, oral and esophageal tumors.Peripheral arterial diseases, varicose veins, coarctation of aortaTumors of Thyroid, Adrenal GlandsAbscess, cancer, fibroadenoma and adenosis of breast.Bleeding peptic ulcer, tuberculosis of bowel, ulcerative colitis, cancer stomach.Renal mass,cancer Prostate..Haemothorax, stones of Gall bladder, Kidney, Ureter and Urinary Bladder.Management of surgical conditions of Rectum, Anus and Anal canal, Gall bladder and Bile ductsSplenomegaly, cholecystitis, portal hypertension, liver abscess, peritonitis, carcinoma head of pancreas.Fractures of spine, Colles' fracture and bone tumors.EndoscopyLaprascopic Surgery.5. Obstetrics and Gynaecology including Family Planning:Diagnosis of pregnancy.Labour management, complications of 3rd stage, Antepartum and postpartum hemorrhage, resuscitation of the newborn, Management of abnormal lie and difficult labour, Management of small for date or premature newborn.Diagnosis and management of anemia. Preeclampsia and Toxaemias of pregnancy, Management of Post menopausal Syndrome.Intra-uterine devices, pills, tubectomy and vasectomy. Medical termination of pregnancy including legal aspects.Cancer cervix.Leucorrhoea, pelvic pain, infertility, dysfunctional uterine bleeding (DUB), amenorrhoea, Fibroid and prolapse of uterus.6. Community Medicine (Preventive and Social Medicine):Principles, methods, approach and measurements of EpidemiologyNutrition, nutritional diseases / disorders & Nutrition Programmes.Health information Collection, Analysis and Presentation.Objectives, components and critical analysis of National programmes for control/eradication of:Malaria, Kala-azar, Filaria and Tuberculosis,HIV/AIDS, STDs and DengueCritical appraisal of Health care delivery system.Health management and administration: Techniques, Tools, Programme Implementation and Evaluation.Objective, Component, Goals and Status of Reproductive and Child Health, National Rural Health Mission and Millennium Development GoalsManagement of hospital and industrial waste.