(a) Briefly describe the role of lifestyle interventions in prevention of coronary artery disease. 10 (b) Discuss the role of…

(a) Lifestyle interventions in CAD prevention

Lifestyle modification is the first-line strategy in primary and secondary prevention of coronary artery disease because it modifies the major metabolic and inflammatory drivers of atherosclerosis. Smoking cessation is the single most important intervention, as tobacco use accelerates endothelial injury, thrombosis and plaque instability; counselling, nicotine replacement or pharmacotherapy should be offered. Diet should follow DASH or Mediterranean patterns, emphasising fruits, vegetables, whole grains, legumes, fish and unsaturated fats while limiting saturated fat, trans fat, salt and refined carbohydrates. Physical activity of at least 150 minutes per week of moderate-intensity exercise improves lipid profile, blood pressure, insulin sensitivity and weight. Weight management, aiming for BMI below 25 kg/m², reduces central adiposity and metabolic syndrome. Salt intake below 5 g/day, avoidance of trans fats (India's FSSAI has capped industrial trans fat at 2% of fat since 2022), limiting alcohol, and adequate sleep of 7–8 hours further reduce risk; South Asians develop CAD a decade earlier, so waist circumference targets are lower (<90 cm in men, <80 cm in women). Stress reduction through yoga, relaxation and psychosocial support lowers sympathetic and inflammatory burden, and cardiac rehabilitation after an event is a structured lifestyle programme that lowers mortality. In India these measures are delivered through population screening and counselling under the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD) and the Eat Right India campaign. Finally, lifestyle measures must be combined with control of diabetes and hypertension, because sustained glycaemic and blood-pressure control prevents progression from subclinical atherosclerosis to clinical coronary events.

(b) Imaging in pyelonephritis

Uncomplicated acute pyelonephritis in adults needs no imaging; imaging is indicated when there is no response after 72 hours, suspected obstruction or abscess, diabetes, immunosuppression, recurrent infection, pregnancy or a child with febrile UTI. Imaging is used to confirm diagnosis, detect complications and assess chronic scarring. Contrast-enhanced CT is the gold standard for acute pyelonephritis; it shows striated nephrogram, wedge-shaped hypodensities, perinephric fat stranding, abscess and obstruction, and is especially useful when diagnosis is uncertain or complications are suspected. Ultrasound is often the first-line investigation, particularly in children and pregnancy; it may show an enlarged kidney, altered echogenicity, perinephric fluid and, with power Doppler, perfusion defects. It is less sensitive than CT for early parenchymal changes but is safe and widely available. DMSA scan is the gold standard for detecting chronic renal scarring; it shows cortical defects and reduced uptake, and is useful after acute infection to identify children at risk of hypertension or renal impairment. CT urography (which has replaced the intravenous urogram) is reserved for evaluating obstruction, calculi, papillary necrosis and emphysematous pyelonephritis (gas in the parenchyma on CT, typical in diabetics), and for planning drainage or surgery. A micturating cystourethrogram (MCU/VCUG) detects and grades vesicoureteric reflux in children after febrile UTI, and MRI with diffusion-weighted imaging is a radiation-free alternative in pregnancy and in contrast allergy or renal impairment. Plain X-ray KUB shows radio-opaque calculi and gas.

(c) WHO ARI pneumonia criteria and treatment

Under the WHO Acute Respiratory Infection Control Programme, children are assessed for cough or difficult breathing and classified by fast breathing, lower chest wall indrawing, stridor and general danger signs. Fast breathing is defined as respiratory rate of 50/min or more in children 2–12 months and 40/min or more in children 1–5 years, counted for a full minute in a calm child. In young infants below 2 months, a rate of 60/min or more, severe chest indrawing, fever or hypothermia, or poor feeding indicates possible serious bacterial infection (severe pneumonia) requiring referral. Lower chest wall indrawing indicates severe pneumonia; it is diagnosed when cough or difficult breathing is accompanied by lower chest wall indrawing, and fast breathing is not required. Stridor in a calm child and danger signs such as inability to drink, convulsions, lethargy or unconsciousness indicate very severe disease and require urgent referral. A child with cough or difficult breathing but no fast breathing or chest indrawing has no pneumonia and receives home care. A child with fast breathing has pneumonia and was treated in the original programme with oral cotrimoxazole for 5 days, with home care and return in 2 days. Severe pneumonia (chest indrawing) required referral and injectable antibiotics (benzylpenicillin or ampicillin), with oxygen if hypoxic. Under the revised WHO classification of 2014, adopted in India's IMNCI and the SAANS campaign (2019), fast breathing and/or chest indrawing is classed simply as "pneumonia" and treated at home with oral amoxicillin (40 mg/kg twice daily, 5 days for chest indrawing, 3 days for fast breathing in low-HIV settings), while "severe pneumonia" is reserved for danger signs or SpO2 <90%, needing referral, oxygen, and injectable ampicillin (or penicillin) plus gentamicin, with ceftriaxone as second line. Very severe pneumonia requires urgent referral, oxygen, intravenous antibiotics and supportive care. Supportive care includes continued feeding, fluids, fever control, soothing the throat with safe remedies, and clearing the nose.

(d) Hypothermia in SAM

In a 3-year-old child with severe acute malnutrition, hypothermia (axillary temperature <35.0°C or rectal <35.5°C) is a medical emergency because it signals infection and coexists with hypoglycaemia. Following the WHO ten steps, the child is assumed to be hypoglycaemic and infected. The child is kept in a warm room (25–30°C) free of draughts, wet clothing is removed, and the body is dried and covered, especially the head, with warmed clothes and a blanket; a heater or an incandescent lamp placed about 50 cm away can be used, but hot-water bottles are avoided because of burns. Skin-to-skin contact or kangaroo mother care with the mother or caregiver is the most effective warming method and should be continued for at least several hours or until stable. The child must be fed immediately with F-75 starter formula (every 2 hours, day and night, about 11 mL/kg per feed) if able to feed. Hypoglycaemia is treated with 50 mL of 10% glucose (or sucrose) orally or by nasogastric tube; if the child is lethargic, unconscious or convulsing, 10% glucose 5 mL/kg is given intravenously, followed by 50 mL by nasogastric tube. Broad-spectrum antibiotics (e.g., parenteral ampicillin plus gentamicin) are started because hypothermia usually indicates sepsis. Warm intravenous fluids may be given if needed for shock or dehydration, but overhydration must be avoided. Temperature is checked every 30 minutes during rewarming (rewarming too fast can cause hyperthermia) and rewarming stops once it reaches 36.5°C; glucose, feeding tolerance and vital signs are monitored closely. Prevention in SAM children depends on maintaining a warm ambient environment, immediate and frequent feeding to prevent fasting hypoglycaemia, covering the head, avoiding unnecessary bathing, keeping the child dry and away from drafts, using appropriate clothing and blankets, and continuous temperature monitoring. These measures are especially important during the stabilization phase of SAM management.

(e) Scabies in a joint family

(i) The organism is Sarcoptes scabiei var. hominis, a microscopic mite. (ii) Transmission in a family occurs through prolonged close skin-to-skin contact, sharing of bedding, clothing and towels, and contact with asymptomatic carriers; crowding and close household living increase spread. (iii) Treatment must be simultaneous for all household members, including senior citizens, antenatal women and the one-month-old infant, even if some are asymptomatic. For the one-month-old infant, precipitated sulfur 5% ointment is preferred because topical permethrin 5% is not the approved first-line option for infants under 2 months; it should be applied to the whole body, including scalp, palms, soles and nails, and repeated after one week. For the antenatal woman, topical permethrin 5% is generally considered acceptable in pregnancy, or precipitated sulfur 5% can be used if preferred; oral ivermectin should be avoided in pregnancy. For senior citizens and other household members weighing 15 kg or more, permethrin 5% cream applied neck-down and washed off after 8–14 hours, repeated after one week, is appropriate; alternatively, oral ivermectin 200 mcg/kg on an empty stomach, repeated after 7–14 days, is convenient for the elderly (who may have crusted scabies needing combined permethrin and ivermectin), but it is avoided in children under 15 kg and in pregnancy. Treatment is applied to all skin including the scalp, face, skin folds and under the nails in the elderly and the infant, whose scabies can involve these areas. Secondary bacterial infection should be treated with appropriate topical or oral antibiotics. Clothes, bedding and towels should be washed at 60°C or dry-cleaned, items that cannot be washed should be sealed for 72 hours, and the environment should be cleaned. Itching may persist for some weeks after successful treatment. Nails are kept short, antihistamines relieve itch (avoiding sedating ones in the infant), and the family is reviewed at 2 and 4 weeks.