Friday, August 14, 2020

Answer: 17-year-old male presents with confusion and drowsiness

A 17-year-old male presents with confusion and drowsiness for 1 day. 

He has been healthy and playing in the high school basketball team for the last 2 years. His practice sessions always included 10 minutes of intense work followed by a period of rest or decreased activity. He also had complaints of dark urine which the previous doctor diagnosed as dehydration and was asked to drink more water. 

He recently started a football club and has been playing football in addition to basketball. He has had oliguria for 4 days. Vitals are BP 124/86 mm of Hg, HR 85 b/min. Pupils are non dilated and reactive to light equally bilaterally. The remainder of the physical examination is within normal limits. Lab work shows:

Question: 17-year-old male presents with confusion and drowsiness

A 17-year-old male presents with confusion and drowsiness for 1 day. 

He has been healthy and playing in the high school basketball team for the last 2 years. His practice sessions always included 10 minutes of intense work followed by a period of rest or decreased activity. He also had complaints of dark urine which the previous doctor diagnosed as dehydration and was asked to drink more water. 

He recently started a football club and has been playing football in addition to basketball. He has had oliguria for 4 days. Vitals are BP 124/86 mm of Hg, HR 85 b/min. Pupils are non dilated and reactive to light equally bilaterally. The remainder of the physical examination is within normal limits. Lab work shows:

Sickle cell retinopathy

 What is the hallmark of sickle cell retinopathy?

Sea fan neovascularization.

All patients with SCD should have dilated funduscopic examinations every 1 to 2 years beginning at age 10, preferably by a retina specialist.

Treatment is usually Laser photocoagulation.

Anti-VEGF medications such as bevacizumab or ranibizumab may lead to partial regression of sea-fan neovascularization.

Sickle cell anemic retinopathy is seen mostly in heterozygous S-C trait and S-Thal trait. 

Fun fact: Sea fans are beautiful soft corals.


Sunday, August 9, 2020

Anion Gap

What is Anion Gap?

We need an equal amount of anions and cations to keep the body electrically neutral. So anion gap is not a real thing, it is just a diagnostic concept. Remember, in cations, we mainly measure Na, the other ‘unmeasured’ but important cations are K, Mg, Ca. Unmeasured means not routinely measured. In anions, we routinely measure Cl- and HCO3-, others important but ‘unmeasured’ anions are PO4, Sulfate and  Albumin.
The formula: Anion gap=Na-Cl-HCO3
(normally 8-16meq) is calculated mostly in metabolic acidosis as either normal anion gap or increased anion gap.

Now the most important thing to always remember is that, if due to anyreason, HCO3 or Chloride (measured anions) decreases, the relative concentration of unmeasured anions will increase, as if the unmeasured anions are trying to compensate the loss of their fellow measured anions by increasing their own concentration 
             In Metabolic Acidosis, HCO3 is low, assume that Na is unchanged for now,  so due to low HCO3, other anions like Cl-( measured) and other unmeasured anion will try to compensate by increasing themselves. If Cl- can increase to replace to loss of HCO3’s negative charge, the anion gap will remain within normal limits, if Cl- is too low and can't compensate, then, by the formula AG=Na(normal)- Cl(low)-HCO3(low), The Anion Gap will increase.

- Vaibhav Jain

Thursday, August 6, 2020

Breastfeeding in COVID-19

Hello Friends!
     On the International Breastfeeding week, I would like to share information about “Breastfeeding in COVID-19”, whether it is safe or not to breastfeed the neonates & infants in this pandemic situation.
The COVID-19 Virus has not been detected in the breast milk of any mother either with confirm or suspected COVID-19. So, COVID-19 testing does not have any immediate implications for decisions on infant and young child feeding .The numerous benefits of breastfeeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.Meanwhile researchers continue to test breast milk from infected mother.

Some information that you all need to know are-
1)WHO recommends that all mothers confirm or suspected COVID-19 continue to have skin to skin contact and to breastfeed. In all socio – economic conditions breastfeeding improves-
- Survival and provide lifelong health
- Development advantage to newborns &infants
- Reduce the risk of breast cancer & ovarian cancer in mother
- Skin to skin contact including kangaroo mother care reduce neonatal mortality especially in low birth weight newborns and it also improves thermal regulation of newborns and several other physiological outcomes. There are numerous benefits of skin to skin contact and breast feeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.

2) While infants & neonates can contract COVID-19 they are at low risk of infection .A few confirm  cases of COVID-19 in young children have experience only mild or asymptomatic illness.

3)In all socio- economic settings Breastfeeding improves survival and provides lifelong health and development advantage to new born & infants.

4) If a mother is confirmed / suspected COVID- 19( for the time when she is likely to be infective ,i.e. while symptomatic or through the 14 days after the start of symptoms ,whichever is longer) then, 
(a) She should wash hands frequently with soap and water or use alcohol based sanitizer before touching the baby.
(b) She should wear a medical mask while feeding .It is important to-
* Replace mask as soon as they become damp 
* Dispose of mask immediately 
* Not reuse a mask 
* Not touch the front of mask but unite it from behind.
- Sneeze or cough into a tissue, immediately dispose of it and use alcohol based hand rub or wash hands again with soap and water.
- Regularly clean & disinfect surfaces.
(c) If medical mask not available to her, breastfeeding should be continued.
Other infection prevention measures such as washing hands , cleaning surface, sneezing or coughing into a tissue are also important .Non- Medical mask( homemade or cloth mask)have not been evaluated .At this time it is not possible to make a recommendation for or against their use. 
(d) If she had just coughed over her exposed chest or breast then she should gently wash the breast with soap and warm water for at least 20 seconds prior to feeding. It is not necessary to wash the breast before every breastfeed or prior to expressing milk.
(e) If she is not able to breastfeed then best alternatives are-
• Expressed breast milk
- Expression of breast milk is primarily done or taught through hand expression, with the use of a mechanical pump only when necessary. Hand expression and using a pump can be equally effective.
- The choice of how to express will depend on maternal preference, availability of equipment, hygiene condition and cost.
- The mother and anyone helping the mother, should was their hands before  expressing breast milk or touching any pump or bottle part and ensure pump, feeding utensils, milk storage container should be cleaned  after each use with liquid soap e.g. dishwashing liquid and warm water .Rinse after with hot water for 10- 15 seconds.
- Express breast milk should we feed to child preferably using a clean cup or spoon by a person who has no sign a symptom of illness and whom  the baby feel comfortable. The mother should was their hand before feeding the newborn / infant.
•Donor human milk
- Mother is unable to express milk and milk is available from human milk Bank, Donor human milk can be feed to the baby while the mother is recovering.
• If expressing breast milk or donor human milk and not feasible or available then consider-   
*Wet – nursing (another woman breastfeed the child).In settings where HIV is prevalent, prospective wet-nurses should undergo HIV counselling and rapid testing according to National guidelines where available. In the absence of testing if visible undertake HIV risk assessment. If HIV risk assessment/counselling is not possible, facilitate and support wet-nursing. Provide counselling on avoiding HIV infection during breastfeeding. Prioritise wet – nurses for the youngest infants.
* Infant formula Milk with measures to ensure that it is feasible, correctly prepared, safe and sustainable. There are always risk associated with giving infant formula Milk to newborns and infants in all setting. It is commonly of variable quality, of the wrong type, not accompanied by an essential package of care, distributed indiscriminately, not targeted to those who need it. That risk associated are increased whenever human  community conditions are compromised example reduce access to health service if baby become unwell / reduce access to clean water / access to supplies of infant formula milk difficult or not guaranteed not affordable and not sustainable.
 Donations of infant formula milk from confirm/ suspected mothers should not be accepted. If needed, supplies should be purchased based on assessed need. 
 Mother can start breastfeed when she feel well enough to do so. There is no fixed time interval to wait after confirmed or suspected COVID-19.There is no evidence that breastfeeding changes the clinical course of COVID-19 in a mother. Health workers or breastfeeding counsellors should support mothers to relactate.
(f) There is no need to provide a' top- up' with an infant formula milk. Giving a ‘top -up' will reduce the amount of milk produced by a mother. Mother who breastfeed should be counselled unsupported to optimise positioning and attachment to insure adequate milk production. Mother should be counselled about responsive feeding and perceived milk insufficiency and how to respond to their infant's hunger and feeding cues to increase the frequency of breastfeeding

5) Recommendations for adult and older children to maintain social distancing aim to reduce contact with asymptomatic person who have covid-19 and transmission of virus that may result. This strategy will reduce the overall prevalence of covid-19 and the number of adults who experience more serious disease.
The aim of recommendations on the care and young children whose mother have confirm or suspected covid-19 infection is to improve the immediate and lifelong survival, children health and development of newborns and infants. These recommendations consider likelihood and potential risks of COVID-19 in infants and also the risks of serious illness and death when infants are not breastfeed or when infant formula milk are used inappropriately as well as the protective side effects of breastfeeding and skin to skin contact.
Thus, It is safe to breastfeed the infants and neonates because no active COVID-19 Virus has not, to date been detected in breast milk of any confirm/suspected mother and it also provides remarkable benefits to the baby.

By- Neha Kumari
2nd year MBBS student

Tuesday, August 4, 2020

Pathology related to Breastfeeding

Breastfeeding has been playing an important role for the development of infant since ages. According to WHO and AAP, Breastfeeding is the normal way of providing young infants with nutrients they need for healthy growth or development. Scaling up breastfeeding could save lives of more than 8,20,000 -children under the age of 5. It could lower the rates of allergies, Ear -Lung Infection , Obesity , Sudden Infant Death ,Necrotizing Enterocolitis And associated sepsis .Not only it could be beneficial for the infant but also for the mother because it could reduce the chances of uterine bleeding , burn calories , reduce the risk of breast / ovarian / uterine cancer , osteoporosis , Arthritis , Type II Diabetes mellitus and Heart Disease. Initially the breast releases colostrum which has high content of immune cells and antibodies, a much lower fat content and also acts as a laxative to pass out the first stool meconium. But there could be several problems associated with breastfeeding. I would like to list down a few of them-

1. DIFFICULTIES FROM LATCHING INTO THE BREAST – A good latch promotes high milk flow and minimizes nipple discomfort for the mother whereas a poor latch results in poor milk transfer to the baby and can quickly lead to sore and cracked nipples.

2. CRACKED NIPPLES- A shallow latch or Thrush (Candiasis) or Dry skin around The Areola could be the general causes. Cracked nipples could be a little frightening and uncomfortable at the beginning and could be associated with some bloody discharge. Treatments for this could be application of Soothing Gel pads, nursing ointments or painkillers like Acetaminophen (Tylenol).

3. ENGORGEMENTS OF BREAST- A sense of breast fullness or heaviness within 36 hrs. of delivery. The increased blood supply, accumulated milk and swelling all contribute to painful engorgement. Engorgement may affect the areola, the periphery of the breast or the entire breast and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola / nipple. This makes latching a daunting task for the baby.  The possible treatments could express or pumping. Gentle massage or pressure could soften the areola. Application of cold compresses to reduce the swelling pain and vascularity even more. One published study suggested that the use of Chilled Cabbage leaves could produce mixed results. Acetaminophen could relieve the pain too.

4. MILK STASIS- When alveolar and lactiferous ducts are blocked and cannot drained properly. This can be treated by varying the baby’s feeding position and applying heat before feeding.

5. MASTITIS- Inflammation of Breast in Association with dolor, rubor, tumor and calor. This could be due to Primary causes as in milk stasis or secondarily with infectitious organisms such as Staphylococcus sp., Streptococcus sp., and E-Coli. Continued Breast feeding, plenty of rest and fluid intake could possibly cure such conditions.

6. Dysphoric Milk Ejection Reflex (D – MER)- A newly recognized condition affecting lactating women that is characterized by abrupt dysphoria or negative emotions that occurs before milk release. The possible cause may be due to inappropriate dopamine activity at the time of milk ejection reflex.

7. INVERTED NIPPLES- A condition where the nipple instead of pointing outwards, is retracted back into the breast. The etiology to these conditions might be due to 
• Fat necrosis
o Breast Carcinoma 
o Inflammatory Breast Cancer 
o Paget’s Disease
o Mammary Duct Ectasia 
o Breast Abscess
o Mastitis
o Weaver Syndrome
o Kennerknecht – Sorgo – Oberhoffer Syndrome

8. RAYNAUDS OF THE NIPPLE/ NIPPLE BLANCHING- Can be caused by vasospasm of the nipple. Blood does not flow properly to the nipple which causes the nipple to blanch. This could be due to early breastfeeding or candidal infection of the nipple. There could be associated throbbing pain in between the breastfeeding sessions when the nipple is blanched.  In some instances, heart medication nifedipine is used to help flow of blood to the nipples.

9. TONGUE TIE/ANKYLOGLOSSIA- This condition is present at birth that restricts the range of motion of the tongue. With tongue tie an unusually short, thick and tight band of tissue (lingual frenulum) tethers the bottom of the tongue’s tip to the floor of the mouth so it may interfere with breast feeding. It could also affect the way a child eats, speaks and swallows.

10. POSTNATAL DEPRESSISON- Many women feel a bit down, tearful or anxious in the first week after giving birth. Symptoms might include insomnia, a persistent feeling of sadness and low mood, loss of appetite, intense irritability and difficulty of bonding with the baby.


Breastfeeding: The Mother & Baby Bond

In today's fast pacing era what can be most necessary and unaltered for a new guest in this world. What can be a moving experience from a women's point of view. Definitely it's breast feeding. An Emotional saga for every women's life. An experience to be relished lifelong. It's not only a rational experience rather a lifetime experience for her. 
From the beginning of human settlements many things have changed but not this loving and caring bond between a mother and her child. The happiness felt by a mother during the nourishment of her newborn is unmeasurable.  She forgets all her pain and discomfort in front of this joy. This is the reason why mothers are portrayed as goddess in every religion and culture.
Apart from these aesthetical values there are many Scientific theories which proves why breastfeeding is important and is considered as an emotional experience. Mother’s milk is highly nutritious and contains varieties of Carbohydrates, protein, vitamines and immune boosting complexes which are sufficient for the growth of baby in 1st six months of life. 
During the process of breast-feeding maternal pituitary releases prolactin and oxytocin. These hormones along with increasing the milk production help in reducing mental anxiety of mother. 
Thus the first connection of baby to her mother is undoubtedly important and can't be substituted. If this process is ever altered I think our existence will be questioned. 

By- Sudipt Anand (S.K.M.C.H)

Monday, August 3, 2020

Breastfeeding: An Emotion

What can be so pure and good for a newly born baby. The first food of the baby is breast milk or mother’s milk. It is the only food the baby can consume. It's not only only a physical process but an emotional and mental process also. Mother and her child goes through an emotional and hormonal change during the process which is beyond the scope of science to feel it.This helps baby to grow and get nourishment.
Health professionals recommend that breastfeeding must begin within the first hour of a baby's life and continue as often and as much as the baby wants. During the first few weeks of life babies may nurse roughly every two to three hours, and the duration of feeding is usually ten to fifteen minutes on each breast. Older children feed less often. There are multiple advantages of breast-feeding to the child and to the mother also.

1) Nutritional superiority - Breast milk contains all kind of nutrients required for a baby's proper mental and physical growth.                     
a) Carbohydrates -  Lactose is present in the breast milk they help in growth of lacto bacilli in the intestine and also help absorption of calcium. Galactose found in the milk help in formation of galactocerebrosides. 
b) Fats - Breast milk contains omega 2&6 fatty acids which are necessary for synthsis of cholesterol and prostaglandins. The PUFA content of milk help in mylination of nerve fibers. It also contains DEHA, which help in brain and retina formation. 
c) Protein - The protein present in the milk are easily digested. These proteins help in neuromodulation and neuro transmission. 
d) Water -  Breast milk contains enough water and electrolytes in them to fully satisfy baby's need. 
e) Vitamins -  The vitamins present in the milk is sufficient for babies first 6 month of life. 

2)Immunological Benefits -  Breast milk contains a number of Immunological benificial factors which help baby in their protection against diseases. 
. PABA = It protect against malaria. 
. Lactoferrin = It protects against E.Coli
. Lipases = It protects against Intestinal pathogens
. It also contains Lactglobulins, Lysozyme, Lactalbumin and Immunoglobulin mainly IgA. 
3) Mental Growth = Studies have shown that breast feed babies have higher IQ and and are more attached to mother that who recieve other form of milk. 

4) Protection against allergies = Babies are highly exposed to risk of allergies due to their low immunity which is supplement by the immunity gained from mother’s milk. 

5) Benefits to Mother = Breast-feeding soon after delivery helps in involution of uterus and prevent postpartum haemorrhage. Breast feeding also reduces the chance of ovarian and breast carcinoma. It also help mother in preventing pregnancy for next 6 months. It also help mothers by helping them to loose extra weight that is gained during pregnancy. 
Thus Breast-feeding is a convenient and best way of raising a healthy baby. It helps to build a special and beautiful relation between a mother and her baby.  

Thank you
Sneha Kashyap
2nd year MBBS

Sunday, August 2, 2020

Breastfeeding: Good Vs Poor Latch

Hello friends!
On International Breastfeeding week, I would like to discuss the difference between Good and Poor Latching during Breastfeeding.

Advantages of Breastfeeding to Neonate

Hello friends!
On the International Breastfeeding week, I would like to share the advantages of Breastfeeding in neonates.

Advantages of breastfeeding to the neonate 
❖ Breast milk provides optimum nutrition for babies. 
❖ During breastfeeding, approximately 0.25-0.5 grams per day of secretory antibodies IgA antibodies pass to the baby via milk. This is one of the most important features of colostrum. 
❖ Breast milk contains several anti-infective factors such as bile salt stimulated lipase and lactoferrin. 
❖ Bile salt stimulated lipase protects against amoebic infections and lactoferrins bind to iron and inhibits the growth of intestinal bacteria. 
❖ Breastfeed infants tend to have fewer cavities and promote proper development of babies' jaw and teeth. 
❖ Babies benefit emotionally because they are held more. 
❖ Breastfed infants tend to have higher IQs due to good brain development early in life. 
❖ In the long term, breastfed babies have a decreased risk of malnutrition, obesity, and heart disease compared to formula-fed babies.
That's all.
Thank you
Isha Kumari
2nd year MBBS
GMC Bettiah

Breastfeeding: Facts

Hello friends!
On the International Breast feeding week, I would like to share some must know facts about Breastfeeding.

Fact 1: Breastfeeding for the first six months is crucial.
WHO recommends that mothers should initiate breastfeeding within one hour of birth. Infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health, and thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods, while continuing to be breastfed; and breastfeeding should continue for up to two years or beyond.

Fact 2: Breastfeeding protects infants from childhood illnesses
Breast milk is the ideal food for newborns and infants. It gives infants all the nutrients they need for healthy development. It is safe and contains antibodies IgA that help protect infants from common childhood illnesses such as diarrhoea and pneumonia, the two primary causes of child mortality worldwide. Breast milk is readily available and affordable, which helps to ensure that infants get adequate nutrition.

Fact 3: Breastfeeding also benefits mothers
Exclusive breastfeeding is associated with a natural (though not fail-safe) method of birth control (98% protection in the first six months after birth). It reduces risks of breast and ovarian cancer, type II diabetes, and postpartum depression.

Fact 4: Breastfeeding has long-term benefits for children
Beyond the immediate benefits for children, breastfeeding contributes to a lifetime of good health. Adolescents and adults who were breastfed as babies are less likely to be overweight or obese. They are less likely to have type-II diabetes and perform better in intelligence tests.

Fact 5: Infant formula does not contain the antibodies found in breast milk.
The long-term benefits of breastfeeding for mothers and children cannot be replicated with infant formula. When infant formula is not properly prepared, there are risks arising from the use of unsafe water and unsterilized equipment or the potential presence of bacteria in powdered formula. Malnutrition can result from over-diluting formula to "stretch" supplies. While frequent feeding maintains breast milk supply, if formula is used but becomes unavailable, a return to breastfeeding may not be an option due to diminished breast milk production.

Fact 6: Transmission of HIV through breastfeeding can be reduced with drugs
An HIV-infected mother can pass the infection to her infant during pregnancy, delivery and through breastfeeding. However, antiretroviral (ARV) drugs given to either the mother or HIV-exposed infant reduces the risk of transmission. Together, breastfeeding and ARVs have the potential to significantly improve infants' chances of surviving while remaining HIV uninfected. WHO recommends that when HIV-infected mothers breastfeed, they should receive ARVs and follow WHO guidance for infant feeding.

Fact 7: Marketing of breast-milk substitutes are highly monitored.
An international code to regulate the marketing of breast-milk substitutes was adopted in 1981. It calls for: all formula labels and information to state the benefits of breastfeeding and the health risks of substitutes. No promotion of breast-milk substitutes. No free samples of substitutes to be given to pregnant women, mothers or their families. No distribution of free or subsidized substitutes to health workers or facilities.

Fact 8: Support for mothers is essential.
Breastfeeding has to be learned and many women encounter difficulties at the beginning. Many routine practices, such as separation of mother and baby, use of newborn nurseries, and supplementation with infant formula, actually make it harder for mothers and babies to breastfeed. Health facilities that support breastfeeding by avoiding these practices and making trained breastfeeding counsellors available to new mothers encourage higher rates of the practice. To provide this support and improve care for mothers and newborns, most countries have implemented the WHO-UNICEF Baby-friendly Hospital Initiative, which sets standards for quality care.

Fact 9: Mothers should continue breastfeeding at work
Many mothers who return to work abandon breastfeeding partially or completely because they do not have sufficient time, or a place to breastfeed, express and store their milk. Mothers need a safe, clean and private place in or near their workplace to continue breastfeeding. Enabling conditions at work, such as paid maternity leave, part-time work arrangements, on-site crèches, facilities for expressing and storing breast milk, and breastfeeding breaks, can help.

Fact 10: Solid foods should be phased in at six months
To meet the growing needs of babies at six months of age, mashed solid foods should be introduced as a complement to continued breastfeeding. Foods for the baby can be specially prepared or modified from family meals.

Mukesh Kumar
2nd year MBBS
Southern Medical University, China

Technique of Breastfeeding

Hello friends!
On International Breastfeeding Week, I am sharing the proper technique for Breastfeeding. 
Must know methods for everyone.

Techniques of Breastfeeding 
Breastfeeding is nature's precious gift for infants. Breastfeeding is advised because human milk is species-specific nourishment for the baby, produces optimum growth and development, and provides substantial protection from illness. Lactation is beneficial to the mother's health and biologically supports a special MOTHER-BABY relationship.

But most breastfeeding problems are caused by the poor attachment of the baby to the breast. Thus, it is very important to learn how to feed the baby with the correct position and attachment.

Support the mother's body as support back well and use pillow, cushion, or footstool to provide comfort. Before breastfeeding, every mother should wash their hands. 
The correct way to support baby -
1. In sitting position 
a) Cradle hold-
Hold the baby horizontally facing the mother. When nursing from the right breast, use the right arm to rest on the forearm, baby's back supports on the same forearm and holds baby's bottom with hand. Support the breast with the left hand. 
b) Transition hold (cross over hold)
When nursing from the right breast, use the left arm to hold the baby. Support baby back with the left forearm, while placing the thumb and fingers at the base of the baby's head below the ears of the baby. Support the breast with the right hand. 
c) Football hold
Hold the baby under the mother's arm and let the baby face towards the breast. Support the baby with a pillow underneath. Hold the baby close the mother with the nose pointing to the nipple, use the forearm to support baby back and neck, and the hand to hold the baby head. This position is suitable for mothers who have had a Caesarean section. Since mother does not put pressure on the abdomen. 

2.Inside lying hold 
Baby and mother lying on their sides facing each other. The mother should be relaxed. The baby needs to well supported and secure as tuck a rolled-up towel or small pillow firmly behind baby' back to keep in position. Adjust the baby's distance from the lower breast by placing a folded blanket under the baby's head. To assist with the latch on using the opposite hand to support the breast(right hand for left breast vice-versa) 
Getting baby latch on to the breast -support the base of the baby's head. Baby's head slightly extended, so that the nipple is aimed at the roof of the baby's mouth. Lightly touch the baby's lip with the nipple and wait till baby opens his/her mouth wide. Bring baby to mother's breast. Not mother breast to the baby. 

Signs of good attachment-baby open his/her mouth wide with lips flanged out, more areola is seen above the baby's lip then below baby's chin is pressed onto the breast. 
Breastfeeding should not hurt if the mother keeps a finger into the corner of baby's mouth to break the suction and gently take baby off mother's breast.

Shashikala Kumari
2nd year MBBS
GMC Bettiah