Wednesday, December 24, 2008

Prevention of Type 2 Diabetes. What you can do? The Life Circle approach

Each year 7 million people develop diabetes and the most dramatic increases in type 2 diabetes have occurred in populations where there have been rapid and major changes in lifestyle, like India, demonstrating the important role played by lifestyle factors and the potential for reversing the global epidemic.
A person with type 2 diabetes is 2 – 4 times more likely to get cardiovascular disease (CVD), and 80% of people with diabetes will die from it. Premature mortality caused by diabetes results in an estimated 12 to 14 years of life lost.
India leads the global top ten in terms of the highest number of people with diabetes with a current figure of 40.9 million, followed by China with 39.8 million. Behind them come USA; Russia; Germany; Japan; Pakistan; Brazil; Mexico and Egypt. Developing countries account for seven of the world’s top ten.

A complex interplay of genetic, social and environmental factors is driving the global explosion in type 2 diabetes. For low and middle-income countries, economic advancement can lead to alterations to the living environment that result in changes in diet and physical activity within a generation or two. Consequently, people can develop diabetes despite relatively low gains in weight. In the developed world, diabetes is most common among the poorest communities. Either way, wherever poverty and lack of sanitation drive families to low cost-per-calorie foods and packaged drinks, type 2 diabetes thrives.

Diabetes is deadly. It accounts for 3.8 million deaths per year, similar in magnitude to HIV/AIDS. Once thought of as a disease of the elderly, diabetes has shifted down a generation to affect people of working age, particularly in developing countries.

The UN recognition of Diabetes follows the passing of Resolution 61/225, the World Diabetes Day Resolution, in December 2006. The landmark resolution was the first goal of an ambitious campaign led by the IDF which recognizes diabetes as a chronic, debilitating and costly disease associated with major complications that pose severe risks for families and countries throughout the world. The UN has thrown its support behind it and encourages countries to act now. The Resolution can be viewed here .

People forming blue circle on World Diabetes day

Kathmandu Declaration and Life Circle approach

To mark World Diabetes Day 2008 on 14 November, the South-East Asia Region (SEAR) of the International Diabetes Federation (IDF) has announced the development of a landmark declaration. The “Kathmandu Declaration” is an action plan, providing guidelines and a framework for the prevention and care of diabetes through the pioneering concept of the “life circle”, which is in keeping with the blue circle from the Unite for Diabetes logo. The life circle approach concentrates on the prevention of type 2 diabetes from preconception to adulthood, highlighting the risk factors and prevention strategies at each stage in life through behavioral and environmental changes. The salient features of the approach are the following.

Prevention before bearing your child [Pre Conception Period]
You can try to prevent you and your yet to be born children getting Type 2 Diabetes.
You can do this by
1. Maintaining a BMI of less than 23 [for Indians and other South Asians; less than 25 for Caucasians]
and a waist circumference of less than 90 for males and less than 80cm for females.

[Waist circumference should be measured at the mid point between the horizontal lines through the bottom of ribs and top of pelvis]

2.Regular physical activity of at least 30 minutes a day for 5 days a week.[more if you need to loose weight]
3. Check your blood sugar to rule out Diabetes or pre-diabetes before becoming pregnant
4.Good dietary habits which includes increased amount of vegetables and fresh fruits and minimum high calorie foods.

Prevention of type 2 Diabetes in childhood and adolescence
Make sure that your child is not over weight.Actively discourage sedentary habits and over eating.Do your workouts with your kids if possible.Too much stress on studies will make your child highly paid but an unhealthy professional.
Prevention of type 2 Diabetes in adulthood
To find out your risk for type 2 diabetes, check each item that applies to you.
1. My BMI is more than 23 or my waste circumference is more than 90cm[males] or 80cms[females]
2. I have a parent, brother/ sister Uncles/Aunts, Cousins with diabetes.
3. I am from South Asia.
4. I have had gestational diabetes, or I gave birth to at least one baby weighing more than 3.5 kilograms.
5. My blood pressure is 140/90 mm Hg or higher, or I have been told at least once that my blood pressure is more than normal.
6. My cholesterol levels are not normal.

My HDL cholesterol—“good” cholesterol—is below 35 mg/dL, or

7. my triglyceride level is above 250 mg/dL.
8.I am fairly inactive. I exercise fewer than three times a week.
9.I have polycystic ovary syndrome, also called PCOS—women only.
10.On previous testing, I had impaired glucose tolerance (IGT) i.e blood sugar 2 hour after meal between 140 and 199mg or impaired fasting glucose (IFG), i.e fasting blood sugar between 100 and 125mg
11.I have other clinical conditions associated with insulin resistance, such as acanthosis nigricans.

12.I have a history of Coronary heart disease or Stroke.

The more items you checked, the higher your risk.

How can I reduce my risk?
You can do a lot to lower your chances of getting diabetes. Exercising regularly, reducing fat and calorie intake, and losing a little weight can help you reduce your risk of developing type 2 diabetes. Lowering blood pressure and cholesterol levels also helps you stay healthy.
If you are overweight
Then take these steps:
Reach and maintain a reasonable body weight.
Make wise food choices most of the time.
Be physically active every day.

If you are fairly inactive
Then take this step:
Be physically active every day.

If your blood pressure is too high
Then take these steps:
Reach and maintain a reasonable body weight.
Make wise food choices most of the time.
Reduce your intake of sodium and alcohol.
Be physically active every day.
Talk with your doctor about whether you need medicine to control your blood pressure.
If your cholesterol or triglyceride levels are too high
Then take these steps:
Make wise food choices most of the time.
Be physically active every day.
Talk with your doctor about whether you need medicine to control your cholesterol levels.
Making Changes to Lower My Risk
Making big changes in your life is hard, especially if you are faced with more than one change. You can make it easier by taking these steps:
Make a plan to change behavior.
Decide exactly what you will do and when you will do it.
Plan what you need to get ready.
Think about what might prevent you from reaching your goals.
Find family and friends who will support and encourage you.
Decide how you will reward yourself when you do what you have planned.
Your doctor, a dietitian, or a counselor can help you make a plan. Consider making changes to lower your risk of diabetes.
Reach and Maintain a Reasonable Body Weight
Your weight affects your health in many ways. Being overweight can keep your body from making and using insulin properly. Excess body weight can also cause high blood pressure.
Body mass index (BMI) is a measure of body weight relative to height. You can use BMI to see whether you are underweight, normal weight, overweight, or obese. Use the Body Mass Index Table to find your BMI.
Find your height in the left-hand column.
Move across in the same row to the number closest to your weight.
The number at the top of that column is your BMI. Check the word above your BMI to see whether you are normal weight, overweight, or obese.

If you are overweight or obese, choose sensible ways to get in shape.
Avoid crash diets. Instead, eat less of the foods you usually have. Limit the amount of fat you eat.
Increase your physical activity. Aim for at least 30 minutes of exercise most days of the week.
Set a reasonable weight-loss goal, such as losing 1-2 kilograms a month. Aim for a long-term goal of losing 5 to 7 percent of your total body weight.

Make Wise Food Choices Most of the Time
What you eat has a big impact on your health. By making wise food choices, you can help control your body weight, blood pressure, and cholesterol.
Take a look at the serving sizes of the foods you eat. Reduce serving sizes of main courses such as meat, desserts, and foods high in fat. Increase the amount of fruits and vegetables.
Limit your fat intake to about 20-25 percent of your total calories. For example, if your food choices add up to about 2,000 calories a day, try to eat no more than 56 grams of fat. Your doctor or a dietitian can help you figure out how much fat to have. You can also check food labels for fat content.
Limit your sodium intake to less than 2,300 mg—about 1 teaspoon of salt—each day.
Talk with your doctor about whether you may drink alcoholic beverages. If you choose to drink alcoholic beverages, limit your intake.
You may also wish to reduce the number of calories you have each day. Your doctor or dietitian can help you with a meal plan that emphasizes weight loss.
Keep a food and exercise log. Write down what you eat, how much you exercise—anything that helps keep you on track.
When you meet your goal, reward yourself with a nonfood item or activity, like watching a movie.
Compiled and edited from IDF and NIH websites. A big thanks to Dr C.S.Yagnik,Pune for his inputs.
The series of meetings leading to the Kathmandu declaration is supported by an educational grant from Merck Sharp & Dohme.

Tuesday, December 16, 2008

Cost of gaining height

You may recall that few months ago I had posted about a man who looked like a boy.He was 23 years old but had the features only of 12 years of age.His height was 123 cms and his body feature were like a small boy.He was a case of Pituitary Dwarfism. Let me tell you what happened since.

The hormone tests proved that he is having a deficiency of Growth Hormone and Male sex hormone called Testosterone.Then I took a series of Radio graphs[Xray films] to see whether his growing ends of bones had fused.In normal males it will fuse anytime between 18 and 21 years.He is 23 now,so chances are it might have fused.But fortunately the radio graphs showed it had not fused.

That meant there is a chance that he may gain in height if given injections of Growth Hormone.That was good news,but the bad news was the injections are expensive. 15 day course of injections will cost around 8000 Rupees.He may have to take such injections for several months.

The family was very poor.The patient's father was a manual labourer and have to support a large family.My first thought was not to burden them by telling them about costly injections.As he was already 23 the chances of gaining much height is very less.The hormones injected may cause the growth plate of the bones to fuse thereby preventing further gain in height.

Bur not telling their options was unethical.So I gave a long explanation which his father listened with rapt attention. From the vacant look I could realise that he did not understand much.
He put everything on my head. Saru parayunathu pole cheyyam.[Will do whatever sir say]
Now I have the added responsibility of deciding for that family.

So I decided.Let us try the medicines for 2 months and see.You tell me when you have the money ready for 15 days medicines.I will order it and give it to you directly.We can save some money by doing that.He agreed.

After a week he called me and said the money for 15 days of injections is ready.I ordered the medicine and company couriered it in my address.I taught the father how to take the injections. The money had to be send to the Company office by cheque or draft.I asked him to do that.He confessed that he do not know anything about Banks and asked me to do it for him.I did not know what to do.He just gave me the cash and left.

After 15 days he came again with his kid.There was no increase in height[ as it may take few more weeks to get the effect].Cash was ready and I handed over the medicine.
After the end of next 15 day period he called and said there is a cash shortage.They were planning to sell a piece of land,but was not able to get a good price.I asked him to come to see me with his son.

I measured the height.There was an increase of 2 cm.All of us were happy to see the increase.

He asked me for few days time to get the cash ready. I told him that a gap in therapy was not good.

Should I volunteer to give him a loan? If he asked for a loan what should I do? I was wondering.
But he did not ask for a loan.He assured me he will get the money in few days.

I know that the father was struggling hard to get money for the injection for his son. Few more months of injections may further increase his height by few centimetres. But at what cost?

Tuesday, December 9, 2008

It seemed they all wanted her to die -Part 2

You may remember the post with above title few days ago.As a follow up I have both good and bad news.
Good news first.
The 'Positive' girl slowly improved. I took her out of ICU after 4 days and by 6th day she was insisting on going home. But she was very weak and taking very little food. I delayed for a day and then discharged her giving a prescription for 7 days. Before discharge I had a long talk with her mother and one her uncles.I told them that she is still not out of danger.I told them the plan of treatment.I told them if we do all we can for her she can be saved.I reassured that there is no threat of any one of the family members getting infected.They listened to me seriously asking me to clarify if they could not understand.Over all I thought they are coping well and have a genuine interest in the welfare of the girl.I told them to come to the hospital with her on the 8 th day of discharge.

Now the bad news.

Now it is the 15th day of her discharge. They have not brought her to me on the 8th day as per my advise. What might be the reason? Had they taken her to another doctor? If it is so, it is OK.Had they lost interest in her and is not continuing the treatment? That is unpardonable negligence.Or ......had she died?
I don't know what to do. Should I try to trace her?

Thursday, December 4, 2008

Non medical reason for referring a patient-Part 2

You may recall my post few days ago on the above subject. Let me continue the story.
The patient a woman of 42 years was brought to my hospital next day morning. My physical examination and the blood results revealed that she is having Dengue fever with a decrease in Platelets, the cell that helps in clot formation when the blood vessel is injured. Apart from vomiting and mild fever she was doing well.
I reminded the relatives about what I told them the day before. I said to them that Dengue fever can be life threatening.
'Next few days are critical. Even if you take her elsewhere the management will be the same. Now you decide.If you like to stay I will try my best to make the patient all right'.
The decision was quick.'We have faith in you doctor'.
I was happy to see their faith in me.It is my experience that if you explain everything about the Patient's condition in simple terms looking in the eye the faith of the patient and the relatives increases.
With in 2 days of supportive therapy her Platelet count improved and she became asymptomatic. I discharged her from the hospital on the fourth day.The family was very happy and thankful.I saved them a lot of money and hardships.
Many patients are referred to a higher centre with out sufficient reasons.Nowadays doctors try to play it safe.
I took a calculated risk here.I admitted a patient to my small hospital with a probable life threatening illness who was referred to a big City Hospital by another Physician.The risk paid off and here we had a happy ending. That may not be the result in all cases.

Sunday, November 30, 2008

Questions and answers about HIV transmission

What are the main routes of HIV transmission?
These are the main ways in which someone can become infected with HIV:
1.Unprotected penetrative sex with someone who is infected.

2.Injection or transfusion of contaminated blood or blood products, donations of semen (artificial insemination), skin grafts or organ transplants taken from someone who is infected.

3.From a mother who is infected to her baby; this can occur during pregnancy, at birth and through breastfeeding.

4.Sharing unsterilised injection equipment that has previously been used by someone who is infected.

Can I become infected with HIV through normal social contact/activities such as shaking hands/toilet seats/swimming pools/sharing cutlery/kissing/sneezes and coughs?

No. HIV is not an airborne, water-borne or food-borne virus, and does not survive for very long outside the human body. Therefore ordinary social contact such as kissing, shaking hands, coughing and sharing cutlery does not result in the virus being passed from one person to another.
Can I become infected with HIV from needles on movie/cinema seats?

There have been a number of stories circulating via the Internet and e-mail, about people becoming infected from needles left on cinema seats and in coin return slots. These rumours appear to have no factual basis.
For HIV infection to take place in this way the needle would need to contain infected blood with a high level of infectious virus. If a person was then pricked with an infected needle, they could become infected, but there is still only a 0.4% chance of this happening.
Although discarded needles can transfer blood and blood-borne illnesses such as Hepatitis B, Hepatitis C and HIV, the risk of infection taking place in this way is extremely low.
There is a wide spread belief among 'negative' people that HIV positive persons will try deliberately to spread the disease.There is no factual basis for this belief.

Is there a risk of HIV transmission when having a tattoo, body piercing or visiting the barbers?
If instruments contaminated with blood are not sterilised between clients then there is a risk of HIV transmission. However, people who carry out body piercing or tattooing should follow procedures called 'universal precautions', which are designed to prevent the transmission of blood borne infections such as HIV and Hepatitis B.
When visiting the barbers there is no risk of infection unless the skin is cut and infected blood gets into the wound. Traditional 'cut-throat' razors used by barbers now have disposable blades, which should only be used once, thus eliminating the risk from blood-borne infections such as Hepatitis and HIV.

Am I at risk of becoming infected with HIV when visiting the doctor or dentist?
Transmission of HIV in a healthcare setting is extremely rare. All health professionals are required to follow infection control procedures when caring for any patient. These procedures are called universal precautions for infection control. They are designed to protect both patients and healthcare professionals from the transmission of blood-borne diseases such as Hepatitis B and HIV.

Can I get HIV from a mosquito?
No, it is not possible to get HIV from mosquitoes. When taking blood from someone, mosquitoes do not inject blood from any previous person. The only thing that a mosquito injects is saliva, which acts as a lubricant and enables it to feed more efficiently.

Can I become infected with HIV through biting?
Infection with HIV in this way is unusual. There have only been a couple of documented cases of HIV transmission resulting from biting. In these particular cases, severe tissue tearing and damage were reported in addition to the presence of blood.

Can HIV be transmitted outside of the body?
Whilst HIV may live for a short while outside of the body, HIV transmission has not been reported as a result of contact with spillages or small traces of blood, semen or other bodily fluids. This is partly because HIV dies quite quickly once exposed to the air, and also because spilled fluids would have to get into a person's bloodstream to infect them.
Scientists agree that HIV does not survive well in the environment, making the chance of environmental transmission remote. To obtain data on the survival of HIV, laboratory studies usually use artificially high concentrations of laboratory-grown virus. Although these concentrations of HIV can be kept alive for days or even weeks under controlled conditions, studies have shown that drying of these high concentrations of HIV reduces the amount of infectious virus by 90 to 99 percent within a few hours.
Since the HIV concentrations used in laboratory studies are much higher than those actually found in blood or other specimens, the real risk of HIV infection from dried bodily fluids is probably close to zero.

Does circumcision protect against HIV?
There is very strong evidence showing that circumcised men are about half as likely as uncircumcised men to acquire HIV through heterosexual sex. However, circumcision does not make a man immune to HIV infection, it just means that it's less likely to happen. Male circumcision probably has little or no preventive benefit for women.

If I am taking antiretroviral drugs and have an 'undetectable' viral load, am I still infectious?
Even if your tests show that you have very low levels of HIV in your blood, the virus will not have been totally eradicated and you will still be capable of infecting others. Some drugs do not penetrate the genitals very well and so do not disable HIV as effectively there as they do in the blood. This means that while you may have little active virus showing up on blood tests, there may still be quite a lot of HIV in your semen or vaginal fluids. Transmission may be less likely when you have a low viral load, but it is still possible so you should always take appropriate precautions.
Click here if you want to know more

World AIDS Day December 1

Take the Lead. Pledge your Leadership to stop AIDS in India

World AIDS Day is just around the corner!! Take the Lead and Pledge your Support for World AIDS Day, December 1st.

Stand up. Make a difference.
If you are in India, you can TEXT us your pledge by doing the following:

SMS "PLEDGE" to the number: 56070
If you are not in India you can submit your video or written pledge to us.

Click here to learn more
Pass on the pledge to your friends!!! You can forward the SMS to your friends.
To know more about World AIDS Day events in India click here

Tuesday, November 25, 2008

Non-Medical reasons for referring a Patient-Part 1

You may think that if a patient is referred to a higher medical centre[with better facilities] from a smaller hospital it is purely due to medical reasons. Many a time it is not.
Today I was confronted with such a referral.

It was near the end of my working day. Four men came in to my consultation room wanting some advice regarding a patient admitted under another Physician in a small hospital nearby. She was diagnosed to have Dengue fever and had been referred to higher centre.

They had brought all the patients records.I went through the clinical notes and lab charts.She was not in a critical condition.But the doctor treating her had asked them to take her to Hi-tech hospital in the nearest City.
One of the men,whom I know before asked, 'Is there a hospital in this town which can manage such cases?'
'Yes, even the Hospital in which the patient is currently admitted may be able to take care of such cases. Dengue fever patients need constant monitoring,that is all.If there is a fall in blood pressure or bleeding they may need blood transfusions'.I said.
'Then why the referral?' He asked.
I asked them what the treating doctor told them about patient's condition.They revealed that the doctor had told them that the patient has a serious life threatening infection. The patient can be said to be out of danger only after 3-5 days.
'Would you have accepted death of the patient if it had happened in that hospital?'
I asked. 'If patient died there in spite of all the recommended treatment methods you would definitely would not accept it and will raise voices against the doctor and the hospital.You would have asked the doc why he did not refer the patient to better centre'.

[Most probably stones will be thrown and the doc manhandled, which is now the fashionable thing in Kerala.I did not say that aloud.Did not want to give them ideas]

'On the other hand if the patient died in the big hi-tech City hospital you will accept it as your fate and will be satisfied with yourself that you have done enough.That is the reason for the referral.So it will better for you to take the patient to the City',I concluded.

Their faces showed indecision.They went out of my room to discuss among themselves as I saw my last patient for the day.I thought they will not come back again.But they trooped in to my room once more. I did not expect what they asked.

'Can you treat the patient in your hospital?

I did not know what to say.My hospital was slightly better equipped than the hospital in which the patient is admitted currently.I wanted to take up the challenge.10 years ago I might have jumped at the opportunity. But age and bitter experiences have changed me a lot..[as explained in my earlier posts 30vs40 part 1]. I wanted time to decide.
'Let me see the patient and decide.Bring her to the hospital tomorrow morning'.I replied

Tomorrow they may or may not come.If they come I may take up the challenge.
To know what happened to that patient click here.

Thursday, November 20, 2008

Life and Death

Today I realised how thin is the line between life and death.

It was late afternoon.My appointments in outpatient department in my hospital was running late by more than an hour[as usual]. The coffee I ordered to keep me awake was unduly late in coming.
In walked an elderly, thin and ill looking gentleman.The chart showed me he was 74. He was accompanied by an innocent looking girl. The girl did the talking.She said her grand father is feeling tired and is having no appetite for the last few days. He is also not sleeping much.She attributed it to him taking care of his ailing wife who is admitted in a state of coma in the same hospital with a massive stroke few days ago.
He was pale, eyes sunken, all skin and bones.I asked him what was troubling him. He was hard of hearing.So I raised my voice and asked again.He said he had no appetite nor he is able to sleep.He told me about is wife.He said the wife is showing some improvement and there is still hope that she will become conscious one day.

I examined him quickly still thinking why the coffee is not on my table yet.His pulse was little weak,blood pressure and heart sounds ok.They have already done some blood tests. It showed he is anemic and also having mildly elevated blood sugar.

I thought everything is due to anemia. So I raised my voice to tell him about his sugar free, green leafy vegetable rich diet.He asked me whether he can take rice both at lunch time and at dinner.I said yes,but he did not hear it.He suddenly slumped in his chair,his face becoming more pale and his hands rigid.His breath was just a gasp.I called him loud and tried to feel his now absent pulse.The grand daughter was screaming with fright and asked what was wrong.
I with help of the nurse carried that frail man on to the examination couch.He was taking gasping breath but no heart sounds.I started cardiac resuscitation by rhythmically thumping his chest with the proximal part of my palms.I asked the nurse to take the young girl out and to bring help immediately in form of a stretcher to take the patient to the ICU.The nurse went to telephone to dial but I yelled at her to run to the emergency department for help.

For me it seemed it took a long time for the orderlies to come with the stretcher but actually they came in 3 minutes.I was continuing my cardiac resuscitation till I reached the ICU.
In the ICU the nurses put an IV line and stuck the electrodes of the cardiac monitor on his chest.I looked at the monitor.There was no activity.It was asystole or Cardiac standstill,a form of cardiac arrest which is difficult to reverse. I shouted orders one by one. A male nurse was continuing the Chest thump and I could hear a rib creak.I called out to be careful. By that time breathing had almost stopped.I called out for an endo tracheal tube to be put into the wind pipe. A nurse handed me the laryngoscope and another the endo tracheal tube.I could put in the tube with the help of the scope properly with in seconds.Now his breathing is taken care of as the nurse started pumping oxygen into his lungs with the ambu bag.

The male nurse was still continuing the cardiac resuscitation on the chest.I called out for more iv drugs to be given.
'Defib' I shouted.
The machine to give electric shock to the heart to try to make it come alive was ready.
'360 joules', I ordered and put the pads on that thin chest, asked everybody to stay away and pressed the button.The patient jerked and the smell of burned skin came into my nose. 'Give me more jelly on the pad', I shouted.
I looked at the monitor.It showed a flurry of activity as the cardiac resuscitation continued.It raised my hopes.I ordered more drugs to be pushed IV. But slowly the line in the monitor became flat.
'Defib' once more I shouted.This time a nurse did that as I watched the patient jerking again receiving the shock. This time there was not much activity in the monitor screen. The electric shock was repeated again and again, the jerking of the lifeless body continued and the monitor showed the flat line of death.

I looked at my watch. It was 30 minutes ago that this man asked me if he can eat rice both at lunch and dinner time.But it seemed a long long time ago.. And meanwhile he had passed the line between life and death.

Now I had a few live patients to see and I was already so late. I asked my junior, the resident medical officer to do the paper work and the rest of the formalities.

When I reached the OP, the coffee was there on my table, already cold.By then I was fully awake and so I ignored the coffee. As the next patient came to sit on the chair that was just now vacated by the life of that old man, I realised how thin is the line between life and death.

Wednesday, November 19, 2008

Is homeopathy good for Chickenpox?

Is homeopathy good for Chickenpox?
Many people ask this question to me.I will tell them my experience.

A Staff Nurse working in my Hospital came to me with the typical rash of Chickenpox.The eruption started only that morning. I told her it is chickenpox and in most of the cases it wont create any problem.It is a self limiting[meaning will subside by itself] viral infection.She asked about the anti viral treatment.I told her with treatment the recovery is faster by few days especially if started on the day of the eruption of rash.As she did not have much leave she opted for anti viral treatment[Acyclovir]. She recovered fast and was back to work in 8 days.

About 4 weeks later the Nurse came again to me with her mother who had healing and active rashes all over her body.She had secondary bacterial infection of her skin as a complication of Chickenpox.She was exhausted and dehydrated.Her mother developed rashes 10 days ago.She was taking homeopathic treatment, but was suffering badly. She was advised salt free diet and other dietary restriction. I gave her treatment for skin infection due to bacteria and few symptomatic remedies,asked her to take salt normally and reassured her.It took another 10 days for her mother to become all right again.
At that time the Nurse's sister a College student was shown to me with early chickenpox rash.I again gave her the option of just taking symptomatic medicines or taking anti viral medicines also.She did not opt for anti virals. Her illness had an uneventful course and she recovered completely in 12 days.
Chickenpox is self limiting and usually do not produce any complications in young persons.Anti viral therapy reduces the number of eruptions and increases the speed of recovery.Anti viral therapy is a useful option in those who want to recover fast.

Homeopathy do not have any additional proven benefit in management of Chickenpox.But severe diet restriction along with some stronger homeopathic medicines are found to increase the number of eruptions and increase the exhaustion and fatigue in patients, there by delaying the recovery.
Chickenpox in older people may cause complications.Such patients may have to be looked after carefully.
For more authentic information on Chickenpox visit here

Monday, November 17, 2008

It seemed they all want her to die

She is 21 years old.She is my patient for the last few days.She is sick, really sick, probably spending her last days under my care.
The family is around her.Her widowed mother,her Uncles,her grand mother etc.They are taking care of her in the usual loving and caring way as any other family will do. But some how for me it seemed they all want her to die.

Why? Because she is an HIV positive person.After being treated for various illnesses symptomatically the real reason for her problem, her positive status was revealed only few days ago.She was immediately referred to the nearest Government facility treating such patients.
The family took her home instead.After 2 days her Uncles came to me.They wanted some treatment but did not want hospital admission.

'Let me first see her condition and decide I said.
They brought her soon.Her condition was really poor.I explained to the relatives. I told them it may be better to take her to a Higher centre with better facilities.They flatly refused. I realised then that I am her last hope.
It seemed they all wanted her to die.

I am trying my level best.But she may be fighting a losing battle.

The follow up of this patient can be read in my posts in December and January

Saturday, November 15, 2008

World Diabetes Day

Today November 14th is the World Diabetes Day.
World Diabetes Day (WDD) is the primary global awareness campaign of the diabetes world. It was introduced in 1991 by the International Diabetes Federation (IDF) and the World Health Organization (WHO) in response to the alarming rise in diabetes around the world. In 2007, the United Nations marked the Day for the first time with the passage of the United Nations World Diabetes Day Resolution in December 2006, which made the existing World Diabetes Day an official United Nations World Health Day.

World Diabetes Day is a campaign that features a new theme chosen by the International Diabetes Federation each year to address issues facing the global diabetes community. While the themed campaigns last the whole year, the day itself is celebrated on November 14, to mark the birthday of Frederick Banting who, along with Charles Best, first conceived the idea which led to the discovery of insulin in 1922

No Child Should Die of Diabetes
This is the campaign theme this year.

Diabetes and children
Diabetes is one of the most common chronic diseases to affect children. It can strike children of any age, even toddlers and babies. If not detected early enough in a child, the disease can be fatal or result in serious brain damage. Yet diabetes in a child is often completely overlooked: it is often misdiagnosed as the flu or it is not diagnosed at all.

Every parent, school teacher, school nurse, doctor and anyone involved in the care of children should be familiar with the warning signs and alert to the diabetes threat.

Know the diabetes warning signs
Frequent urination
Excessive thirst
Increased hunger
Weight loss
Lack of interest and concentration
Blurred vision
Vomiting and stomach pain (often mistaken as the flu)
*In children with type 2 diabetes these symptoms may be mild or absent.

Type 1 and type 2 diabetes.

Diabetes is a chronic, potentially debilitating and often fatal disease. It occurs as a result of problems with the production and supply of the hormone insulin in the body. The body needs insulin to use the energy stored in food. When someone has diabetes they produce no or insufficient insulin (type 1 diabetes), or their body cannot use effectively the insulin they produce (type 2 diabetes).

Type 1 diabetes is an autoimmune disease that cannot be prevented. Globally it is the most common form of diabetes in children, affecting around 500,000 children under 15. However, as a result of increasing childhood obesity and sedentary lifestyles, type 2 diabetes is also increasing fast in children and adolescents. In some countries (e.g. Japan), type 2 diabetes has become the most common form of the disease in children.

Globally, there are close to 500,000 children under the age of 15 with type 1 diabetes.
Every day 200 children develop type 1 diabetes.
Every year, 70,000 children under the age of 15 develop type 1 diabetes.
Type 1 diabetes is increasing in children at a rate of 3% each year
Type 1 diabetes is increasing fastest in pre-school children, at rate of 5% per year.
Finland, Sweden and Norway have the highest incidence rates for type 1 diabetes in children.
Type 2 diabetes has been reported in children as young as eight and reports reveal that it now exists in children thought previously not to be at risk.
In Native and Aboriginal communities in the United States, Canada and Australia at least one in 100 youth have diabetes. In some communities, it is one in every 25.
Over half of children with diabetes develop complications within 15 years.
Global studies have shown that type 2 diabetes can be prevented by enabling individuals to lose 7-10% of their body weight, and by increasing their physical activity to a modest level.
Type 2 diabetes in children is becoming a global public health issue with potentially serious outcomes.
Type 2 diabetes affects children in both developed and developing countries.

Diabetes is a deadly disease. Each year, almost 4 million people die from diabetes- related causes. Children, particularly in countries where there is limited access to diabetes care and supplies, die young.

Diabetic Ketoacidosis (DKA), a build-up of excess acids in the body as a result of uncontrolled diabetes, is the major cause of death in children with type 1 diabetes. With early diagnosis and access to care, the development of severe DKA should be preventable.
Insulin was discovered more than 85 years ago. Today children in many parts of the world still die because this essential drug is not available to them.
Children with diabetes should monitor their blood sugar regularly to help control their diabetes. This monitoring equipment is often unavailable or not affordable.
In Zambia, a child with type 1 diabetes can expect to live an average of 11 years. In Mali, the same child can expect to live for only 30 months. In Mozambique the child is likely to die within a year.
The World Diabetes Day campaign in 2008 aims to:

Increase the number of children supported by the IDF Life for a Child Program.
Raise awareness of the warning signs of diabetes
Encourage initiatives to reduce diabetic ketoacidosis and distribute materials to support these initiatives.
Promote healthy lifestyles to help prevent type 2 diabetes in children.


from International Diabetes Federation

Sunday, November 2, 2008

Featured blog post

My post How I got interested in HIV/AIDS was featured in Desipundit. Thank you for the recognition.

Wednesday, October 29, 2008

Call for a Google doodle for World Diabetes Day on November 14

India is the diabetes capital of the world with estimated 41 million Indians having diabetes.Every fifth diabetic in the world is an Indian.It is believed that about one third of the Diabetic in India do not know they have Diabetes.

You've seen the cool "doodles" that Google has done for Holidays, important moments in history etc etc.

Well the Diabetes Online Community wants Google to do one on November 14Th for World Diabetes Day to increase awareness about Diabetes.
So click here to Petition Google for a World Diabetes day doodle.

Thank you for bringing more awareness to Diabetes!!!

Tuesday, October 28, 2008

How to know when you have a Major Depression

The stimulus for this post are recent blog posts on suicide by Seema and Cris. So I thought I will share some knowledge about Depression and how to tackle it. This is adapted from Psychiatry Text Books and websites

How to find out you or your friend is having a major problem of Depression?

Most people with depression will not have all the symptoms listed below, but most will have at least five or six.


1.Feel unhappy most of the time (but may feel a little better in the evenings)
2.Lose interest in life and can't enjoy anything
3.Find it harder to make decisions
4.Can't cope with things that you used to
5.Feel utterly tired
6.Feel restless and agitated
7.Lose appetite and weight (some people find they do the reverse and put on weight)
8.Take 1-2 hours to get off to sleep, and then wake up earlier than usual
9.Lose interest in sex
10.Lose your self-confidence
11.Feel useless, inadequate and hopeless
12.Avoid other people
13.Feel irritable
14.Feel worse at a particular time each day, usually in the morning
15.Think of suicide.

You may not realise how depressed you are for a while, especially if it has come on gradually. You try to struggle on and may even start to blame yourself for being lazy or lacking willpower. It sometimes takes a friend or a partner to persuade you that there really is a problem which can be helped.

You may start to notice pains, constant headaches or sleeplessness. Physical symptoms like this can be the first sign of depression.

How to help someone who is depressed?

Listen. This can be harder than it sounds. You may have to hear the same thing over and over again. It's usually best not to offer advice unless it's asked for, even if the answer seems perfectly clear to you. If depression has been brought on by a particular problem, you may be able to help find a solution or at least a way of tackling the difficulty.

It's helpful just to spend time with someone who is depressed. You can encourage them, help them to talk, and help them to keep going with some of the things they normally do.

Someone who is depressed will find it hard to believe that they can ever get better. You can reassure them that they will get better, but you may have to repeat this over and over again.

Make sure that they are buying enough food and eating enough.

Help them to stay away from alcohol.

If they are getting worse and start to talk of not wanting to live or even hinting at harming themselves, take them seriously. Make sure that they see their doctor.

Encourage them to accept help. Don't discourage them from taking medication, or seeing a counsellor or psychotherapist. If you have worries about the treatment, then you may be able to discuss them first with the doctor.

Why does a person get depressed?

As with our everyday feelings of low mood, there will sometimes be an obvious reason for becoming depressed, sometimes not. It can be a disappointment, a frustration, or that you have lost something - or someone – important to you. There is often more than one reason, and these will be different for different people. They include:

Things that happen in our lives
It is normal to feel depressed after a distressing event - bereavement, a divorce or losing a job. You may well spend a lot of time over the next few weeks or months thinking and talking about it. After a while you come to terms with what's happened. But you may get stuck in a depressed mood, which doesn't seem to lift.

If you are alone, have no friends around, are stressed, have other worries or are physically run down, you are more likely to become depressed.

Physical Illness
This is true for life-threatening illnesses like cancer and heart disease, and also for illnesses that are long and uncomfortable or painful, like arthritis or bronchitis. Younger people can become depressed after viral infections, like flu or glandular fever.

Some of us seem to be more vulnerable to depression than others. This may be because of our genes, because of experiences early in our life, or both.

Regular heavy drinking makes you more likely to get depressed – and, indeed, to kill yourself.

Women seem to get depressed more often than men. It may be that men are less likely to talk about their feelings and more likely to deal with them by drinking heavily or becoming aggressive. Women are more likely to have the double stress of having to work and look after children.

Depression can run in families. If you have one parent who has become severely depressed, you are about eight times more likely to become depressed yourself.

What about bipolar disorder (manic depression)?
About one in 10 people who suffer from serious depression will also have periods when they are too happy and overactive. This used to be called manic depression, but is now often called Bipolar Disorder. It affects the same number of men and women and tends to run in families (see Help is at Hand leaflet on Bipolar Disorder).

Isn't depression just a form of weakness?

Other people may think that you have just 'given in', as if you have a choice in the matter. The fact is there comes a point at which depression is much more like an illness than anything else. It can happen to the most determined of people – even powerful personalities can experience deep depression.

When should a depressed person seek help?
When your feelings of depression are worse than usual and don't seem to get any better.
When your feelings of depression affect your work, interests and feelings towards your family and friends.
If you find yourself feeling that life is not worth living, or that other people would be better off without you.

It may be enough to talk things over with a relative or friend. If this doesn't help, you probably need to talk it over with your family doctor. You may find that your friends and family have noticed a difference in you and have been worried about you.

Helping yourself

Don't keep it to yourself
If you've had some bad news, or a major upset, tell someone close to you - tell them how you feel. You may need to talk (and maybe cry) about it more than once. This is part of the mind's natural way of healing.

Do something
Get out of doors for some exercise, even if only for a walk. This will help you to keep physically fit, and will help you sleep. Even if you can't work, it's good to keep active. This could be housework, do-it-yourself (even as little as changing a light bulb) or any activity that is part of your normal routine.

Eat well
You may not feel like eating - but try to eat regularly. Depression can make you lose weight and run short of vitamins which will only make you feel worse. Fresh fruit and vegetables are particularly helpful.

Beware alcohol!
Try not to drown your sorrows with a drink. Alcohol actually makes depression worse. It may make you feel better for a short while, but it doesn't last. Drinking can stop you dealing with important problems and from getting the right help. It's also bad for your physical health.

If you can't sleep, try not to worry about it. Try listening to the radio or watch some TV while you're lying in bed. Your body will get a chance to rest and, with your mind occupied, you may feel less anxious and find it easier to get some sleep.

Tackle the cause
If you think you know what is behind your depression, it can help to write down the problem and then think of the things you could do to tackle it. Pick the best things to do and try them.

What kind of help is available?
Most people with depression are treated by their family doctor. Depending on your symptoms, the severity of the depression and the circumstances, the doctor may suggest:

self-help as suggested above
counselling treatment
antidepressant tablets

Keep hopeful
Remind yourself that:

Many other people have had depression.
It may be hard to believe, but you will eventually come out of it.
Depression can sometimes be helpful – you may come out of it stronger and better able to cope. It can help you to see situations and relationships more clearly.
You may be able to make important decisions and changes in your life, which you have avoided in the past.

Help site for Depressed in Kerala: Maithry

Friday, October 24, 2008

How I got interested in HIV/AIDS?

In the late 1990s, I was working in a small [Government] Taluk Hopsital. HIV 'Positive' persons I saw in my practise were few and I was happy to refer them to higher centres.

Then I got transferred to a busy District Headquarters Hospital in 2001. There I could not escape dealing with 'positive' persons.
Every week the infectious disease ward will see a new 'positive' patient coming to die.
Most of them by then might have spend a fortune on magical remedies. The most infamous among them was the medicines of Fair Pharma from Kochi. For more detailed information about how one Majeed cheated poor patients and build the costliest house in Kerala click here. Now fortunately the 'medicine' is banned in Kerala by the Court after a longstanding legal battle with 'Positive' people and PUCL.

The patients in my hospital were given symptomatic treatment and left to die. Some come and die alone while the more lucky ones have a wife or mother to be with them during their last days.
I was depressed seeing all these deaths.
What can I do for them? I asked myself.
I had no experience in treating HIV/AIDS patients. In the medical college where I studied in early and mid 1990s, 'positive' persons were rarely seen. I knew a lot from the text books but practical knowledge was nil.
Those days the Government was giving lot of training in HIV/AIDS for doctors and other health care workers, but it was only about prevention.
HIV/AIDS is a death sentence. So train yourself and others how not to get it.
This was the message of such trainings. Nobody mentioned treatment. We were not trained to cope with these dying 'positive' patients.
In the developed world by the year 2000, more than 10 drugs were available effective in treating HIV/AIDS. Few were available in India too at that time. They were expensive and somewhat toxic but still they worked. And they were cheaper than the Fake medicines of Fair Pharma.
More over, HIV/AIDS patients need treatment for opportunistic infections that attack them as their immunity is low.
So when a 'positive' patient is sick, first we have to find out which opportunistic organism or organisms have infected him/her. Then give the proper treatment so that he/she becomes better. Later, ART [anti retro viral therapy] was started. Some time in severely sick patient we may have to start both treatments together.

Training myself in HIV/AIDS management, I started treating these patients in earnest. I procured medicines from drug companies directly and thus was able to give it to patients much below market rates. The stigma of buying such medicines from Drug Store was circumvented as I myself provided the medicines.

The results were dramatic. Patients in death bed about to say their final prayers were able to look after themselves with in months. Those who sticked on to the medication schedule for more than a year began working and earn for themselves.

I lost many patients too, but I tried my level best. Some came to me at a very late stage. Many could not continue the medicines because of the high cost of ART. Many by then had become social outcasts and committed suicide.

I urged other Physicians to take up the challenge of HIV. I conducted lectures in the IMA[Indian Medical Association]. I told them that it was ,we the modern medicine doctors, who are making the 'positive' persons go to Quacks like Majeed [Fair Pharma]. As we are not ready to take care of them, they are helpless. Unscrupulous persons squeeze out the last penny from them giving false hopes.

That made some difference. Few of my colleagues started taking up such cases.

By 2003-2004, things started changing in a positive direction for 'positives'. ART drugs became cheaper. India became one of the biggest manufacturer and exporter of cheap generic HIV drugs. Govt of India started giving ART drugs free of cost at selected centres. Kerala Government followed suit.
The emphasis in training of health care workers shifted from prevention to treatment. From a 'death sentence' HIV/AIDS became projected as a chronic manageable disease needing lifelong medication like Diabetes.

Now a 'Positive' person comes to my clinic every other day. Most of them are old patients coming for follow up. A newly detected 'positive' person is seen once or twice a month. Most of them are taking the free ART drugs from Medical Colleges. Some who can afford [and is afraid of perceived stigma at Govt centres] take medicines from me.
Deaths occur but only rarely.

I cherish the sight of happy faces and healthy bodies of all those positive persons. That sight make my life meaningful.

Monday, October 20, 2008

Primary care Physician versus Sub specialist

After my post graduate training in Internal Medicine [ie MD], I had two options. Either to work as a primary/secondary care General Physician or go for a sub- specialisation [or as it is called in India, Super specialisation,ie DM]. I chose the first option. Why? Do I regret it?

Why I chose not to study more? Primary reason was I had become fed up with studies . I had spent almost 26 years of my life studying by then[including KG].
Also I was married and had just become a proud father. Wanted to earn something for myself and my budding family.
Another factor that made my decision easy was the appointment letter from the Government, posting me as a Physician in a small town not very far from my home.

There was also another big reason. I hated confining myself to one organ or organ system. Internal medicine had all the thrills. The wide variety of illnesses that an internist manage made it an exciting profession.
At that time, I had some noble ideals too [young and romantic?]. I wanted to help as many patients as possible especially the poor. So rather than being a super specialist in a 5 star hospital looking after the cream of the society, I preferred the Govt job as an internist in a small, run down Taluk hospital.
Do I regret it?
Yes, some times.
Especially when patients ask, 'Sir enthinde specialista?'[ in what subject are u specialised in?]or when they ask 'do you feel I should see a specialist?'
Some times it is the relatives who ask the same question.
I reply to them trying to make them feel I am an all rounder, knowing about all diseases.
Also, I regret it some times when I realise that the sub specialist's consultation fee is twice or thrice that of mine.
But most of the time I don't regret it. Looking back I feel my decision was right.

I enjoy my profession. I like the thrill of finding out the cause of fever in a FUO [fever of unknown origin]. I like the satisfaction I get when I correctly diagnose the cause of breathlessness in a poor patient by just patiently listening to the history and using the stethoscope,without ordering any fancy investigations. I like the way people come to me for advise regarding anything related to medicine. I am happy taking disease prevention classes to house wives or school kids or teachers or Taxi drivers or 'Positive'[HIV] people. I feel I am doing something when I console and give hope to a crying man or woman when they first realise they are 'Positive'.
So as of now I am happy being a Generalist who 'know a lot about a lot of illnesses rather than a super-specialist who 'know more and more about less and less'.

Monday, October 13, 2008

Sad News

The Type 1 Diabetic patient in 'Strange Interview' and 'Happy News' called me to tell that she had a spontaneous abortion.
Her recent blood sugars were between 80 and 220mg but her frequency of testing was only about once a day or once in 2 days.
Early foetal loss is most commonly due to congenital defects in foetus caused by high blood sugar during first few weeks.
For a diabetic woman who wants to be pregnant, keeping a very good control over her blood sugar is very important.The first 42 days after conception is the most important period, but in most cases the woman will be aware that she is pregnant only after a missed period, which is about 14 to 21 days after conception.
So planning the pregnancy in advance and keeping a tight control on blood sugar is absolutely essential.
The loss of that foetus was a personal failure for me too. I should raise the standard of my care of care of Diabetes in Pregnancies.
I had emphasised all these to her and I hope she will have a successful pregnancy next time.

Thirty versus Forty -- Part 2

Reading my last post again I realised I was too negative. Is it true that at Forty I have lost everything that was good in me? No It is not true. Let me try to enumerate the positive changes in me.

My ability to communicate with patients have improved over time eventhough time available for each patient is less. My ability to find out the correct cause of the each patient's problem have also increased very much. This have helped my patients from undergoing unnecessary investigations and mental trauma.

I have established a very good practise with a large number of loyal patients. I read [when I get time] journals and Text Books.Still now I am one of the better informed doctor of my age.
I have a very good relationship with all other doctors I work with.
I have done some good work in training other doctors in HIV/AIDS. I have become a much better speaker in front of general public and even in front of doctors.
The quality of care I give to my patients as a whole have improved.
Lastly and not the least I have a blog of my own which I am able to maintain with frequent posts.
So Forty is not bad at all.

Wednesday, October 8, 2008

Thirty versus Forty

This year I turned 40.
A milestone in many aspects.
10 years ago when I turned 30 where was I?
It would be interesting to study the contrast.

At 30, I was out of medical college after my postgraduate degree and had just started my career. I was raring to go and was flushed with the initial success of my practise. As I had only few patients to see,I spent considerable amount of time talking to patients, making them understand the disease and how to cope with it. I wondered why the senior doctors in my area are not communicating well with the patients. I was happy to see patients 24hrs a day.

Each difficult case was a challenge to me and I researched and referred books and net till late hours to find a solution to each diagnostic problem. Each new issue of my favourite medical journal was awaited eagerly. I wanted to practise medicine the way it is given in Text Books. I hated when the patient or the relatives said that they are going to a higher medical centre for further evaluation. I looked down in other doctors who referred cases without any reason. My belief in Science was immense. Also I believed very much in my patients and their relative's loyalty to me. I never could imagine one of them going for a malpractice litigation against me. I was ready to teach the staff nurses the finer points of patient care at any time.

I had umpteen number of dreams about my future. Researching and finding out a new breakthrough methodology of treatment for an important disease was one of them. Presenting papers after papers in National and International conferences and publishing them was another.

At medical conferences, I was the baby among the audience. I was up to date in knowledge and was proud about it. I was bombarded with advise from seniors to do that,to do this, and not to do this etc. I was also an early product of technology generation. So, I was the one who showed the senior doctors how to use the Internet and the possibilities of cell phones.

At 40, I am in the middle of my career in practising clinical medicine.The sight of crowded waiting room in my clinic do not excite me, rather it makes me feel tired. I stick to my working hours. Any patient coming outside it, is shown an angry face. Finishing the patient appointments in time is the priority now. Time given for each patient became limited.

I am slow to accept changes in treatment methods. Text Books and journals pile up untouched.

A difficult case is easily referred. Any wish expressed by the patient to go elsewhere, brings up a reference letter from me in a jiffy. My belief in the unknown increased. Each person who enter my clinic is viewed as a possible litigant.

The dream of researching and presenting papers still remain a dream. At medical conferences, I am somewhat a veteran. Young faces are seen all around. Many come to me for advice. I try not to show youngsters my lack of up to date knowledge.

Still I try to maintain the spirit and my standard of practise, may be for another decade.

Read the next part of Thirty versus Forty here

Follow up

I had narrated about many people/patients in my postings. This is a post which will tell you about where they stand now.[as far as I know]

The 31 year old newly wed wife who preferred Insulin to tablets is now well controlled on a single tablet. She also started working part time and looking forward to get pregnant.

The 50 year old lady who took money from me [as narrated in patient taking money from doctor]for her bus ticket returned the amount promptly next month. But I have not heard from the other guy whom I helped on the same day for getting Government certificate.

The 65 years old Type 2 Diabetes patient who disturbed my sleep by missing her Insulin injections for a few days was hospitalised for 3 more times, all around 2 am, with hypoglycemia.The doctor on duty managed her all the time with out disturbing my sleep.

The patient in Another sad 'positive' story is doing well with anti Tuberculosis treatment.His CD4 count is also low and may need anti HIV medicines too shortly.

The guy in Craze for specialist consultation was diagnosed to have Hepatitis B. He went to a Gastro-enterologist for better care, but was unhappy with the lack of communication of that particular specialist.He came back to me again and has now recovered well.He is back in Bangalore working.
The 12 year old girl with Diabetes in Type 1 or Type 2 did not keep her follow up appointments. I hope she is getting treatment and monitoring from some where else, may be from Government run clinics as the family was very poor.

Sunday, October 5, 2008

Chronic severe Joint pain of Chikungunya

The rainy season due to the South West Monsoon over the Indian sub continent is over.Epidemic of acute severe joint pain and swellings associated with fever due to Chikungunya infection has also subsided.Now I am seeing more and more patients with Chronic severe joint pain of varying duration, a sequel of Chikungunya infection.

Let me tell you a little more about this virus and the illness it causes in humans.

Chikungunya is a re-emerging, mosquito-borne viral infection causing fever, rash and acute or sudden severe joint pains of several joints.Chikungunya (Chick’-en-GUN-yah) in Swahili an African language meaning “that which contorts or bends up” refers to the contorted (stooped) posture of patients who are afflicted with severe joint pains (arthralgia) the most common feature of the disease.
Chikungunya virus is a single-stranded RNA Alphavirus, from the family Togaviridae. Other Alphaviruses also causing fever, rash and arthralgia, include O’nyong-nyong, Mayaro,Barmah Forest, Ross River and Sindbis viruses. Chikungunya virus is most closely related to O’nyong-nyong, but remains genetically distinct.

The disease was first described by Marion Robinson and W.H.R. Lumsden, following an outbreak along the border between Tanzania(erstwhile Tanganyika) and Mozambique, in1952. Since 1953, the virus has caused outbreaks in Africa and South Eastern Asia, including India, Sri Lanka, Myanmar, Thailand, Indonesia, the Philippines and Malaysia, which are well documented. There is historical evidence that Chikungunya virus originated in Africa and subsequently spread to Asia. Phylogenetic studies support this theory, with Chikungunya virus strains falling into three distinct genotypes based on origin from West Africa, Central/East Africa or Asia.

Chikungunya is transmitted by the bite of the infected Aedes mosquito from an infected person to a healthy person. The disease does not get transmitted directly from human to human (i.e. it is not a contagious disease). In a pregnant woman with Chikungunya there is risk of transmitting the disease to her foetus.
The fever starts usually about 2 to 3 days after the entry of virus into the human body. There will be severe chills and shaking of the body at the onset of fever.At the same time the joint pain and swelling starts.The patient will not be able to move with in minutes of onset of illness.The joints of hands mainly the metacarpo phalangeal and proximal inter phalangeal joints become warm swollen and very painful.Wrist and elbow are also affected to a lesser extend.The joints of ankle,feet and to a lesser extend hip are all affected.
Itchy reddish raised rash is typically seen[70%] when the fever subsides, which in most of my patients was by 3 days.Many patients and Physicians confuse it with drug rash due to allergy to the medicines the patient took for fever and joint pain.
Rash is typically seen on the cheeks, nose and outer part of ears.The ear lobe is typically painful to touch. The rash is also seen over the trunk and limbs with severe itching which lasts for only 2 days. There will be painful swelling of ankle and shin with dark red discoloration. Painful oral ulcers are also seen during this time.Last year I had few patients with enlarged cervical lymph nodes, which disappeared in few days.

Although rare, the infection can result in meningo-encephalitis, especially in newborns and those with pre-existing medical conditions. Pregnant women can pass the infection to their foetus. Severe cases of Chikungunya can occur in the elderly, in very young ones (newborns) and in those who are immuno-compromised.

Chikungunya outbreaks typically result in several hundreds or thousands of cases but deaths are rarely encountered.
Differential diagnosis of Chikungunya includes Dengue and Dengue Haemorrhagic Fever,
O’nyong-nyong virus infection and Sindbis virus infection.
It has been reported that attack rates in susceptible populations may be as high as 40-85 per cent and the ratio of symptomatic to asymptomatic patients is about 1.2:1.

Children are less likely to experience joint pain, but may have other features such as febrile fits, vomiting, abdominal pain and constipation.

The discoloration of the nose usually lasts for months.I call it the seal of Chikugunya as I can identify a person who had Chikungunya in the recent past seeing that seal.
Some patients may remain feverish for some more days. The joint pain become less in few days. In about 60 percent of the patients the ilness including the joint pains last only about a week.They become completly all right with only a little bit of tiredness remaining.
But in about 40% of patients joint pain increases or persists.The chronic joint pain of Chikungunya resembles that of Rheumatoid arthritis. The joints commonly involved are the wrists and the knees.The ankle and smaller joints of feet and hands are also involved.Stiffness of these joints in the morning lasting more than 30 mts is typical. The patient feels better as he/she continues to move the joints.
The joint stiffness and pain lasts for about 3 months in about 30% of patients in my practise. But in an unfortunate 10% it may last indefinitely.

Lab Diagnosis of Chikungunya fever

Virus isolation and PCR techniques are costly and is available in very few centres. Serological diagnosis is possible only after a week of onset by detecting antibodies. As the treatment is mostly symptom specefic diagnosis will not alter patient management much. So the typical triad of fever, acute onset joint pains and rash along with a low white cell count in blood sample is sufficient enough to diagnose Chikungunya fever

Treatment of Chikungunya fever

Paracetamol 10 to 15mg per kg body weight given 3 to 4 times a day reduces the fever.It is needed only in the first 2 to 3 days of illness.

Non Steroidal anti inflammatory agents have to be given liberally to reduce the pain and swelling. This may have to be continued for few weeks in some patients with persistent joint pain. Renal and Gastric safety have to ensured while taking such medicines.
Short course of steroids like Prednisolone also helps in resistant cases.
Other analgesics like Tramadol are also useful.
Disease modifying anti rheumatic agents like Chloroquine have been found useful in some studies.Personally I feel Chloroquine is not of much help as it is a slow acting drug taking almost 3 months to be fully effective.

Most of the patients who turned to alternative systems of medicine for relief came back to me saying there is no relief to pain.Many had to take NSAIDs along with their Ayurvedic and Homeopathic medicines which proved that other systems have nothing much to offer.

In short Chikungunya fever is easy to diagnose but not that easy to treat, but to those who suffer it is pure hell.

Friday, October 3, 2008

Smoking banned in public places from today

India on Thursday once again imposed a countrywide ban on smoking in public spaces in its fight against tobacco use, four years after a largely ignored earlier prohibition saw people continue to puff away in restaurants, clubs and bars.The ban, aimed at the country's 120 million smokers, has received a good response from people across the country,Health Minister Anbumani Ramadoss asserted.
"It is a continuous process, ... and the message will go across through repeated awareness campaigns by the government and the media," Ramadoss, a tireless anti-smoking campaigner, told reporters.

The new order bars smoking in hotels, eateries, cafes, pubs, bars, discotheques, offices, airports, railway stations, bus stops, shopping malls and parks. People can continue to smoke in private homes and open spaces.The new ban has directed establishments to appoint anti-smoking officers who will be liable if people smoke.

Britain, France, Ireland and Thailand are among the countries that already have similar bans in place.
The fine for violating India's order is 200 rupees (4.29 dollars), but health authorities said higher fines of up to 25 dollars were being contemplated.
The new Smoking in Public Places Rules 2008 came into force on the anniversary of the birth of Mahatma Gandhi the Father of Nation, who was known for his ascetic habits.
Citing a survey that found that 52 per cent of children took up smoking after watching film stars lighting up on the screen, Ramadoss appealed to Bollywood celebrities not to encourage smoking.
"People look up to celebrities and follow them," the minister said. "Our popular film star Rajnikanth has stopped smoking in movies. Other stars should also set an example."
Besides the police, government officers; inspectors of central excise, sales tax, transport and health departments; and principals of schools have been given powers to fine violators on their respective premises.
Officials acknowledged that enforcement might not be easy.

India is the third-largest tobacco producer and consumer in the world after China and the United States.
According to a Health Ministry release, more than 2,200 Indians die every day from tobacco use. They are at risk from cardiovascular diseases like heart attacks, strokes and cancer.
A recent study by a team of doctors showed that tobacco smoking would kill 1 million people annually beginning in 2010.
Saying India is in the midst of a "catastrophic epidemic of smoking deaths," the doctors warned that nearly 70 per cent of the million deaths would take place among smokers in their prime.

In this large, nationally representative case–control study, it was found that in both rural and urban India, among men between the ages of 30 and 69 years, the rate of death from any medical cause in smokers was 1.7 times that in nonsmokers of similar age, educational level, and alcohol status (use or nonuse). Among female smokers, mortality from any medical cause was double that among their nonsmoking counterparts.
If you are still not convinced about quitting smoking read this and decide.

Wednesday, September 24, 2008

What to do if an HIV positive person comes to you for help?

This post is for all health care providers and Social workers in India.
You know an HIV positive person who needs medical help.What to do?
First thing you have to make sure is whether he/she is really 'positive'. Three positive rapid tests detecting antibody is considered confirmatory. These tests are done virtually free of cost at all major Government Hospitals. The person can go directly there to the testing centre and get tested.No need for a doctor to order the test.
If he/she do not want to test in a Government testing centre you can ask him/her to get tested in a good private lab. There the more costly Western Blot test is usually done to confirm the diagnosis.
If the diagnosis is confirmed the most important thing is to reassure the patient that HIV/AIDS is a treatable condition now and the treatment is available free of cost at ART Centres attached to certain major Hospitals. Before starting treatment few other blood tests also have to be done to assess the immune status and overall health of the patient.
It is important to note that all positive persons do not need treatment.If there are no illness and if the person's immunity status is good[meaning the CD4 count is more than 200], treatment is not started immediately.The person needs to follow up regularly to check his immune status.
What do you mean by Immune status?
It is a measure of the ability of the person's body to fight against infections. HIV virus slowly destroys the ability of the body to fight against infections.Such an immune compromised individual can get infections easily.
Why treatment is delayed till the immunity is destroyed?
In early stages of infection especially the first 5 years the body partially win the battle against HIV. Slowly but surely the virus get the upper hand [in most of the positive persons] and the body's immune system gets destroyed. Only at this stage the person becomes ill. We start anti HIV treatment at that time so that we can prevent the person falling ill due to various infections.
Starting treatment before that do not give much benefit.As of now we can only reduce the multiplication of the virus to a minimum.We cannot eradicate the virus. Also the anti HIV medicines have many side effects.There is also chance of drug resistance if the dosages are missed. Considering all this treatment initiation early in the course of HIV infection is not very useful.
It is also important to test the spouse of the person.If the mother is positive the children if any also have to be tested.
If there is a pregnant positive woman, she needs treatment to prevent her child getting infected. This also is provided at ART centres.
Compassion and good advise is what that is needed for a newly detected 'positive' person.

Tuesday, September 23, 2008

Obstinate Patient?

The other day I had a tough time with one of my patient.
She was 54 years of age.She was diagnosed Type 2 Diabetes 5 years ago. Her blood sugar was under fair control with a tablet taken in the morning before breakfast. But for the last 3 months it was high in the mid 300s. I wanted to increase the dosage of her medicine.I told her it will be better to take half a tablet before dinner also.
But her response surprised me.She refused to take medicine in the evening.
'Why'? I asked.
' I am taking an Ayurvedic herbal powder as medicine for Diabetes in the evening' I cant stop that.
I got irritated.May be I was in an irritable mood.
'You first decide on the system of medicine you want to follow.If you want to follow modern medicine you obey my instructions' I shouted.[ I never shouts but my voice was raised].
She was taken back by my raised voice.
'I have been taking that powder for last 3 years'. She pleaded.
'So what?' 'It is not reducing your Blood sugar.So better stop'. My voice was still raised.
She pleaded again but I held on to my tough stand.
Her eyes were red and tears appeared. I did not know what to do for some time.
Then I relented. 'You take your powder in the evening 2 hours before the tablet'.
'If both are taken in the evening will there be any interaction?" She was worried.
I said there wont be any problem. She was relieved and I was able to defuse a difficult situation.
May be I should have proposed that compromise formula earlier.I should not have raised my voice.Some days I may become too irritable.

Friday, September 19, 2008

A Study in Contrast

The other day two of my patients were boys who presented so differently.Their stories were a study in contrast.
The first boy came along with his anxious parents.Both of them were school teachers. The boy was around 14 years and appeared healthy.
' What brings you here?' I asked.
' His urine is frothy'.The mother said.Is he having a kidney problem? They were very anxious as a classmate of their son had Kidney disease.
I examined him in detail and could not find anything wrong.Then I asked for a series of tests of urine and Blood and that too were normal.
I reassured the parents and send them off.

The other' boy' came with his father.They were from a village 30kms away. They came with a reference letter from a Local doctor.The ' boy' looked as if he is about 12 years old. When I looked down at the patient file in front of me I was shocked to see the age written as 23.Was it a clerical mistake?I asked the father about the boy's age.Yes it is 23. I read the reference letter.Yes he was referred to me to find a reason for his short stature.
I examined him. His height was 123cm and weight 24 Kilograms. He did not show any features of puberty. He had no hair growth over face, chest, armpits or genitalia.
His penis was small and testicles rudimentary. His voice was like that of a 10 year old child. It seemed as if his body got stuck at 10 years for the last 13 years.
'When did you notice that there is something wrong in your son?' I asked the father.
He told me that once a doctor told him the boy had problems and need many tests to find out the cause,but nothing was done.
Why those tests were not done?
Money was the major problem he said apologetically. 'Also I was sick for several years.So there was nobody to take him to distant City to do the tests.' He added.
He is probably a case of ' Pituitary Dwarfism'. It is an abnormality rarely seen in children.They stop growing early or growth is very much delayed. This is caused by deficiency of Growth hormone . Such children may have deficiency of other hormones also.This may result in lack of sexual maturity as seen in this boy.
Early diagnosis in the childhood is important. Treatment with Growth Hormone Injections usually makes a big difference.But it have to be given before adulthood.By 18 to 20 years the bone plates fuses and further growth is not possible.
Treatment with sex hormones may help this 'boy' to mature.But he will never gain height. He could have gained height if treatment was started when he was around 15 or earlier.
Such contrasting tales I see in my practise regularly. India is full of such contrasts. Over anxious literate and well off parents who know many things and is afraid of all known and unknown diseases attacking their children on the one hand,and the illiterate poor rural folk who accepts everything that is given to them as destiny on the other hand.
India is a land of
Luxury,opulence and high education on one side
poverty,illiteracy and ignorance on the other side.

When will this huge divide go away?

Tuesday, September 9, 2008

Diabetes management in the Third World

He is 32 year old male. He is a poor manual labourer ready to do any kind of job.He is also a Type 1 Diabetes patient for last 7 years.

He lived near the place I worked previously.He presented to me 7 years ago with sudden loss of weight and severe fatigue. His blood sugar was around 500mgs. He was treated with insulin and fluids and he became better.A trial of oral tablets for Diabetes was tried but did not work. He could not afford C peptide estimation or antibody estimation to prove that he is having Type 1 Diabetes. As he responded only to Insulin he was assumed as type 1 and treated with twice daily premixed Insulin.

As I moved out from that area I did not see him for few years. Last week he came to me again. He came for some relief to his severe unbearable ear ache. I asked him about his Diabetes.He reassuringly told me that he is taking Insulin injections regularly twice a day.He was not concerned about his Diabetes.He is having this ear ache and discharge for last few months. I examined him and saw that he had thick pus coming out of his right ear. He also had high blood pressure and severe numbness of his feet.
'When did you check your blood sugar?' I asked.
He was not very sure. 'May be 3 months ago', he replied.
What was the sugar value? I persisted
'May be around 300. It was always around that when i check'. He revealed.
'Do you keep your Insulin in refrigerator'? I enquired. I remembered that he used to keep his Insulin at a pharmacy nearby as he or his neighbours did not have a Fridge.
'No .I keep it in a plastic Mug filled with water'.
'Why not in the pharmacy'? I asked.
His explanation was like this. The pharmacy in which he used to keep his Insulin had closed few years ago.Also somebody had told him that Insulin if not kept in a Fridge, should be kept under water.
Here is a Type 1 Diabetes patient who is storing his Insulin improperly and thereby reducing its potency. He is taking this low potency Insulin and is checking his blood sugar rarely.His blood sugar is always high and now he is developing Diabetic nephropathy and neuropathy.Due to this poorly controlled blood sugar he had also developed acute ear infection about which only he is bothered.
What should I do?
I told him the importance of keeping the Insulin in a cool environment.I asked him to see anyone of his neighbours have a Fridge.If not I told him to buy an Earthen pot, put water and few pieces of ice in it and put the insulin in it so that it is submerged in water.I also gave him a week's course of antibiotics for his ear infection and few anti BP tablets. I refused his offer of consultation fee.
Should I have done more? Should I have donated a refrigerator to his house? Or should I have helped him in any other way?

I don't know.
There are thousands of such Type 1 Diabetes patients through out the third world. Only very fortunate few survive more than 10 years after diagnosis.
Let us hope the future will be bright for such patients. Let us work for more just world.

Sunday, September 7, 2008

Is it AIDS doctor?

A 48 year old man came to my clinic with his brother. The man is working in one of the Persian Gulf Countries. He was in Persian Gulf for the last few years but was not regularly employed.He was staying with and was dependent on his friends and relatives most of the time. 5 months ago he was fortunate enough to get a good job. Finally he started sending money to his family in India.

His illness also started 5 months ago.He began getting loose stools. Some times there was blood in the stools.He lost all his appetite and became thin.His friends asked him to see a doctor. He did not had a health insurance or other benefits.He knew that seeing a doctor there means lot of money.He applied for leave to come to India for treatment,but it was rejected. He continued to suffer and lost around 20 kilograms in weight. Sensing something wrong his boss gave him leave.Thus he presented before me.

He was extremely ill looking, thin and emaciated. He said he is having frequent tummy pain along with loose stools.Some times it is mixed with blood, which he attributed to Piles. He was pale and his blood pressure was on the lower side.I asked him to lie down. I examined his abdomen. He had a fairly large and hard palpable Liver.He also had pain on pressing his lower abdomen on the left side.For me the diagnosis was obvious.

I asked him to do some blood tests and an Ultra sonogram of his abdomen and come back to me with the reports in 2 hours.
Both of them went out but the patient's brother returned immediately, came close to me and asked
'Is it AIDS doctor?
I wish it was AIDS. I replied.
His face showed his confusion.I explained. Probably it is advanced Colonic cancer which had spread to Liver. If in operable the chances of survival are very slim.
If it is AIDS I can offer a lot and he will live healthy for long.But......
The Ultrasound scan suggested my impression was correct.He was referred to higher centre. Subsequent CT Scan and a colonoscopic biopsy confirmed the diagnosis.

Yesterday was his day of surgery.It was planned to remove the colonic tumour and to give chemotherapy later for the Liver lesion. His brother called me in the afternoon.He was crying when he said that the colon tumour was in operable as there was adherence to Urinary bladder. They just did a diversion of bowel to abdominal wall so that he wont have obstruction to bowel movements. His days are numbered.

Colonic cancers especially on the left side are slow growing and are diagnosed early because of alteration in bowel habits and bloody stools. When diagnosed early it is a curable cancer.
This patient because of his circumstances delayed seeking medical help which now proved was suicidal.