A malayali doctor's blog

What you wanted to know about Dengue fever

2011-08-11T08:00:00.004+05:30

What is Dengue fever (DF)? What are Dengue haemorrhagic fever and Dengue shock syndrome?

Dengue [pronounced Den' gee] infection is caused by a virus. There are 4 types of Dengue viruses,namely DENV 1, DENV 2, DENV 3, and DENV 4. It occurs commonly as dengue fever. Occasionally the patient suffering from dengue may develop bleeding. Common sites for bleeding are nose, gums or skin. Sometimes, the patient may have coffee ground vomiting or black stools. This indicates bleeding in gastro intestinal tracts and it is serious. The patient with dengue who has bleeding has dengue haemorrhagic fever (DHF ). Rarely the patient suffering from dengue may develop shock because of low blood pressure, then it is called dengue shock syndrome ( DSS). DHF and DSS are common in persons who had a previous infection with another type of Dengue virus.

How do one get infected with Dengue virus?

The Dengue viruses are transmitted to humans by the bite of an infected mosquito. The Aedes aegypti mosquito is the most important transmitter or vector of dengue viruses, although many of the recent outbreaks were transmitted by Aedes albopictus. It is estimated that there are over 100 million cases of dengue worldwide each year.

Aedes aegypti has a peculiar white spotted body and legs and is easy to recognize even by laymen. It breeds in clean water and has a flight range of only 100 – 200 metres.The mosquito gets the Dengue virus after biting a human being infected with dengue virus.

When does dengue develop after getting the infection?

After the entry of the virus in the person, it multiplies in the lymph glands in the body. The symptoms develop when the virus has multiplied in sufficient numbers to cause the symptoms. This happens generally about 4-6 days ( average) after getting infected with the virus.

Can people suffer from dengue and not appear ill?

Yes. There are many people who are infected with the virus and do not suffer from any signs or symptoms of the disease. For every patient with symptoms and signs there may be 4-5 persons with no symptoms or with very mild symptoms.

When should I suspect Dengue?

Dengue should be suspected when you have sudden onset of fever WITHOUT cough,cold,pain on urination etc. The fever is high 103-105 degrees F or 39-40 degrees C. It is accompanied with severe headache (mostly in the forehead), pain behind the eyes, body aches and pains, rash on the skin and nausea or vomiting. The fever lasts for 5-7 days. In some patients, fever comes down on 3rd or 4th day but comes back. All the above symptoms and signs may not be present in the patient. The patient feels much discomfort after the illness.

How does Dengue fever differ from other type of fevers?

Fever is usually abrupt in onset and very high.There wont be any running nose,cough etc.Slowly rising fever peaking only in few days time is unlikely to be Dengue fever.The characteristics of dengue that make it different from other causes of fever are the pain behind the eyes, severe pains in the muscles, severe bone and joint pains, and skin rashes. These features make the diagnosis of suspected Dengue likely. Even though there is joint pains there wont be any joint swellings as in Chikungunya fever.The severe bone pains caused by DF is the reason why DF is also called break-bone fever.

Generally, younger children and those with their first dengue infection have a milder illness than older children and adults.

Dengue hemorrhagic fever is characterized by a fever that lasts from 2 to 7 days, with general signs and symptoms consistent with dengue fever. When the fever declines, symptoms including persistent vomiting, severe abdominal pain, and difficulty breathing, may develop. This marks the beginning of a 24- to 48-hour period when the smallest blood vessels (capillaries) become excessively permeable (“leaky”), allowing the fluid component to escape from the blood vessels into the peritoneum (causing ascites) and pleural cavity (leading to pleural effusions). This may lead to failure of the circulatory system and shock [lack of blood supply/oxygen to tissues], followed by death, if circulatory failure is not corrected. In addition, the patient with DHF has a low platelet count and hemorrhagic manifestations, tendency to bruise easily or other types of skin hemorrhages, bleeding nose or gums, and possibly internal bleeding.

How is the diagnosis of dengue is confirmed?

There are laboratory tests that provide direct or indirect evidence for dengue fever. These tests provide evidence for the occurrence of dengue infection. There are some additional tests that can help to identify the type of dengue infection. The tests for confirmation of Dengue should be done in reliable laboratories.

The method used for diagnosis varies depending on its availability,cost, speed of obtaining the result and reliability. It also very much depend on when during the course of the disease blood sample is taken.

Can dengue fever be treated at home?

Most patients with dengue fever can be treated at home. They should take rest, drink plenty of fluids that are available at home and eat nutritious diet. Whenever available, Oral Rehydration Salt/ORS (commonly used in treating diarrhoea) is preferable. Sufficient fluid intake is very important and becomes more important in case DF progresses into DHF or DSS where loss of body fluid / blood is the most salient feature.It is important to look for danger signs and contact the doctor as soon as any one or more of these are found.

What is the treatment?

Like most viral diseases dengue fever can subside on its own.Paracetamol is the main stay to reduce fever.Pain killers/anti inflammatory agents like Aspirin/Brufen should be avoided since they can increase the risk of bleeding.. Antibiotics do not help. Doctors should be very careful when prescribing medicines. Any medicines that decrease platelets should be avoided.

Symptomatic management is the main stay of treatment.

When should a patient suffering from Dengue go to the hospital or consult a doctor?

Generally the progress towards dengue haemorrhagic fever or dengue shock syndrome occur after 3-5 days of fever. At this time, fever has often come down. This may mislead many of us to believe that the patient is heading towards recovery. In fact, this is the most dangerous period that requires high vigilance from care-givers. The signs and symptoms that should be looked for are severe pain in the abdomen, persistent vomiting, bleeding from any site like, bleeding in the skin appearing as small red or purplish spots, nose bleed, bleeding from gums, passage of black stools like coal tar. Bring the patient to the hospital whenever the first two signs, namely, severe pain in the abdomen and persistent vomiting are detected. Usually it is too late if we wait until bleeding has occurred.

The most dangerous type of dengue is the dengue shock syndrome. It is recognized by signs like excessive thirst, pale and cold skin (due to very low blood pressure), restlessness and a feeling of weakness.

Can dengue fever become dangerous?

The infection can become dangerous since it may cause damage to the blood vessels. The damage may range from increased permeability of the blood vessels, causing leakage of blood fluid/plasma into various organs to completely broken blood vessels that causes bleeding.The symptoms and signs of dengue haemorrhagic fever and dengue shock syndrome are related to damage to the blood vessels and derangement in functioning in components of blood that help it to clot. Mortality in DSS is around 1-5%.

What should the doctors treating dengue do ?

Patients suspected to be suffering from dengue haemorrhagic fever or dengue shock syndrome should be admitted to a hospital without delay.

The progress of these patients should be monitored regularly at 1-2 hours interval.

Platelet counts and haematocrits should be monitored repeatedly to review the progress of patients.

If the haematocrit levels fall dangerously then a blood transfusion should be considered. A fall of more than 20 % as compared to previous levels may be an indication for transfusion.

If the haematocrit values rise the patient should be given fluids intravenously and the fluids carefully monitored to ensure that the patient does not get excess fluids. A rise of Hematocrit more than 20 % as compared to previous levels may be an indication for IV fluids. The doctor should decide based on best judgement of patient's condition.

What should the doctors treating dengue avoid?

Do not prescribe aspirin and brufen or any other medicine that reduces the platelets or increases the tendency to bleed.

Avoid giving too much IV fluids unless the patient is bleeding or the haematocrit level is rising progressively.

Avoid rushing into giving blood transfusion unless the haematocrit is falling dangerously.
Do not give platelet transfusion unless the platelet count is very low or unless there is bleeding.

Can you get dengue again after suffering from it once?

It is possible to get dengue more than once. Dengue can occur because of 4 different but related strains of dengue virus. If a person has suffered from one virus, there can be a repeat occurrence of dengue if a different strain is involved subsequently. Being affected by one strain offers no protection against the others. Recovery from infection by one provides lifelong immunity against that virus but confers only partial and transient protection against subsequent infection by the other three viruses. There is good evidence that sequential infection increases the risk of developing DHF because this partial immunity produces severe immune reaction in the body.

What is the Global incidence of dengue?

The incidence of dengue has grown dramatically around the world in recent decades. It is a disease of the tropical and sub-tropical regions Some 2.5 billion people – two fifths of the world's population – are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year.The disease is now endemic in more than 100 countries Before 1970 only nine countries had experienced DHF epidemics, a number that had increased more than four-fold by 1995.

Where does the mosquito that spreads dengue live?

What is the incidence and mortality of DHF?

An estimated 500 000 people with DHF require hospitalization each year, a very large proportion of whom are children and young adult. About 2.5% of those affected die.

Why there is an increasing incidence of severe Dengue infection World-wide?

Rapid and disorganised Urbanisation,poor solid waste management and lack of running water, leading to storage of water in households etc are some of the factors that is causing an enormous increase in Dengue infections.

The highly domestic mosquito Aedes aegypti rests indoors, in closets and other dark places. Outside it rests where it is cool and shaded. The female mosquito lays her eggs in water containers in and around the homes, and other dwellings. These eggs will develop, become larvae, and further develop into adults in about 10 days.

How can the multiplication of mosquitoes be reduced?

Dengue mosquitoes breed in stored, exposed water collections. Favoured places for breeding are barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water coolers etc.

To prevent the mosquitoes from multiplying, drain out the water from desert coolers/window air coolers (when not in use), tanks, barrels, drums, buckets etc. Remove all objects containing water (e.g. plant saucers etc.) from the house. Collect and destroy discarded containers in which water collects e.g. bottles, plastic bags, tins, used tyres etc.
In case it is not possible to drain out various water collections or to fully cover them, use TEMEPHOS, an insecticide, ( brand name Abate) 1 part per million according to the local guidelines to prevent larvae from developing into adults.

How can I prevent mosquito bites to prevent dengue?

There is no way to tell if a mosquito is carrying the dengue virus. Therefore, people must protect themselves from all mosquito bites.

Dengue mosquitoes bite during the day time throughout the day. Highest biting intensity is about 2 hours after sunrise and before sunset.
Wear full sleeves clothes and long dresses to cover as much of your body as possible.

Use repellents- be careful in using them in young children and old people. Use mosquito coils and electric vapour mats during the daytime also to prevent dengue.

Use mosquito nets to protect children, old people and others who may rest during the day. The effectiveness of these nets can be improved by treating them with permethrin (pyrethroid insecticide). This bed-net is called Insecticide Treated Nets and are widely used in the prevention of malaria.

Is there any advice for the patient with dengue fever to prevent the spread of the disease to others?

The spread of dengue from a patient to others is possible. The patient should be protected from contact with the mosquito. This can be achieved by ensuring that the patient sleeps under a bed-net. Effective mosquito repellents are used where the patient is being provided care. This will prevent the mosquito from biting the patient and from getting infected and spreading it to others.

I am sure there will be many more questions about Dengue fever. Feel free to ask them in the comments column of this post.I will try my best to answer.

This post is dedicated to all those who tragically succumbed to Dengue infection and their families, especially to this young woman. blogger .

Links

http://www.who.int/mediacentre/factsheets/fs117/en/

http://www.cdc.gov/dengue/fAQFacts/index.html

http://www.searo.who.int/en/Section10/Section332/Section1026.htm#2

http://malayalidoc.blogspot.com/2010/08/tips-for-prevention-of-breeding-of.html

http://malayalidoc.blogspot.com/2009/07/feverish-rainy-season.html

http://malayalidoc.blogspot.com/2009/09/what-could-be-her-diagnosis-part-2.html

http://malayalidoc.blogspot.com/2008/11/non-medical-reasons-for-referring.html

http://malayalidoc.blogspot.com/2008/12/non-medical-reason-for-referring.html

Better care than at home?

2011-08-04T06:59:00.001+05:30

The other day I was able to visit an Old age home and was amazed at the care the inmates are getting.

It is a small venture run by a young widow, a trained nurse. She runs the institution in a small rented house.

She started by taking care of an old woman who was abandoned in the Hospital where she was working. She took the old lady to her house to take care. Soon the inmates began to increase.

Many were orphaned old women roaming around the streets, finally ending up in hospital wards. Some were abandoned by the family. Most of these women are in their 70s or 80s. They come from all parts of Kerala. They belong to many religions. Some are mentally not all right. Most of them are suffering from physical ailments. But it seemed all of them were happy living there.

Whenever I see old people as patients, I feel dissatisfied with the level of care they are getting in their homes. Medicines are never given as prescribed and doctor appointments are often delayed and missed. When the family is tight financially the old people's medicines are not bought for few days to weeks. Now this does not happen everywhere but in a large number of homes.

But I was happily surprised at the level of care given at this old age home. Though the inmates were only around 12 the nurse knew each and every detail of their ailments and medicines they were taking. They were given food and medicines in time. Their personal hygiene were well looked after. Whenever a doctor consultation is needed she will call me or someone else she know. She ensures doctor visits and sees the inmates at least once in 2 months.

The inmates were so happy to get such a level of care that they were not coming out to me with any physical complaint, though most of them were very ill.

Spending your last years in your house with the family taking good care of you is the best option any one can have. These women were not fortunate enough to get that. But they are lucky enough to have very good care and love during their final years, something many old people do not get even from their homes.

Too much work

2011-07-23T00:17:00.003+05:30

I have not been posting in this blog for some time now. Thought I should revive it with more posts.

I left the Government service thinking I will be able to give more time, deserving time, to each of my patient when I work as a private consultant. 7 years as a private consultant and I am not happy with the amount of time I am able to give to each patient. This is particularly true during this busy Fever season. As the time I stay in the same place and see patients increases the number of Patients/families who have absolute faith in me increases. Thus a large pool of patients are created who just want an opinion from me. Many a time I am not able to give deserving time for each patient, still they are satisfied. I am now trying to consciously to reduce the number of patients I see, and it is difficult. I will have to make a large number of people unhappy with this, but I feel I do not have a choice. Let me see how it works.

Is 'honor' more important than your wife's health?

2011-02-17T01:51:00.000+05:30

Few days ago a doctor who is well known to me called to ask the diagnosis of one of his distant relative who is under my treatment.
I hesitated.
I asked him why you were asking that question.
He said that the guy was admitted in a critical condition in another hospital.I asked further details and realised that the patient is in deep coma and not in a position to give consent to reveal his diagnosis.
Then I told the doctor that his relative was under my treatment for last 5 years for HIV related illnesses. He was very surprised.Nobody in the family it seems know about it. But I was not surprised.

Let us call this guy Mr K.
He was referred to me 5 years ago by another doctor after he was found to be HIV positive while he was being investigated for recurrent fever. He came alone to me and was mentally a wreck. I could make out that he was thinking about taking his life.
It was very difficult for me to convince him that there is treatment for this and everything is not lost. I told him you can live as near normal life as others if you take proper care and regular medicines. Then I told him that his wife has to be tested.
He said he cannot tell this to his wife as she will be shattered and the family life will be doomed.
" It is better for me to take my life than to tell this to my wife".
"OK you should tell this after some time.But meanwhile do not have any sexual contact,I warned".
He agreed.
Every time he come to me I used to ask him about informing his wife and he was adamant that he cannot.
I continued to prescribe medicines and monitor him. He was doing fairly well continuing his job and doing everything he need to do as the head of the family.
He did not attend my OPD for last few months and I was wondering what happened to him. I was afraid he was not taking medicines properly and his illness must have exacerbated.
What I was afraid of happened.
Just now I received a more dreaded news. His wife was also tested positive for HIV, though she appears relatively healthy at present.
Was she positive at the time of her husband's diagnosis? Or did Mr K broke the promise he gave to me and had sexual contact with her even after knowing he is positive.I hope it was the former.
If she was already positive and I knew it I would have been able to manage her health better.Should I have insisted on bringing the wife and telling the truth before prescribing medicines for Mr K?
Why Mr K refused to tell the truth and test his wife?

Is 'honor' more important than your wife's health?

What is your speciality?

2011-01-19T02:10:00.000+05:30

"What is your speciality?"

I was attending a Party in a relative's house in a City far away from my workplace. I had to face this question more than once that night. I was speechless for a moment.

I am asked that question whenever I am among strangers not connected to Medical profession and always find it difficult to make people understand my area of work.

Should I say I am a General Physician?

Then they will say 'Oh you are a General Practitioner" which is not quite correct though many consider us as glorified General Practitioners.

Should I say I am an Internist?

Then they will ask what that is and I will have to explain that an internist is a doctor who specializes in identifying and treating diseases which do not need surgery. Many will still not understand.

Sometimes I say I am a Diabetologist. I have trained myself to be one and most of my patients are Diabetics thanks to high incidence of Diabetes in Kerala.

But am I just a Diabetologist?

No I do not want to be considered only as a Diabetologist. I also had some training in Rheumatology and also in HIV/AIDS.

Many well wishers have asked me why you are not concentrating on one sub-speciality/super-speciality.

"Why don't you take a DM in Cardiology or Neurology? You can earn double for the same amount of work"

But I never wanted to confine myself to one organ or organ system. Also after spending almost 10 yrs in training in Medicine I did not want another 3 years in Medical College. Being an MD in Internal Medicine I believed I am competent enough to tackle most of the cases that come to me. I could also work in smaller towns without much infrastructure unlike a sub-specialist. I also felt that work of an Internist is more exciting, dealing with a large variety of disease conditions.

So I never tried for a DM.

We the Internists always used to say jokingly that a Sub-specialist [we never call them super-specialist] is a doctor who knows more and more about less and less. Sub-specialists will say we are just jealous.

Now after 14 years of practice as an Internist, when I look back I do not have any regrets.

But I am still speechless when that question is asked.

"What is your speciality?"

Fake therapies.How can we stop it?

2010-12-19T16:52:00.000+05:30

"Doctor, can I take 'Abcdxyz' for control of my Diabetes?"

The patient in front of me was asking about one of those numerous alternative 'medicines' for Diabetes advertised all over the media.

Iam asked such questions very often and my standard reply was I am a practioner of Modern Medicine and had little or no knowledge of other Medicinal Systems.

"Is there any harm in taking such medicines?" will be the next question and I will reply that I do not know.

Do I really do not know anything about such alternative medicines? If so why? Should I have been able to guide my patients better about the usage of alternative medicines?

Modern medicine is the science that tries to use all the new knowledge and technology available for mankind to improve the health of human beings. Being a practitioner of Modern Medicine and a keen follower of all research that is taking place in this field I should be able to tell whether a therapeutic method is superior, inferior or useless in comparison to currently accepted treatment method.

So how can I research the data regarding these so called ‘wonder alternative medicines’ for Diabetes? Is there any research ever done for these drugs?

The truth is no good quality research takes place before such products come into market. The Company that produces and markets such drugs never provides any research data. Just plain logic should make all of us realise that these medicines are ineffective because a medicine that can be proven to reduce blood sugar even by few milligrams can make billions if it was scientifically approved. The mere fact that no effort is made to get scientific approval for such products by conducting scientific studies tells us that these products are just placebos sold to unsuspecting public with massive advertisement budgets.

Should we stop such Fake therapies?

Many will say that even though such therapies are ineffective they can do no harm, so why one should try to stop them.

The Companies are fooling unsuspecting people using the name of ancient Indian science Ayurveda. People are wasting their hard earned money by buying and consuming useless products. They could have used this money for a much more useful purpose in bettering their lives.

Also how can one surely say that there are no harmful effects for such products without any proper studies? So stopping of such fake therapies is important for society's health.

How can we stop such Fake therapies?

Most important step should come from the Government. All such alternative medicines and supplements should undergo rigorous scientific testing before they are sold in the market. Advertisements with exaggerated or false claims should be severely curbed.

As a practising doctor I should strongly discourage patients from taking such unproven therapies. I should explain to them that their money will be wasted and no one has any idea of the side effects that it can produce.

With increasing awareness among Indian consumers I feel that people of our country cannot be taken for granted any more. Useless [and maybe harmful] products minting money for unscrupulous Companies should be stopped.

UK Govt continues support for Homeopathy despite lack of evidence of efficacy

2010-10-27T00:51:00.002+05:30

United Kingdom Parliamentary Committee on Science and Technology was asked to review the efficacy and the policy of Govt funding for Homeopathy last year. On February 22,2010, the committee submitted a report to the Government. The report,one of the most comprehensive evaluation of Homeopathy by a Government Body recommended discontinuation of State funding for Homeopathy.
Here are some excerpts from the report:

...We conclude that the principle of like-cures-like is theoretically weak. It fails to provide a credible physiological mode of action for homeopathic products. We note that this is the settled view of medical science....

....We consider the notion that ultra-dilutions can maintain an imprint of substances previously dissolved in them to be scientifically implausible.....
....In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos.....
...There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious. Competition for research funding is fierce and we cannot see how further research on the efficacy of homeopathy is justified in the face of competing priorities.
It is also unethical to enter patients into trials to answer questions that have been settled already.

...We do not doubt that homeopathy makes some patients feel better. However, patient satisfaction can occur through a placebo effect alone and therefore does not prove the efficacy of homeopathic interventions...
..For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments.
For homeopathy this would certainly require an explanation that homeopathy is a placebo. When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo—that is, homeopathy—may be diminished. We argue that the provision of homeopathy on the NHS, in effect, diminishes, not increases, informed patient choice.

...The Government should stop allowing the funding of homeopathy on the NHS.
We conclude that placebos should not be routinely prescribed on the NHS. The funding of homeopathic hospitals—hospitals that specialise in the administration of placebos—should not continue, and NHS doctors should not refer patients to homeopaths.

Govt Response

Even though the UK Government agreed to most of the points raised by the Committee report,it did not agree to stop NHS funding for homeopathy.Instead the Government is trying to put the ball in the local hospital/clinician's court.

The Govt response said:

We agree with many of the Committee’s conclusions and recommendations. However, our continued position on the use of homeopathy within the NHS is that the local NHS and clinicians, rather than Whitehall, are best placed to make decisions on what treatment is appropriate for their patients - including complementary or alternative treatments such as homeopathy - and provide accordingly for those treatments.

In its response to the report, the Government also said that it will keep the position on NHS funding under review.
"However, we believe that providing appropriate information for patients should ensure that they form their own views regarding homeopathy as an evidence-based treatment," it said.

Scientists point out, however, that if patients are told clearly that there is no credible evidence to support homeopathic treatments, this may undermine the only benefit that homeopathy is likely to provide, namely the well-established "placebo effect" where someone feels and gets better because they believe a treatment is working.

My view

I fully agree that Homeopathy is just a glorified placebo. At the same time it has an important role to play in the society as a pseudo scientific placebo [some may compare it with the good effects of God/religion in society]
In Indian situation it is more relevant. With Modern medicine practise as un-regulated as in India misuse of antibiotics is very wide spread. Many self limiting viral infections when presented to a modern medicine practitioner receives an antibiotic prescription.If all such mild illnesses gets treated by a homeopathic placebo,the emergence of antibiotic resistance could be delayed.
Moreover for many mild illnesses modern medicines with varying toxicity profiles are prescribed instead of reassurance. Here a homeopathic consultation will provide reassurance in the form of harmless homeopathic drugs.
My conclusion is that what ever be its lack of efficacy homeopathy should continue as a harmless placebo.

Links
Parliament Committee report
Govt Response

Tips for prevention of breeding of Aedes mosquito in your urban neighbourhood

2010-08-31T02:40:00.000+05:30

Dengue fever is an acute febrile illness which can be life threatening.The WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year.
Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus.So it is very important for us to know about these mosquitos and to learn how to prevent its breeding in our neighbourhood.

Dengue Virus Transmission

Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. The mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to ten days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. There is no way to tell if a mosquito is carrying the dengue virus. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined.

Aedes aegypti goes through a complete metamorphosis with an egg, larvae, pupae, and adult stage. The adult life span can range from two weeks to a month depending on environmental conditions. The life cycle of Aedes aegypti can be completed within one-and-a-half to three weeks

After taking a blood meal, female Aedes aegypti mosquitos produce on average 100 to 200 eggs per batch. The females can produce up to five batches of eggs during a lifetime. The number of eggs is dependent on the size of the bloodmeal. Eggs are laid on damp surfaces in areas likely to temporarily flood, such as tree holes and man-made containers like barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water cooler, etc. and a lot more places where rain-water collects or is stored. The female Aedes aegypti lays her eggs separately unlike most species. Not all eggs are laid at once, but they can be spread out over hours or days, depending on the availability of suitable substrates. Eggs will most often be placed at varying distances above the water line. The female mosquito will not lay the entire clutch at a single site, but rather spread out the eggs over several sites.

The eggs of Aedes aegypti are smooth, long, ovoid shaped, and roughly one millimeter long. When first laid, eggs appear white but within minutes turn a shiny black. In warm climates eggs may develop in as little as two days, whereas in cooler temperate climates, development can take up to a week. Laid eggs can survive for very long periods in a dry state, often for more than a year. However, they hatch immediately once submerged in water. This makes the control of the mosquito very difficult.

Prevention of breeding of Aedes mosquito

Aedes mosquito lay their eggs in clear,clean water and not in contaminated water.As they fly only a few metres their breeding place is usually in our house itself.

Most common breediing places and tips to prevent breeding

Water storage tank/cistern ---should have mosquito proof lids
water coolers/collection pans in Fridge/ACs ------ water should be drained out periodically

Drum ------tight lids
Flower vase with water [least in brass vase]----------change water frequently,use sand
Potted plants with saucers ------- change water frequently
Ornamental pool/fountain ---------water changed once a week
Roof gutter/sun shades------------check frequently for drain block
Animal water container----------- empty and clean periodically
Ant trap--------------------------use oil/salt
Used tyres-----------------------keep it under roof
Discarded large appliances-------bury or keep it under roof
Discarded buckets,plastic cups,tin cans etc-----bury

Whenever piped water supply is inadequate and available only at restricted hours or at low pressure, the storage of water in varied types of containers is encouraged, thus leading to increased Aedes breeding.It is essential that potable water supplies be delivered in sufficient quantity, quality and consistency to reduce the necessity and use of water storage containers that serve as the most productive larval habitats.

Chemical and biological agents can also be used for prevention of breeding of Aedes mosquito.

from
Denguevirusnet
WHO

'Superbug' scare. Myths and facts

2010-08-14T03:18:00.001+05:30

A scientific article in the Lancet has created big commotion in the media both in India and outside.It is being said that a bacteria which is resistant to all known antibiotics is wide spread in India and Pakistan and is being spread to other countries including U.K through medical tourism.This bacteria termed the 'superbug' is supposed to bring an end to the antibiotic era. Indian Government has come out with a clarification saying the media scare in UK is unwarranted.
Let me try to separate facts from myths in this issue.
Fact 1
WHO has identified antibiotic resistance as one of the greatest threats to human health. In the European Union (EU), about 25 000 patients die every year from infection with multidrug-resistant bacteria, and such infections result in health-care costs and lost productivity totalling at least €1·5 billion per year. Methicillin-resistant Staphylococcus aureus alone infects more than 94 000 people and kills nearly 19 000 in the US every year, more deaths than are caused by HIV/AIDS, Parkinson's disease, emphysema, and homicide combined.
Fact 2
Bacteria with Carbapenemase activity is a fast emerging threat in the field of antibiotic resistance all over the World as you can see from this article. India is actually a late entrant in this field.
Fact 3
There are 4 classes of Carbapenemase A,B,C and D.Each have different sub groups.So there are a large number of such bacteria producing different Carbapenemase isolated from all over the World.
Fact 4
New Delhi metallo-beta-lactamases[ NDM-1] belonging to B sub group of Carbapenemase was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008.It was given such a name assuming that the patient got it while hospitalized in New Delhi.
Fact 5
Further study in India indicated that NDM 1 enzyme producing bacteria are fairly common in a tertiary hospital in Mumbai.
Fact 6
In short NDM1 enzyme is the major cause for antibiotic resistance in Ecoli and Klebsiella species in India.In other countries enzymes are different and are named differently like VIM-1 (for “Verona integron-encoded metallo-β-lactamase” first isolated in Verona, Italy,) SPM-1 (for “Sao Paulo metallo-β-lactamase”), GIM-1 (for “German imipenemase”) SIM 1 (for Seoul imipenemase) etc.
Fact 7
The Lancet article in question is only about NDM 1 producing bacteria. It is a good attempt to find out the extend of spread of antibiotic resistance in bacteria in India.
Fact 8
It showed NDM in UK not only in those who had surgical procedures in India but also in many who have never visited India..Out of the 37 samples with NDM1 collected in UK, only 17 samples had history of travel to India or Pakistan.
Myth
The article in Lancet says
'It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals'.
This is an unscientific comment not based on any data.The authors have not proved that NDM 1 enzyme producing bacteria in UK was imported from India. More than 50% of patients in UK detected to have NDM 1 has never traveled to South Asia.Also the comment is not taking into consideration other groups and sub groups of Carbapenemase enzyme producing bacteria which are more prevalent in UK than in India.

The author of the article in Lancet seems to show undue haste in blaming medical tourism for antibiotic resistance in UK.

It is true that Indian health system abuses antibiotics like most other 3 rd World countries.While protesting the unfair conclusion of the author of the article let us hope that the concerned authorities will open their eyes to the lack of antibiotic policies in most health care centers of India and implement strict regulations so that patients both native and foreign are protected from emergence of resistant bacteria.

Two births that made me happy

2010-07-29T00:24:00.000+05:30

Last week two births made me very happy.

I had blogged about one of the mother before. She was a type 1 Diabetic dependent on Insulin for more than 12 years now. I had blogged about my interview with her to-be-husband in 'Strange Interview' . Also I had posted about the first time she became pregnant in 'Happy News' and about her abortion in 'Sad News'. Now she has delivered a healthy baby. She recently came to me with her husband and the new born and we were all smiling.
Many type 1 Diabetics deliver normal healthy babies but still it is a difficult task. Perinatal mortality and still birth rates are 4 to 5 times of normal pregnancies. That is why we were smiling.

The other birth was the planned conception and delivery of a baby for an HIV positive couple.The couple were my patients for last 5 years.They had asked me the possibility of parenting a child before .Initially I did not encourage them because I did not knew how compliant they will be with the treatment.schedule. They were regular in their follow up and very compliant in taking medicines in time. When they asked me again after 3 years of Anti retro viral therapy I was more positive.I directed them to a suitable center for guidance. After a lot of counseling they were ready to accept the risks involved. They did everything as told and the mother delivered by cesarian section a healthy baby recently.

This proved that nothing is impossible for a 'positive' couple.
Read more about HIV and Pregnancy here

Is alcohol good or bad for the Heart?

2010-03-27T00:32:00.001+05:30

Is alcohol good or bad for the heart?
I am asked this question many a time in my practice. I usually answer without committing myself. I will reply that in very small amounts it may not be harmful.
I am aware that many studies from the West have shown that mild to moderate intake of alcohol,especially Red wines are somewhat protective to the heart. At the same time I know that many who ask this question are alcoholics who just want a positive response from the doctor to continue to indulge in spirits.

A recent study in Indian males disapproves the theory that alcohol in mild to moderate doses has a protective effect on Heart. In a large retrospective survey based study [being the first of it kind in India looking at this question] conducted in 10 centers showed that alcohol consumption even in low amounts increased coronary artery disease risk. Heart attacks were more seen in those who are regular drinkers, occassional drinkers and even ex-drinkers when compared to life long abstainers.

Why Indian male drinkers are more prone to heart disease than Western drinking population?

The reasons are not clear and even lack of protective effect has to be proved with large prospective randomised controlled studies. But some theories are postulated.
1. Indians are more prone to binge drinking than Caucasian population.Binge drinking can cause Heart attack. In the above study around 55% were binge drinkers.
2. Indians tend to drink more stronger spirits that Caucasians. We drink more whiskey and Rum than wine and beer.
3. There may be genetic/racial difference in effect of alcohol on human body. African American drinkers also do not have that much protective effect on Heart as Caucasians.

So in conclusion let me state that the so called protective effect of alcohol on Heart is under a big question mark especially for Indians.
So please do not drink to live.

Pregnant but HIV positive

2010-02-08T00:33:00.001+05:30

The other day I received a call from a Gynaecologist of a nearby Hospital.

'I have an ante-natal [pregnancy] patient who is HIV positive. Should I send her to you now or after delivery?'

The doctor was asking me.

I was happy that she called to inform me, but was disappointed with her question. I had spend some effort as an HIV/AIDS trainer to make doctors aware that pregnant women need anti-HIV treatment to prevent the birth of a 'positive' child. I am not sure whether the above-mentioned doctor attended the training, but I expected her to know the importance of ART [anti HIV treatment] in pregnancy.

'You should send her to me immediately. She needs treatment to prevent the birth of a 'positive' child.' I replied.

The next day the patient came with her husband. I explained the situation to them in detail and asked them to attend the Govt ART center as early as possible. I telephoned the ART Medical Officer about this patient and fixed a suitable time for the patient to reach the center.

That lady will get the treatment, which will greatly reduce the chance of the birth of a 'positive' child from about 40% to less than 5%.

All pregnant females should be tested for HIV and if found positive should immediately receive treatment so that we can eliminate the chance of birth an HIV positive child

Should I give the cervical cancer vaccine to my daughter?

2010-01-19T08:05:00.003+05:30

A mother of a 12-year-old girl was asking me this question the other day.

"Should I give my daughter cervical cancer vaccine?"

I was not prepared for the question. Though I know such a vaccine is available I have not studied it in detail. So my answer was little bit evasive.

' It is a new vaccine. Needs to be studied more .........."

I was curious why she asked the question.

"My sister who lives in USA gave her daughter the vaccine. I was wondering whether I should give it to my daughter too."

I realized that I would be asked similar questions again and again as the vaccine has been launched in India. More over I may have to take a decision about it personally since I have a daughter of about same age.

This post is an attempt by me to answer the question raised by that mother after considering all the facts available at present.

What is cervical cancer?

The cervix is another name for the neck of the womb. It is the opening to the womb from the vagina. It is really a strong muscle. Normally it is quite tightly shut, but during labour it opens up to let the baby out.

The cervix has a layer of skin-like cells on its outer surface. When these cells become cancerous it is called squamous cell cervical cancer.

There are glandular cells lining the inside of the cervix. The glandular cells produce mucus. Cancer of these cells is called adenocarcinoma of the cervix.

The area where cervical cells are most likely to become cancerous is called the transformation zone. It is the area around the opening of the cervix that leads on to the narrow passageway running up into the womb.

What causes cervical cancer?

HPV infection

Human papilloma virus or HPV is the major cause of cervical cancer. There are many different types of HPV. It is sometimes called the genital wart virus as some types of HPV cause genital warts. In fact, the types that cause warts are not the types that cause cervical cancer. But there are other types of HPV that are considered 'high risk' for cancer of the cervix. HPV is passed on from person to another through sexual contact.

Women who get cervical cancer have had past infections with HPV. High risk types of HPV can cause changes in the cells covering the cervix that make them more likely to become cancerous in time. It is said that around 50 to 80 % of women get infected with HPV some time in their lifetime.

Most people with HPV do not develop symptoms or health problems from it. In 90% of cases, the body’s immune system clears HPV naturally within two years.

But most women infected with these viruses do NOT develop cervical cancer. So other factors must also be needed for someone with HPV infection to develop cervical cancer.

HPV is passed on through genital contact, most often during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact. HPV can be passed on between straight and same-sex partners—even when the infected partner has no signs or symptoms.

A person can have HPV even if years have passed since he or she had sexual contact with an infected person. Most infected persons do not realize they are infected or that they are passing the virus on to a sex partner. It is also possible to get more than one type of HPV.

HPV can cause normal cells on infected skin to turn abnormal. Most of the time, you cannot see or feel these cell changes. In most cases, the body fights off HPV naturally and the infected cells then go back to normal. But in cases when the body does not fight off HPV, HPV can cause visible changes in the form of genital warts or cancer. Warts can appear within weeks or months after getting HPV. Cancer often takes years to develop after getting HPV.

Other risk factors for Cervical Cancer

Women who smoke are more likely to get cervical cancer than those who do not. Taking the birth control pill could increase a woman’s risk of cervical cancer. It is not clear why this is. Women with a weakened immune system are also more likely to get cervical cancer, as are those who have had a large number of children.

Preventive measures against HPV infection

For those who choose to be sexually active, condoms may lower the risk of HPV. To be most effective, they should be used with every sex act, from start to finish. Condoms may also lower the risk of developing HPV-related diseases, such as genital warts and cervical cancer. But HPV can infect areas that are not covered by a condom - so condoms may not fully protect against HPV.

People can also lower their chances of getting HPV by starting sexual activity at a later age, being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That's why the only sure way to prevent HPV is to avoid all sexual activity.

Preventive measures against Cervical Cancer

Screening/PAP smear

Cervical screening is very important because we can stop cervical cancer from developing in the first place. This is one of the few cancers that are preventable because pre-cancerous cell changes can be picked up before they have a chance to develop into a full-blown cancer.

The screening test is often called a cervical smear. A nurse or doctor takes a small sample of cells from the surface of your cervix and spread straight onto a glass slide or put into a liquid. When it reaches the lab, your sample is put under a microscope. The cells are examined and any abnormal ones reported.

The smear test picks up pre-cancerous changes. If you have an abnormal result, it does NOT mean you have cervical cancer. But you may need further tests or treatment for an abnormal smear.

You have to be screened like this every 3 to 5 years from 25 years of age.

Vaccine against HPV

Now I come to the topic I wanted to discuss.

How good are these vaccines in preventing Cervical Cancer?

Are there any risks in taking this vaccine?

Though they are marketed as cervical cancer vaccines, they only prevent the infection of few types of HPV that are responsible for about 70% of cervical cancers. The studies that were conducted were for a period of about 2 to 3 years only. No long-term study results are available yet. Also no studies were conducted in girls less than 16 years of age. The studies had shown that the Vaccine can prevent abnormal cell changes for 2 to 3 years, but long-term effectiveness is not known.

Cervical intra epithelial neoplasia (abnormal cell growth) is graded from 1 to 3. Grade 1 indicates active HPV infection and is not considered to be pre-cancerous; current guidelines discourage treatment of this condition. Grade 2 is treated in most women but is not considered as true marker of developing cancer, as up to 40 percent of such lesions regress spontaneously; current guidelines suggest that some young women with such lesions do not need treatment. Grade 3 cervical neoplasia has the lowest likelihood of regression and the strongest potential to become cancerous.

In the HPV vaccine trials not much efficacy was reported in Grade 3 disease. This was attributed to other types of HPV, [against which we do not have vaccines] taking over and producing Cancer.

Though 3 doses are currently recommended whether there is a need for booster dose is not known

In conclusion the overall efficacy is only about 17 to 20 %.

Even after taking the vaccine the Women should undergo routine screening and safe sex practices to get maximum benefits.

Although it was licensed for use in the United States in June 2006, the first phase 3 trials of the HPV vaccine with clinically relevant end points — cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3) — were not reported until May 2007,

Why the US FDA and CDC was in such a hurry to give approval to this vaccine?

The editorial in the New England Journal of Medicine [NEJM] said:

The vaccine was highly successful in reducing the incidence of precancerous cervical lesions caused by HPV-16 and HPV-18, but a number of critical questions remained unanswered.
For instance, will the vaccine ultimately prevent not only cervical lesions, but also cervical cancer and death?
How long will protection conferred by the vaccine last?
Since most HPV infections are easily cleared by the immune system, how will vaccination affect natural immunity against HPV, and with what implications?
How will the vaccine affect preadolescent girls, given that the only trials conducted in this cohort have been on the immune response? ......

.....In the meantime, there has been pressure on policymakers worldwide to introduce the HPV vaccine in national or statewide vaccination programs. How can policymakers make rational choices about the introduction of medical interventions that might do good in the future, but for which evidence is insufficient, especially since we will not know for many years whether the intervention will work or — in the worst case — do harm?

....... serious questions regarding the overall effectiveness of the vaccine in the protection against cervical cancer remained to be answered, and more long-term studies were called for before large-scale vaccination programs could be recommended.

Is the vaccine safe?

.Even though most of the reported adverse events were not serious, there were some reports of hypersensitivity reactions including anaphylaxis, Guillain-Barré syndrome, transverse myelitis, pancreatitis, and venous thromboembolic events. The editorial in the JAMA [Journal of American Medical Association] says, "it is also difficult to conclude that a serious event is not caused by the vaccine". That means the safety is not fully assured.

Should I recommend the HPV Vaccine?

The JAMA editorial says:

When do physicians know enough about the beneficial effects of a new medical intervention to start recommending or using it? When is the available information about harmful adverse effects sufficient to conclude that the risks outweigh the potential benefits? If in doubt, should physicians err on the side of caution or on the side of hope? These questions are at the core of all medical decision making. It is a complicated process because medical knowledge is typically incomplete and ambiguous. It is especially complex to make decisions about whether to use drugs that may prevent disease in the future, particularly when these drugs are given to otherwise healthy individuals. Vaccines are examples of such drugs, and the human papillomavirus (HPV) vaccine is a case in point.

........Whether a risk is worth taking depends not only on the absolute risk, but on the relationship between the potential risk and the potential benefit. If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to a woman is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened. So rationally she should be willing to accept only a small risk of harmful effects from the vaccine.

When weighing evidence about risks and benefits, it is also appropriate to ask who takes the risk, and who gets the benefit. Patients and the public logically expect that only medical and scientific evidence is put on the balance. If other matters weigh in, such as profit for a company or financial or professional gains for physicians or groups of physicians, the balance is easily skewed. The balance will also tilt if the adverse events are not calculated correctly.

My conclusion is like this.

I will not recommend HPV Vaccine with the present available scientific evidence due to the fact that the efficacy in preventing invasive cervical cancer is not much and there is a small but considerable risk of adverse events.
Even though India reports more than 70000 deaths yearly due to cervical cancer,this coslty vaccine [around 10000 Rs for 3 shots] is highly unlikely to make any change in incidence of Cervical cancer in India due low efficacy and prohibitive cost.

Links and references
NEJM editorial
JAMA editorial
Controversy on cancer vaccine
more on cervical cancer

Life style changes in the New Year

2010-01-03T12:33:00.000+05:30

I do not practice what I preach.

I preach to my patients about

'the importance of regular exercise in maintaining good health'.

I preach about

'importance of eating less fatty food'

I preach about

'reducing weight to reach an ideal BMI'

I preach about

'eating plenty of fruits and vegetables'

I preach about

'cutting down on snacks'.

I do not practice what I preach.

I never do regular exercise. Never cut down on fatty foods. Eat fruits rarely but snacks frequently.

May be it is time for me to practice what I preach starting from this year.I aim to achieve a BMI of 25 by the end of this year. Currently it is 28.4.

Let me try my best.

To calculate your BMI and to know more about a healthy BMI click the link below.
http://www.nhlbisupport.com/bmi/bmi-m.htm

A very 'Positive' news from Pakistan

2009-12-02T01:40:00.001+05:30

Cricket is the national sport in Pakistan as it is in India, but what makes the First Positive Cricket Team stand out from all the other Karachi-based clubs is that its members are all HIV positive.

The team was put together a year ago by the Pakistan Society, an NGO working for the rights of people living with HIV. They played -- and won -- their first match in August, and haven't looked back.

Dr. Saleem Azam, president of the Pakistan Society, told CNN, "Every time they play the players have a boost physically, emotionally and psychologically, and they feel a lot better."

Azam says that there is a considerable stigma in Pakistan surrounding HIV/AIDS and he hopes the team can help combat discrimination towards HIV sufferers.

"People assume the team must be very sick-looking, like walking skeletons, but when they see them playing and winning matches they have to think again," said Azam.

"We've given them a very strong message that having HIV does not mean you must retire from life and become helpless. You can have HIV and live a very happy life if you take your antiretroviral treatment regularly.
When the team won handsomely, leaving their opponents and the fans amazed that HIV-positive players could be so active - one of the team members was asked whether antiretroviral medication was also a form of performance-enhancing drugs.

"The stigma is the worst consequence of this illness, so it will be the greatest service to people with HIV if we are able to help them overcome this stigma. The change is coming, but it's very, very slow."

While changing attitudes takes time, Azam says the team has already built bridges between the players and their estranged families. He told CNN that some players who had been ostracized by their families were now back in contact with them, with one family requesting to travel to matches with the team.

First Positive has already played a match in Hyderabad, about 200 km (125 miles) from Karachi, and next month they will take to the road for two more matches, which will see them spread their message elsewhere in the country.

"This is how the team will be known the country over," said Azam.

"People will come to know more and more about the team, and I hope eventually they will be successful in combating this stigma and discrimination."

Abdul Lateef is captain of the FPCT. He contracted HIV six years ago and told CNN that the team is helping to change others' attitudes towards people with HIV.

"We are reaching the minds of the people," he said.

"Everybody thinks there are things that HIV positive people cannot do. We have shown we can play and we have proved to everybody we can do anything they can do."

We are thankful that the authorities were so cooperative with us, and provided us with the space that was needed for the match without any discriminatory attitude. Rather, their attitude was positive and encouraging," said Azhar Hussain Magsi, a manager at the Pakistan Society.

"More matches are scheduled to take place all over Pakistan in the coming weeks ... We are also having talks with other NGOs in India, and look forward to having an international HIV-positive cricket match.

Having personally witnessed the wonders that anti retro viral therapy can produce in many patients, I cannot think a better way of illustrating the fact that HIV/AIDS is treatable and HIV positive patients are as human as we all are than the site of a 'Positive' cricket team winning a match against the 'negative' team on the cricket field.

An India-Pakistan cricket match between HIV positive players!!!

That will be a great event.

adapted from
CNN
AIDS Portal

World AIDS Day 2009.A statistical update

2009-12-02T01:14:00.002+05:30

Another World AIDS Day is here.Let me update you with the current statistics and trends.
New figures released by the World Health Organization and UNAIDS estimate the number of new HIV infections have declined each year by about 17% from 2001 to 2008.
The number of new infections in sub-Saharan Africa is approximately 15% lower, which is about 400,000 fewer infections in 2008.
In East Asia new HIV infections declined by nearly 25% and in South and South East Asia by 10% in the same time period.
In Eastern Europe, after a dramatic increase in new infections among injecting drug users, the epidemic has leveled off considerably.
However, in some countries there are signs that new HIV infections are rising again.

But for every five people infected, only two start treatment.
The UN report noted about 4 million people were receiving AIDS drugs at the end of 2008, compared with 3 million the previous year. Nonetheless, an additional 5 million people need treatment and are not receiving it.

Number of people living with HIV in 2008

Total 33.4 million [31.1 million–35.8 million]

Adults 31.3 million [29.2 million–33.7 million]

Women 15.7 million [14.2 million–17.2 million]

Children under 15 years 2.1 million [1.2 million–2.9 million]

People newly infected with HIV in 2008

Total 2.7 million [2.4 million–3.0 million]

Adults 2.3 million [2.0 million–2.5 million]

Children under 15 years 430 000 [240 000–610 000]

AIDS-related deaths in 2008

Total 2.0 million [1.7 million–2.4 million]

Adults 1.7 million [1.4 million–2.1 million]

Children under 15 years 280 000 [150 000–410 000]

There are more people living with HIV than ever before as people are living longer due to the beneficial effects of antiretroviral therapy and population growth.
However the number of AIDS-related deaths has declined by over 10% over the past five years as more people gained to access to the life saving treatment.
UNAIDS and WHO estimate that since the availability of effective treatment in 1996, some 2.9 million lives have been saved.

Antiretroviral therapy has also made a significant impact in preventing new infections in children as more HIV- positive mothers gain access to treatment preventing them from transmitting the virus to their children. Around 200 000 new infections among children have been prevented since 2001.
Indian Statistics
There are 3 million persons in India living with HIV, equivalent to approximately 0.36 percent of the adult population. The revised national estimate reflects the availability of improved data rather than a substantial decrease in actual HIV prevalence in India.

The transmission route is still predominantly sexual (87.4 percent); other routes of transmission by order of proportion includes perinatal (4.7 percent), unsafe blood and blood products (1.7 percent), infected needles and syringes (1.8 percent)
and unspecified and other routes of transmission (4.1 percent)2.

In India also there is a declining trend in new infections in southern states and Maharashtra while the epidemic is yet to level in Northern States.

This year’s World AIDS Day theme of Universal Access and Human Rights, highlights the critical link between universal access to HIV prevention, treatment, care and support and respect for human rights in the response to the global AIDS epidemic. Without addressing human rights abuses, many of the populations most vulnerable to or living with HIV will lack access to prevention and treatment services.

What Diabetic patients should know

2009-11-14T23:57:00.006+05:30

Another World Diabetes day has come and gone. It was a day of free blood sugar testing,free or subsidised testing for complications of Diabetes,Run for Diabetes,Seminars and Awareness classes etc etc.

In my own way I was also giving free consultation to Diabetes patients.When the testing and consultation are free there will be a rush of patients and I had the same experience.So it was an exhausting day.

Not all who had come were very poor. Many test their blood sugars only occasionally even though they could very well afford it. Many have never tested their Cholesterol,eyes or Kidney functions. Lack of knowledge about Diabetes and its complications were evident in most of the patients. The theme of World Diabetes day UNDERSTAND DIABETES; TAKE CONTROL is so relevant for this group of patients who came rushing to my Hospital for free testing and consultation.
To know more about World Diabetes Day click here

What Diabetic patients should know

Targets for Diabetics
Fasting Blood Sugar 70-120mg/dl
Post meal[after 90 mts] less than 180mg/dl
HbA1c less than 7 percent
Blood Pressure less than 130/80
HDL Cholesterol more than 40 mg/dl
LDL Cholesterol less than 100mg/dl
Triglycerides less than 150mg/dl

What and When to test

1.Test Blood sugar as frequently as possible. At least twice or thrice a month if well controlled.Test HbA1c every 6 months

2.Check Blood Pressure every 3 to 6 months. More frequently if high or low.

3.Lipid Profile [cholesterol test] at least every 6 months if found high once.Otherwise once a year.

4. Cardiac check up [ECG and Tread Mill test and if needed Angiography] once on diagnosis and then every 2-4 years if first examination was normal and there are no symptoms. More frequently if first tests are abnormal or if there are cardiac symptoms.

5.Kidney tests like Urine micro albumin and Serum creatinine every year.

6. Eye check up including retina examination after putting an eye drop to dilate the pupil on diagnosis of Diabetes and then once every 1-2 years.

7. Neuropathy testing on diagnosis and every 2 years if there are no symptoms.

Mass drug prophylaxis against filariasis

2009-11-13T02:08:00.002+05:30

To eliminate lymphatic filariasis, the Kerala State Government Health Department has launched a mass drug administration (MDA) programme in 11 districts in the State on Novemeber 11,2009.
A lot of confusion is there in the minds of many among the public about the need and possible side effects of this mass drug administration.

Why this mass anti-filarial drug administration in healthy persons?

Let me try to clarify.

What is Lymphatic filariasis?

Lymphatic filariasis is a parasitic disease caused by microscopic, thread-like worms. The adult worms only live in the human lymph system. The lymph system maintains the body's fluid balance and fights infections. Lymphatic filariasis is spread from person to person by mosquitoes.

People with the disease can suffer from lymphedema and elephantiasis and in men, swelling of the scrotum, called hydrocele. Lymphatic filariasis is a leading cause of permanent disability worldwide

Disease burden

Although lymphatic filariasis very rarely causes death, it is a major cause of clinical suffering, disability and handicap. More than 1.3 billion people in 83 countries and territories (Map) — approximately 18% of the world's population — live in areas at risk of infection with lymphatic filarial parasites. Approximately one third of those at risk live in India, one third in Africa and the remainder in Asia, the Pacific and the Americas.
It is estimated that around 120 million people in tropical and subtropical areas of the world are infected. Almost 25 million men suffer from genital disease (most commonly hydrocoele); an estimated 15 million people — the majority of them women — have lymphoedema or elephantiasis of the leg.

Indian Situation

Filariasis is endemic in 19 States/union territories in India. Estimates based on surveys by Filariasis Survey Units suggested that: about 454 million people (120 million in urban areas) are living in known endemic areas; there are 29 million filariasis cases in the country and 22 million micro-filaria carriers.

The magnitude of infection in children has become much better understood in recent years; indeed, most infections appear to be acquired in childhood, with a long period of subclinical asymtomatic period that progresses to the characteristic, clinical manifestations of adults.

Global Programme to Eliminate Lymphatic Filariasis

In 1997, as a result of advances in the diagnosis and treatment of lymphatic filariasis (LF), the disease was classed as one of six infectious diseases considered to be “eradicable” or “potentially eradicable”. Consequently, the World Health Assembly adopted resolution 50.29, calling for elimination of the disease as a global public health problem.

Elimination strategy

The strategy proposed by WHO to achieve the goal of elimination comprises two components:
1.interruption of transmission of filarial infection in all endemic countries through drastic reduction of microfilariae prevalence levels;

2.prevention and alleviation of disability and suffering in individuals already affected by LF.

Interruption of transmission of infection can only be achieved if the entire population at risk is covered by mass drug administration (MDA) for a period long enough to ensure a reduction in the level of microfilariae in the blood to a point where transmission can no longer be sustained.
That's why mass administration of anti filarial drugs are advised in healthy individuals living in areas of risk.

The following recommended drug regimens must be administered once a year for at
least 5 years, with a coverage of at least 65% of the total at-risk population:

a.6 mg/kg diethylcarbamazine citrate (DEC) + 400 mg albendazole; or

b.150 µg/kg ivermectin + 400 mg albendazole (in the case of co-endemicity with onchocerciasis).

c.A third option is to follow a treatment regimen using DEC-fortified cooking salt daily for a period of 12 months.

As a part of this programme 11 Districts in Kerala has started the second round of MDA this Novemeber using DEC and Albendazole.

Side effects of the drugs.

There has been reports in the media about children becoming sick after taking the tablets. Is this true? Is it serious?

Both DEC and Albendazole is best taken in full stomach. Many temporary side effects can be prevented by taking care to eat well before ingesting the medicines.
Side effects due to these medicines are rare, not serious and lasts for few minutes to hours only.
Most common side effects are dizziness,nausea,vomiting,headache and fatigue. Some may develop fever and skin rashes which may indicate succesful elimination of microfilaria.

Children below 2 years and elderly people above 65 are not required to take the drugs.
All others are advised to take the drugs.

Let us try to eliminate the dreaded elephantiasis from our community.

H1N1 Flu 2009 - Epidemiological and Clinical data from India

2009-11-11T02:16:00.002+05:30

The 2009 H1N1 Influenza [Swine flu] pandemic is continuing to spread in India, may be with less virulence. The Indian Health authorities have published the initial epidemiological and clinical data of this pandemic.I am publishing some of the data here for wider dissemination.
Here is the link for the information I am publishing here.

As of November 10th 2009 there has been 505 deaths out of a total of 14680 confirmed cases.

Total Lab confirmed cases 1468

Total number of Deaths 505

States Number of Deaths

Maharashtra 209

Karnataka 118

Andhra Pradesh 49

Gujarat 40

Kerala 22

Rajasthan 17

Delhi 16

Rest of the States reported less than 10 deaths.

Chronic cough and Alternative medicine

2009-11-07T01:10:00.002+05:30

"Doctor, He is coughing badly for the last 4 months."

A man in his mid 20s was saying about his thin and frail looking father who was sitting slumped on my patient's chair.

"4 months!!! You did not take him to any doctor?" was my angry question.

Son: "Yes, he was under a doctor's treatment for 4 months".

Me: "Were any blood tests done or any sputum or X ray examination done?'

Son: 'One blood test was done long back, which was normal.'

Me: 'Who was the doctor who treated him?' [I was curious].

Son: 'Father does not like strong modern medicines, so he was under the care of a

Homeopathic doctor'.

Me: 'Then why have you brought him here?'

Son: 'He is becoming weak day by day, lost weight and is not eating anything'.

I was almost sure of the diagnosis before I examined him. There were nothing obvious in his clinical exam except some altered breath sounds and pallor. So I asked him to take an X ray film of the Chest without wasting anymore time.

In an hour's time the Son came in to my room with the X ray. Yes as I suspected the X ray showed tell tale signs of Tuberculosis of the Lungs.

"It is TB". I offered him reference to the Government Health Center [for confirming the diagnosis by sputum examination and for free medicines]. He, as I guessed took the offer as he was not that well off.

Few days ago I had another man of about 65 years with almost similar history. Cough for 3 to 4 months and homeopathy treatment. He also turned to be suffering from sputum positive Tuberculosis.

Why these doctors are not thinking about TB? Are they taught the signs and symptoms of Lung TB? Can they treat Tuberculosis?
Only modern anti tuberculous antibiotics can cure a patient of TB, not homeopathic or ayurvedic medicines.

I know many homeopathic and Ayurvedic doctors who refer patients to Modern Medicine doctors as soon as they realise they cannot help the patient. But some never do, may be fearing they will be considered incompetent or due to sheer lack of knowledge.

I know all doctors can make mistakes. I have made many mistakes too. But if you find a patient is not getting better, a doctor should re-think the diagnosis, do further tests or refer to some one else better equipped to deal with the illness. I always do that.

Both the above patients must have spread the tuberculosis bacteria around their house and surroundings in the 3 to 4 months they were coughing out sputum.

If the situation is like this how can we ever eradicate or control TB?

Avoid Pregnancy during this flu season

2009-10-29T03:06:00.001+05:30

The other day immediately after a panel discussion for doctors on 2009 H1N1 flu [Swine flu] conducted by the local branch of Indian Medical Association [in which I was a panelist] a lady doctor came to me with a question.

She introduced herself and informed me that she is 4 month pregnant.

'Is it advisable for me to continue seeing patients?"

For a moment I was not sure what to answer. I had never seen a guideline asking pregnant health care workers to avoid seeing patients during this pandemic of 2009 H1N1.

But when you look at the scientific evidence there is obviously increased risk if a pregnant person get infected with 2009 H1N1 virus.

I answered like this.

"Obviously there is an increased in risk and if there is a possibility that you may have to examine many patients with flu symptoms it is better you avoid such a job.

Then she said she would take leave till her delivery.

Recently the CDC in USA has come out with statistics of pregnant women affected by the new H1N1 flu. It says of the 100 pregnant women who were admitted with severe illness due to 2009 H1N1 flu in USA, 28 died. This is a high rate of mortality. That’s why pregnant women are on the top of the list for eligible candidates for the new influenza vaccine.

In India, in my state of Kerala of the 14 persons who died till date due to H1N1 flu, 3 were pregnant. Statistics are similar in most other parts of the world.

Vaccines may not available for most of the pregnant women in third world countries this winter.

So what is the solution?

If possible avoid pregnancy this flu season.

Effect of climate change on Health

2009-10-15T11:22:00.001+05:30

Today October 15th is the Blog Action Day and this year's theme is climate change.

What are the effects of climate change on health?

Rapidly changing Climate is a major challenge to public health together with poverty, inequity, and infectious and non-communicable diseases. Furthermore, the poorest countries will suffer the greatest consequences of climate change even though they contributed the least for emissions.

Patterns of disease and mortality

Global temperature rise will directly affect health. The heat waves of 2003 in Europe caused up to 70 000 deaths, especially from respiratory and cardiovascular causes. Rising temperatures are likely to generate heat-related stress, increasing the short-term mortality rate due to heatstroke. Regions that are heavily urbanised will be more adversely affected than rural ones.

Rising temperatures will also affect the spread and transmission rates of vector-borne and rodent-borne diseases. Temperature affects rate of pathogen maturation and replication within mosquitoes, the density of insects in a particular area, and increases the likelihood of infection. Therefore, some populations who have little or no immunity to new infections might be at increased risk. Vector reproduction, parasite development cycle, and bite frequency generally rise with temperature; therefore, malaria, tick-borne encephalitis, and dengue fever will become increasingly widespread. In some cases, extreme events, such as heavy rains, will wash away eggs and larvae and decrease vector populations.

Mosquitoes responsible for malaria will grow, by accessing warm high altitudes, in places once free of the disease. It is estimated that 260—320 million more people will be affected by malaria by 2080 as a consequence of new transmission zones.

Dengue fever is sensitive to climate. The disease is prominent in urban areas because of inadequate water storage that affects about 100 million people worldwide. Climate change will increase the number of regions affected by arbovirus, such as Australia and New Zealand. Heavy rainfall and a rise in temperature increase the rate of infection. By 2080, about 6 billion people will be at risk of contracting dengue fever as a consequence of climate change, compared with 3·5 billion people if the climate remained unchanged.

Schistosomiasis, fascioliasis, alveolar echinococcosis, leishmaniasis, Lyme borreliosis, tick-borne encephalitis, and hantavirus infections are all projected to increase as a result of global climate change.

As ocean temperatures rise with global warming and more intense El Niños, cholera outbreaks might increase as a result of more plankton blooms providing nutrients for Vibrio cholerae. In 1998, increased rainfall and flooding after hurricane Mitch in Nicaragua, Honduras, and Guatemala caused a leptospirosis outbreak, and an increased number of cases of malaria, dengue fever, and cholera.

Food

Climate change threatens human health through its effect on under nutrition and food insecurity. Chronic and acute child malnutrition, low birth weights, and sub optimal breastfeeding are estimated to cause the deaths of 3·5 million mothers and young children every year. Furthermore, one in three children under the age of 5 years born in developing countries suffer from stunting due to chronic under nutrition. Climate change will compound existing food insecurity.

A study suggests that half of the world's population could face severe food shortages by the end of the century because rising temperatures take their toll on farmers' crops. Harvests of staple food crops, such as rice and maize, could fall between 20% and 40% as a result of increased temperatures during the growing season in tropical and subtropical regions.

Water and Sanitation

Safe and reliable access to clean water and good sanitary conditions are essential for good health. In 2002, 21% of people living in developing countries did not have sustained access to an improved water source, and 51% did not have access to improved sanitation.

Changing rainfall and temperature over the next decades are likely to make provision of clean water, good sanitation, and drainage even more complicated than it is now. Average annual rainfall is forecast to decrease in some regions and increase in others, and droughts and floods are likely to become more frequent and intense. Regional temporal patterns of rainfall might also be altered: the problem is not simply sustained drought, but also severe rainfall all at once followed by less rainfall, thus annual rainfall might rise, but still cause drought.

More than a sixth of the world's population currently live in glacial-fed water catchments, which are vulnerable to climate change. Increasing rates of glacial melting are predicted to lead to great reductions of water availability. In the near future, high peak flows in glacial-fed rivers are expected, as the rate of glacier-mass loss increases, followed by dramatic reductions in river flow and freshwater availability as glaciers progressively disappear. Rising temperatures are also likely to result in earlier snow thawing and increased rain relative to snow precipitation, bringing peak river flows earlier in the year, potentially exacerbating dry season water scarcity.

Reduced river flows and increased water temperature will lead to declining water quality as the dilution of contaminants is reduced, less oxygen is dissolved in water, and microbiological activity increases. These effects could lead to major health problems for vulnerable people, especially during drought, and might increase the risk of conflict and major population migration.

Poverty

Many of the most serious public health consequences of climate change will be experienced by the world's poorest nations, increasing global health inequities. Basic infrastructure for much of the world's population is inadequate to meet essential health care needs, and our ability to cope effectively with the aftermath of natural disasters is insufficient. Overall, all the underlying social, economic, and ecological determinants of global illness and premature death will be exacerbated by climate change. Progress towards the Millennium Development Goals and achievement of the 2015 targets might be impaired or reversed. Because climate change acts mostly as an amplifier of existing risks to health, poor and disadvantaged people will experience greater increments in disease burden than rich, less vulnerable populations.

Gender

Gender inequity is another important factor. In developing countries, women are among the most vulnerable to climate change; they not only account for a large proportion of the agricultural workforce but also have few alternative income opportunities. Women manage households and care for family members, which limit their mobility and increase their vulnerability to natural disasters and other local sudden climate changes. Efforts to keep the adverse effects of climate change to a minimum should ensure that policies address issues of women's empowerment.

Climate change is not just an environmental issue but also a health issue. The ability to adapt to the health effects of climate change depends on measures that reduce its severity—i.e., mitigation measures that will drastically reduce carbon emissions in the short term, but also increasing the planet's capacity to absorb carbon. This is a crucial issue that must be acted upon urgently.

Source: The report of The Lancet Commission on health effects of climate change published in The Lancet dated 16th May 2009.

Latest update on Novel H1N1 influenza pandemic 2009

2009-10-08T04:10:00.003+05:30

Novel H1N1 influenza pandemic [swine flu pandemic] in India is not news anymore. There is no breaking news on TV channels about deaths caused by negligence of doctors. Health Minister is invisible. Newspapers have stopped counting the deaths. Many in India believe that the 'swine flu' is not killing anymore because they are not reading/viewing such news now. But what is the actual situation?

There have been a total number of 11354 confirmed cases of novel H1N1 flu infections in India till October 7th 2009.Of, which 366 persons have died. This is the officially confirmed figure and not an estimate. Many believe that a large number of infections and death may not have been included in the official data. Official statistics show that there have been 147 deaths in Maharashtra and 101 deaths in Karnataka.

The Indian Health authorities who studied the first 82 deaths that occurred till Aug 31 said that maximum deaths occurred in the adult age group.

Among the dead were 43 men and 39 women, including three pregnant women.

Of the first 82 deaths, 61 were in urban areas and 19 in rural areas. There were five deaths in the age group of 0-5 years and three from 6-15 age group. Thirteen victims were from the age group of 16 to 25 years, while 18 people died in the age group of 26-35 years.24 people died in the age group of 36-45, as compared to 18 deaths in the age group of 46-65. Only one person died in the above 65-year category.

Statistics from other countries also show similar age distribution.

Worldwide Brazil [1164 deaths], USA [814 deaths] and Argentina [539 deaths] lead India [366 deaths] in death toll.

It is expected that by the end of this winter India will overtake all other countries in the death toll.

Yet another feather in India's cap?

H1N1 flu vaccine

Vaccine for novel H1N1 flu is available in few countries now.

The groups recommended by CDC in USA to receive the 2009 H1N1 influenza vaccine include:

1.Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated;

2.Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by “cocooning” them from the virus;

3.Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;

4.All people from 6 months through 24 years of age

Children from 6 months through 18 years of age because cases of 2009 H1N1 influenza have been seen in children who are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and
Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,

5.Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza

2 shots are recommended for those below 10 years and one shot for others.

.

What is the cause of his respiratory distress?

2009-09-27T02:32:00.000+05:30

He was admitted sometime late in the night. The doctor on night duty had called me and told me about this patient. He said that a patient with no history of asthma has come with severe respiratory difficulty. The pulse oximeter showed unusually low value of oxygen level in blood. ECG showed only an increased heart rate and X-ray Chest was hazy on either side.

" Sir, What could it be?"

'Let the blood results come and let me see the patient in the morning”. I replied.

The patient was 46 years old, working in one of the Metro Cities. He came to his hometown here 5 days ago. He was having cough and breathing difficulty for about 2 weeks now and was getting some treatment with mild relief. There was on and off fever and severe fatigue. He was suffering from Diabetes for last 2 years, but not on any regular medication nor was doing frequent blood sugar tests. He had lost weight considerably in last few months.

His clinical examination showed white patches on his tongue with chest showing features of pneumonia. With Oxygen administration in high pressure he was much better than the time of admission.

His blood sugar was high and Liver function Tests were slightly deranged. The WBC count was low with lymphocytes predominating suggesting a non-bacterial cause for pneumonia..X ray Chest showed ground glass like haziness.

What is this?.............

Sub acute onset of illness, severe breathlessness and low Oxygen level, fungal patch on the tongue, low WBC count, ground glass haziness on Chest X ray............

Yes, I want to test his HIV status.

He has features of Pneumocystis Pneumonia, caused by a fungus found in patients with very low level of immunity, mostly HIV positive patients.

Patient was drowsy and was not in a state to give his consent for the test. I talked to his wife and got an oral consent. Did she want to say something? Or was I imagining?

The rapid test for HIV antibody was positive. I called the wife again and told her about the result. Then she told me everything. Yes they know he was 'positive’. She was also 'positive' too. He was seriously ill 2 years ago and was found to 'positive'. He took medications for about a year and was much better. Against doctor's advice he suddenly stopped the Anti retro-viral medicines and started some alternative system of medicine with the hope [that someone gave him] that he will be completely cured. He slowly became ill again and is now in this state.

I have heard this story many times. Modern medicine being based on scientific evidence based medicine will not claim cure for conditions, which has no cure. But most of the illnesses can be well controlled with continuous medications. This is true not only for HIV/AIDS but also for other chronic illnesses like Diabetes, Hypertension, Coronary Heart Disease etc.

After taking modern medicine treatment for some time many people try to experiment other systems of medicines/practitioners because they falsely claim complete cure. Finally after worsening of their condition and realizing there is no permanent cure they come back to modern medicine. By this time much damage to the body would have been incurred.

He is critically ill now. If he had continued on medicines advised for him under modern medicine treatment he would not have been fighting for his life like this.

Who should be blamed here?

What could be her diagnosis? Part 2

2009-09-14T02:48:00.003+05:30

She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.

She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.

By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.

Is it a ruptured ectopic pregnancy?

A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.

I know the Gynaecologist must have ruled it out already before referring to me.

Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.

Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.

Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.

What could be her diagnosis?

This was my post last week.

What did I do? I began to go thru the data again in my mind.

After 5 days of fever she developed shock. So an infection must be the cause.

Bacterial or Viral or Malaria?

Low WBC count usually rules out Bacterial infection. The pattern of fever and lack of history of travel to Malaria prone areas should rule it out. [Mercifully Kerala has almost zero cases of indigenous Malaria. All our Malarial fevers are imported from neighboring States].

So it must be a viral infection. Many viral infections cause low WBC count and low Platelet count. But only a few can cause Shock. In this rainy season such a viral infection producing shock can only be Dengue Shock Syndrome.

Any other clue that suggests Dengue infection?

Yes the moderate amount of free fluid in the peritoneal and pleural cavity. [Abdomen and chest]. This is classically seen in DSS due to increased capillary permeability causing plasma leak in to those spaces.

The low platelet count can cause bleeding if it falls below 20000.Then it is called Dengue Hemorrhagic fever.

The diagnosis is by detection of the virus by RT-PCR, which is very costly and the result may reach my place only after a week or by detection of antibody against the virus, which may become positive only after 7-10 days.

As the treatment is symptomatic with pumping in of large amount of fluids and if needed platelets and plasma, I did not send a blood sample for antibody detection at that time.

I started the treatment earnestly. Fortunately the relatives had confidence in my institution and me. Her urine output improved in a day and after about 3 days of pumping in of so many bottles of fluids and plasma her blood pressure started coming up.

Initially her PCV [packed cell volume] was high due to plasma leakage and blood concentration. Later it began to fall showing the treatment is effective. Rarely fall in PCV may also be due to bleeding. So a careful watch for bleeding is required.

I send the blood sample for diagnosis only on the 3rd day of admission. By that time she was shifted out of ICU. When the result came as positive for Dengue infection she was well in to the road of recovery.

When she was discharged on the 9 Th day of admission her Ultra sonogram showed a normal live foetus and no free fluid in the peritoneal and pleural cavities.

I have seen several patients with features of Dengue fever this season. All most all of them recovered without going in to shock as I pushed lot of intravenous fluids suspecting Dengue in all patients with high fever, headache, no joint pain, low WBC and low platelet.

There is a significant increase in Dengue fever cases this year in South India as evidenced by news reports. Large number of cases has also been reported from Sri Lanka.

I am hoping that all my patients with Dengue fever will recover fully like the patient in the story.

What could be her diagnosis?

2009-09-06T06:40:00.001+05:30

"Doctor, I have a patient in shock [very low blood pressure]. Please see her and give your opinion".

The Gynaecologist of my Hospital was asking me on the hospital phone.

"How come you were called first"? I asked. A patient in shock is my area.

'She happened to be 3 months pregnant" was the answer.

I was soon in the intensive care by the patient's bedside.

She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.

She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.

On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.

By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.

Is it a ruptured ectopic pregnancy?

A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.

I know the Gynaecologist must have ruled it out already before referring to me.

Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.

Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.

Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.

What could be her diagnosis?

Indian Government Guidelines for management of Novel H1N1 flu cases

2009-08-20T02:07:00.003+05:30

The Indian Government has issued new guidelines for managing Novel H1N1 Influenza A infection. The details are available here.

Under the new guidelines, any person with flu like symptoms such as fever, cough, sore throat, cold, running nose etc. should go to a designated Government facility for giving his/her sample for testing for the H1N1 virus.

After clinical assessment, the designated medical officer would decide on the need for testing.
This is important. You cannot demand a test.
Government wants to avoid unnecessary testing as the test kits are costly and most of the infections are mild needing no specific treatment.
Except for cases that are severe, the patient would be allowed to go home (This was not allowed under the existing guidelines).
The sample of the suspect case would be collected and sent to the notified laboratory for testing.
If tested as positive for H1N1 and in case the symptoms are mild, the patient would be informed and given the option of admission into the hospital or isolation and treatment at his own home.
In case the patient opts for home isolation and treatment, he/she would be provided with detailed guidelines / safety measures to be strictly adhered to by the entire household of the patient. He/ she would have to provide full contact details of his entire household. The house hold and social contacts would be provided with the preventive treatment.
Notwithstanding the above guidelines, the decision of the doctor of the notified hospital about admitting the patient would be final.

In case the test is negative, the patient will accordingly be informed.
These guidelines have been issued by the Government in public interest and shall be reviewed from time to time depending on the spread of the pandemic and its severity in the country. These guidelines would however not apply to passengers who are identified through screening at the points of entry. The existing policy of isolating passengers with flu like symptoms would continue.

Is my son having 'swine' flu?

2009-08-19T02:47:00.003+05:30

' Is my son having 'swine' flu?"
Father of a young IT professional who is admitted under my care was asking. He was admitted for fever and cough.He had just come back from a Metro City where there were many cases of Novel H1N1 Influenza A infections.
How can I answer him?
He is sick for 2 days,but not very sick.None of his colleagues or room mates were sick.There is nothing to suspect a severe infection. But can I be sure it is not H1N1 flu?
No, unless I have got a negative test result.
To do the test for this patient I will have to send him to nearby Govt Hospital.The doctor there had informed me that the result is delayed by at least 5 days. By that time the patient would have recovered fully or may be in a critical condition.
Then what is the use of sending for the test?
What should I tell this worried Parent?
I explained that as of now I do not suspect H1N1 flu. I also told him about the delay in getting the result. I said I am confident that he will recover fast.
I hope the patient recovers fast and my dilemmas in diagnosis will soon be over.

How serious is the Novel H1N1 influenza infection?

2009-08-09T04:56:00.003+05:30

Since I first posted about 'Swine flu' in April a large amount of information has been accumulated about this on going pandemic. Here is an update.
What is influenza (flu)?
Influenza (flu) is a viral infection. People often use the term "flu" to describe any kind of mild illness, such as a cold or a stomach upset, that has symptoms like the flu. But the real flu is different. Flu symptoms are usually worse than a cold and last longer. The flu usually does not cause vomiting or diarrhea.
Most flu outbreaks happen in late fall and winter.
What causes the flu?
The flu is caused by influenza viruses A and B. There are different strains, or types, of the flu virus every year.
What are the symptoms?
The flu causes a fever, body aches, a headache, a dry cough, and a sore or dry throat. You will probably feel tired and less hungry than usual. The symptoms usually are the worst for the first 3 or 4 days. But it can take 1 to 2 weeks to get completely better.
It usually takes 1 to 4 days to get symptoms of the flu after you have been around someone who has the virus.
Most people get better without problems. But sometimes the flu can lead to a bacterial infection, such as an ear infection, a sinus infection, or bronchitis. In rare cases, the flu may cause a more serious problem, such as pneumonia
Certain people are at higher risk of problems from the flu. They include young children, pregnant women, older adults, and people with long-term illnesses or with impaired immune systems that make it hard to fight infection
What is Swine flu?
Novel H1N1 (referred to as “swine flu” early on) is a new influenza virus causing illness in people. The epidemic probably started in Mexico in mid-March 2009 and spread to USA in April. This virus is spreading from person-to-person worldwide, probably in much the same way that regular seasonal influenza viruses spread.

The virus is being described as a new subtype of Influenza A(H1N1) not previously detected in swine or humans. The 2009 novel A(H1N1) strain contains an unusual mix of gene segments. The genetic sequencing of samples in the Centers for Disease Control (CDC) Atlanta shows that the new flu virus contains segments from four different viruses: from North American swine viruses, North American avian Viruses, human influenza, and two Eurasian swine viruses.

How does novel H1N1 virus spread?
Spread of novel H1N1 virus is thought to occur in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing by people with influenza. Sometimes people may become infected by touching something – such as a surface or object – with flu viruses on it and then touching their mouth or nose.

What are the signs and symptoms of this virus in people?
The symptoms of novel H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. A significant number of people who have been infected with this virus also have reported diarrhea and vomiting. Severe illnesses and death has occurred as a result of illness associated with this virus.
In a study of 30 c0nfirmed patients from USA the most common admission diagnoses were pneumonia and dehydration. Nineteen patients (64%) had underlying medical conditions; the most common were chronic lung disease (e.g., asthma and chronic obstructive pulmonary disease), conditions associated with immunosuppresion, chronic cardiac disease (e.g., congenital heart disease and coronary artery disease), diabetes, and obesity. The most common symptoms were fever, cough, vomiting, and shortness of breath; diarrhea was uncommon. Of the 25 patients who had chest radiographs, 15 (60%) had abnormalities suggestive of pneumonia, including 10 with multilobar infiltrates and five with unilobar infiltrates.
How severe is illness associated with novel H1N1 flu virus?
Illness with the new H1N1 virus has ranged from mild to severe. While most people who have been sick have recovered without needing medical treatment, hospitalizations and deaths from infection with this virus have occurred. The case fatality of this current epidemic is estimated by some experts as around 0.2%
In seasonal flu, certain people are at “high risk” of serious complications. This includes people 65 years and older, children younger than five years old, pregnant women, and people of any age with certain chronic medical conditions. About 70 percent of people who have been hospitalized with this novel H1N1 virus have had one or more medical conditions previously recognized as placing people at “high risk” of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease.
One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of novel H1N1-related complications thus far.
CDC laboratory studies have shown that children and few adults younger than 60 years old do not have existing antibody to novel H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus. It is unknown how much, if any, protection may be afforded against novel H1N1 flu by any existing antibody.
How long can an infected person spread this virus to others?
People infected with seasonal and novel H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after. This can be longer in some people, especially children and people with weakened immune systems and in people infected with the new H1N1 virus.

Prevention & Treatment
What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against novel H1N1 virus. However, a novel H1N1 vaccine is currently in production and may be ready for the public by September. As always, a vaccine will be available to protect against seasonal influenza There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza.
Take these everyday steps to protect your health:
Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
Avoid touching your eyes, nose or mouth. Germs spread this way.
Try to avoid close contact with sick people.
If you are sick with flu-like illness, it is recommended that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Keep away from others as much as possible to keep from making others sick.
Other important actions that you can take are:
Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.
Be prepared in case you get sick and need to stay home for a week or so; a supply of over-the-counter medicines, alcohol-based hand rubs, tissues and other related items might could be useful and help avoid the need to make trips out in public while you are sick and contagious.
If I have a family member at home who is sick with novel H1N1 flu, should I go to work?
Employees who are well but who have an ill family member at home with novel H1N1 flu can go to work as usual. These employees should monitor their health every day, and take everyday precautions including washing their hands often with soap and water, especially after they cough or sneeze. If they become ill, they should notify their supervisor and stay home. Employees who have an underlying medical condition or who are pregnant should call their health care provider for advice, because they might need to receive influenza antiviral drugs to prevent illness.
What should I do if I get sick?
If you live in areas where people have been identified with novel H1N1 flu and become ill with influenza-like symptoms, including fever, body aches, runny or stuffy nose, sore throat, nausea, or vomiting or diarrhea, you should stay home and avoid contact with other people. Stay away from others as much as possible to keep from making others sick.Staying at home means that you should not leave your home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings.
If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed.
If you become ill and experience any of the following warning signs, seek emergency medical care.
In children, emergency warning signs that need urgent medical attention include:
Fast breathing or trouble breathing
Bluish or gray skin color
Not drinking enough fluids
Severe or persistent vomiting
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough
In adults, emergency warning signs that need urgent medical attention include:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting
Flu-like symptoms improve but then return with fever and worse cough
Are there medicines to treat novel H1N1 infection?
Yes. the use of oseltamivir or zanamivir is recommended for the treatment and/or prevention of infection with novel H1N1 flu virus. Antiviral drugs are prescription medicines (pills, liquid or an inhaled powder) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current pandemic, the priority use for influenza antiviral drugs is to treat severe influenza illness (for example hospitalized patients) and people who are sick who have a condition that places them at high risk for serious flu-related complications.
All patients with Novel H1N1 flu need not take the anti-viral medicines.
Antiviral treatment with either oseltamivir or zanamivir is recommended for all patients with confirmed, probable or suspected cases of novel influenza A (H1N1) virus infection who are hospitalized or who are at higher risk for seasonal influenza complications.
Pregnant women who gets influenza like illness in regions affected by pandemic should be started on anti-viral medicines as soon as possible even before confirming the diagnosis.

Our understanding of the disease continues to evolve as new countries become affected, as community-level spread extends in already affected countries, and as information is shared globally. Many countries with widespread community transmission have moved to testing only samples of ill persons and have shifted surveillance efforts to monitoring and reporting of trends. This shift has been recommended by WHO, because as the pandemic progresses, monitoring trends in disease activity can be done better by following trends in illness cases rather than trying to test all ill persons, which can severely stress national resources. It remains a top priority to determine which groups of people are at highest risk of serious disease so steps to best to protect them can be taken.
Average age of cases increasing
In most countries the majority of pandemic (H1N1) 2009 cases are still occurring in younger people, with the median age reported to be 12 to 17 years (based on data from Canada, Chile, Japan, UK and the United States of America). Some reports suggest that persons requiring hospitalization and patients with fatal illness may be slightly older.
As the disease expands broadly into communities, the average age of the cases is appearing to increase slightly. This may reflect the situation in many countries where the earliest cases often occurred as school outbreaks but later cases were occurring in the community. Some of the pandemic disease patterns differ from seasonal influenza, where fatal disease occurs most often in the elderly (>65 years old). However, the full picture of the pandemic's epidemiology is not yet fully clear because in many countries, seasonal influenza viruses and pandemic (H1N1) 2009 viruses are both circulating and the pandemic remains relatively early in its development.
Although the risk factors for serious pandemic disease are not know definitively, risk factors such as existing cardiovascular disease, respiratory disease, diabetes and cancer currently are considered risk factors for serious pandemic (H1N1) 2009 disease. Asthma and other forms of respiratory disease have been consistently reported as underlying conditions associated with an augmented risk of severe pandemic disease in several countries.
A recent report suggests obesity may be another risk factor for severe disease. Similarly, there is accumulating evidence suggesting pregnant women are at higher risk for more severe disease. A few preliminary reports also suggest increased risk of severe disease may be elevated in some minority populations, but the potential contributions of cultural, economic and social risk factors are not clear.
Vaccine situation
Vaccine may be available by September against Novel H1N1 virus.

adapted from CDC and WHO websites.

H1N1 flu death in Pune. 'Angel' Ministers and 'Villain' Doctors

2009-08-05T05:18:00.006+05:30

The tragedy of death of 14 year old girl in Pune,India's first death due to H1N1 flu['swine' flu] has created a media frenzy among our news hungry 24/7 tv channels.
The girl reported symptoms of sore throat, runny nose, headaches on July 21 and consulted a general practitioner. Since the symptoms improved, she attended school. But the fever returned and she was admitted to the Jehangir Hospital on July 27. Incidentally, the girl was admitted for treatment of suspected pneumonia.
Her lung aspirate was sent to the National Institute of Virology on July 31 and she tested positive for swine flu. She had been put on Oseltamivir on July 30.
“She had vague and non-specific symptoms,” Dr Prasad Muglikar, Medical Superintendent, Jehangir Hospital told The Indian Express. “After admission, her condition deteriorated rapidly and she had to be put on a ventilator. As part of investigations, we sent samples to the NIV. They confirmed she was infected with the H1N1 virus,” he said, pointing out “she had already visited two private practitioners and was in a breathless state when she was admitted on July 27.”

Who is to blame?
That is the first question all news anchors and reporters are asking.
The answer I thought is obvious. H1N1 virus must be the culprit. But the answers I heard was entirely different. See these reports.

Terming the death of a swine-flu infected girl in Pune as "unfortunate", Maharashtra Chief Minister Ashok Chavan has said negligence on part of the private hospital which treated the 14-year-old was to blame for it.
"This incident is really unfortunate. I feel there was total negligence on part of those who admitted her to the hospital and negligence on part of the hospital,"

The life of the swine-flu affected teenaged girl in Pune could have been saved had she tested positive for the virus and taken Tamiflu, a drug against the disease, on time, the Health Minister said on Monday night.Union Health Minister Ghulam Nabi Azad said the girl had first gone to a private hospital who treated her for "normal flu".
When she did not recover, she got herself admitted to another private hospital where again she was treated not for H1N1 but for pneumonia, he said.
"So, after having treated her for two days, the private hospital realized that there is some more than pneumonia. But by that time, both her lungs were involved," the minister said.
By the time, she was detected with the disease and given the medicine, "it was too late".
"I feel that had she got the test done right in the beginning, it would have come out positive and then should would have been administered Tamiflu and her life could have been saved," Azad told NDTV.
These are not expert doctors talking. The Chief Minister and the Union Health Minister's statements had not come after an enquiry by an expert panel. They must have asked their local Party men and must have got information from them that it is better to blame the doctors and the hospital. That is the sorry state of affairs in India.
As of 31st July the World Health Organisation has reported 1154 confirmed deaths due to H1N1 flu out of 162380 confirmed cases. Highest number of deaths, 302 is from the United States of America and Mexico with 141 deaths comes second.
Were all these deaths due to negligence of doctors?

Brazil had its first death due to H1N1 flu in late June.See how the health minister reacted there.

Brazil had its first death from the H1N1 influenza, or swine flu, on Sunday, after a 29-year-old man succumbed to the virus which he picked up in Argentina, Health Minister Jose Gomes Temporao said.
He first showed symptoms on June 15 while on a trip to Argentina, which has had several deaths due to the flu. After returning to Brazil on June 19, he was admitted to a hospital the following day where he was confirmed to have the H1N1 virus.
The ministry has in recent days warned Brazilians against traveling to Argentina and Chile. It also said the total confirmed cases of the deadly flu had reached 627 in Brazil.
Officials expect further deaths as the virus spreads during the coming winter months, which began a week ago in Brazil.

All the Health authorities in the World have reacted like this except India. No Indian media reporter was smart enough to ask the Indian Health Minister on basis of what expert report he is commenting that the doctors are to blame.
In India most of the studies have shown that about 70 percent of people approach privately owned health care facilities for all their needs. Why is it so?
Among the countries of the World, Indian Government spend the least for Health. It is always around 1 percent of the GDP while most other countries spend between 5 to 10 percent of the GDP.
That is why our ill-equipped Government run health care facilities are equally shunned by patients, doctors and politicians.
Instead of blaming with out any scientific or rational basis the doctors who treated the girl, will our politicians and Health policy makers try to revamp the tottering Health Care system?

"Never do such blood tests on your own"

2009-08-02T03:29:00.003+05:30

"Never do such blood tests for fever on your own"
I was educating the husband and wife in front of me. They were listening intently with a tinge of shame on their face.
30 year old man came to me with a series of blood test results. He is a Sales Engineer. He is having on and off fever for last 10 days. He took Paracetamol for 2 or 3 days and then noticed his urine is dark yellow in color.He immediately went to a Laboratory and asked them to do tests to see if he has jaundice. Test results showed his bilirubin is slightly high.[2.1mg]
He went to a Physician saying he has jaundice. The physician asked him to do more blood tests on Liver function and gave him some medicines for 2 days. Instead of taking that medicine and doing the tests he went to local quack to get native medicine for jaundice.
His fever was continuing on and off with no relief.So he went to another laboratory and asked them to do tests for Typhoid fever. They did the Widal test and found it to be slightly positive for paratyphi. He approached another physician to get treatment for Typhoid. He was advised admission to hospital but he refused.He was given a course of antibiotics useful for Typhoid.
Still fever was continuing. He came to see me.
After taking all this history I started examining him.He was sweating like anything in rainy cold weather.
'Did you take Paracetamol some time ago'? I asked.
"No' was his reply.
" Then why you are sweating like that?". Are you like this always?" I was curious.
'He is like this for last 5 days.Every day in the morning he gets high fever and rigors and then in 1-2 hours he sweats like this without any medicine,"said his wife.
oh........now I know why he is having fever, said my mind.
Let me confirm it with one more question.
'Have you travelled to any of the neighbouring States recently?" I asked.
"Yes to Mangalore and Bangalore" was the reply.
Being a Sales Engineer covering 3 States he is constantly in travel.
Even without a confirmatory blood smear examination I was convinced that he is having Malaria. High grade fever with rigor and chills coming same time of the day and which disappear with severe sweating without any medicines is highly suggestive of Malaria.
I told him my diagnosis and asked him to give a blood sample for Malaria immediately.
" But I have done lot of blood tests",he was confused.
" That was precisily the reason for delay in diagnosis in your case',I said.
'Never do such blood tests on your own for fever. You presented to the doctor with a lab diagnosis and the doctor did not look for a reason for fever other than what you provided.
Jaundice can occur in Malaria and the Typhoid test is not such a reliable test.Indigenous Malaria is very rare in Kerala. That's why I asked you about travel. Mangalore is notorious for Malaria.

I did his blood smear and it showed plenty of plasmodium vivax,which cause Malaria. With in few days of medicines on out-patient basis he was cured of his illness.

"This is one of the best disease you can have"

2009-07-19T23:45:00.006+05:30

" This is one of the best disease you can have"..........
......oops what I am saying to this patient?
I stopped myself.Is there anything like a good disease or a bad disease?
I was speaking to a 40 year old lady sitting in front of me. She had come to me 2 days ago with feeling of fatigue and tiredness. She is sleepy during day time even though she sleeps well at night.She said she is feeling depressed as she is not able to work properly. She is working as a clerk in an office and also have to do lot of work in her house.
" How is you bowel habits? Are you constipated? " I asked.
' Yes, I do not get regular motion nowadays" she said in a hoarse voice.
"Is your voice like this or is there any recent change?"
"Oh that is because of my throat,it is like this for few days now" she replied.
" Do you always feel like sleeping under a blanket?
" Yes feeling chilly sometimes" was her reply.
" Any increase in hair loss?"
" Yes, after I started using that new shampoo it is like that. I stopped using that but still I loose tonnes of hairs every day".
She seemed to have a reason for all her problems.
When I touched her hand the skin felt coarse. Otherwise I could not find anything wrong in her physical examination. I carefully palpated her neck and could make out mild enlargement of her thyroid gland. Even if I did not find an enlargement I never had any doubt what test to order for her. She needed a Thyroid function test. Most probably she is suffering from Hypothyroidism.

Now the report of the Thyroid function test is in front of me and I was sitting with a smug smile.
"Is it normal doctor?" She might have thought it is normal seeing my smile.
'No it is abnormal. You are suffering from Hypothyroidism".
"Is it a dangerous disease?" Her face showed her extreme worry.
"No. It is treatable but usually not curable."
"So I am having an incurable disease?" She seemed to be almost in tears.
Then I said the above line.
"This is one of the best disease you can have."
"Hypothyroidism is easy to treat in almost all the patients," I explained.
"Your thyroid gland is incapable of producing enough hormone.So you need to take Levothyroxine,a hormone tablet daily and check to see your thyroid hormone levels are maintained in normal range. The medicine is safe and after you have stabilised your dose you need to test only once in a year. There are no complications. So it is much better than conditions like Diabetes,increased blood pressure or increased cholesterol".
"When can I stop the medicine?"
" Most probably you will have to continue the medicine life-long".
" Can I try Ayurveda or Homeopathy? I do not like to take toxic 'English' medicines life long".
"As far as I know Ayurveda and Homeopathy or any other alternative system of medicine do not have any therapy for Hypothyroidism. I very well know that family members of Ayurvedic and Homeopathic doctors are taking 'English' medicine Levothyroxine.So better not to take a chance."
Then I narrated the story of a nurse who had hypothyroidism. She was working in my hospital. About 7 years ago. I had diagnosed hypothyroidism in her and started treatment. As I had changed my place of work I did not see her for long time. Recently she came to me with almost the same symptoms as she had 7 years ago. I was surprised.I thought she may need an increase in dose of the drug. I asked her how much of levothyroxine she is taking. To my surprise she said she stopped the medicine 8 months ago. Some one said Homeopathy can cure hypothyroidism and so she is now taking homeopathic treatment. I was shocked to hear this,that too from a Nurse. I asked her to do her Thyroid function tests which proved that she is again hypothyroid.
' So don't worry,soon you will be all right". I reassured my worried patient.
I am sure with in 2 months she will be fine.Among the chronic illnesses such a confidence I get only while treating hypothyroidism,because it is an easily treatable condition.
That is why I said 'this is one of the best disease you can have".

To know more about Hypothyroidism click here

Feverish Rainy Season

2009-07-10T23:51:00.005+05:30

The Monsoon is here.Though it really began pouring down only last week the Fever season started by early June. OPDs are overflowing and it is hard to get a hospital bed.
What kind of fevers are more commonly seen this year?
The usual influenza like upper respiratory tract infection is the commonest but the more serious fever this year is Dengue fever.Chikungunya fever is less common when compared to last year.
Dengue Fever[DF]
Dengue is a mosquito-borne infection that in recent decades has become a major international public health concern. Dengue is found in tropical and sub-tropical regions around the world, predominantly in urban and semi-urban areas.As per current estimates, availability of at least 100 countries are endemic for DF and about 40% of the world population (2.5 billion people) are at risk in tropics and sub-tropics. As per estimates, over 50 million infections with about 400,000 cases of DF are reported annually which is a leading cause of childhood mortality in several Asian countries.

Dengue is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue viruses. Symptoms appear 3—14 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.
Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs (e.g. Ibuprofen) is not recommended.
Dengue hemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication, affecting mainly children. Early clinical diagnosis and careful clinical management by experienced physicians and nurses increase survival of patients.
My Experience
When a patient presents with sudden appearance of high grade fever and headache without congested nose or cough my thoughts are about Dengue fever.If there is severe joint pain and swelling especially of small joints of hand I may consider Chikungunya as the first possibility.
I will then order a Complete Blood Count. A low total WBC count along with low Platelet count make my suspicion of Dengue fever stronger. Chikungunya fever may also have a low WBC count but the Platelets are usually not very low.
I admit the patient if the Platelet count is below 100000 or if the patient looks very sick. Maintaing hydration and blood pressure is most important. I had more than 20 patients with suspected Dengue fever since the beginning of June, but only one had the complication of Dengue hemorrhagic fever.There were no loss of life.

Diagnosis of Dengue fever is mainly by clinical features and not by laboratory methods.By the time the antibody levels rises and is detectable by blood tests the disease would have subsided.

Prevention of Dengue fever is mainly by reducing the mosquito breeding.Aedes breeds primarily in man-made containers like earthenware jars, metal drums and concrete cisterns used for domestic water storage, as well as discarded plastic food containers, used automobile tyres and other items that collect rainwater.
Vector control is implemented using environmental management and chemical methods. Proper solid waste disposal and improved water storage practices, including covering containers to prevent access by egg-laying female mosquitoes are among methods that are encouraged through community-based programmes.
The application of appropriate insecticides to larval habitats, particularly those that are useful in households, e.g. water storage vessels, prevents mosquito breeding for several weeks but must be re-applied periodically. Small, mosquito-eating fish and copepods (tiny crustaceans) have also been used with some success.
Fever season is always a challenge for an Internist like me. I love that challenge. Hope I can rise up to it.

Discrimination against 'positive' persons.Another shocking story

2009-06-21T06:24:00.006+05:30

Authorities at the Guru Govind Singh Government Hospital in Jamnagar,Gujarat,India labelled a 25-year-old pregnant woman as ‘HIV positive’ with a sticker on her forehead and paraded her in the hospital in the presence of her six-month-old daughter and mother-in-law, on Saturday June 20, 2009.

Yes, news report of yet another inhuman and cruel discrimination against HIV positive persons. This is depressing reading. I watched the news report in NDTV too and was shocked to see the video clip showing the woman's full face.How can the TV channels be so in-sensitive!!!

I had posted about stigma and discrimination against HIV positive persons before, especially about that I encountered in my clinical practise. Read some of them here.

Why there is Stigma and Discrimination against HIV positive persons?

1. Fear of contagion,ie the irrational fear that going near a 'positive' person will make you 'positive'.

2.HIV/AIDS is still considered by many as a death warrant.

3. Being 'positive' is considered 'immoral' by many people.It is considered to be a result of sins committed or due to Personal irresponsibility and deserve to be punished.

4, Many believe that HIV positive persons are vengeful and try their best to transmit the disease.

Why there should not be any Stigma or discrimination against HIV positive persons?

1. HIV is not transmitted from person to person by social or even intimate contacts. Read here how HIV is not transmitted.

2.HIV/AIDS is not a Death Warrant. It is a chronic manageable disease like Diabetes and Hypertension.

3. HIV/AIDS is just like any other disease.There is nothing immoral about it.More than 70 percent of positive persons in the World are those who never had sex outside marriage and had never abused IV drugs.

4. Discrimination against HIV positive persons will increase the transmission of the virus and epidemic will explode further. Seeing the discrimination in the Society a 'positive' person [who fears he/she is positive but has not tested] will be reluctant to test for HIV. They will continue to transmit the disease. If one knows he/she is 'positive' they will not reveal it, fearing stigma.Thus they will not get counselling and treatment which will reduce transmission. A pregnant 'positive' woman,like the one who was discriminated in Jamnagar should take medicines to prevent transmission of the virus to her child. Stigma will prevent her doing that and she may get a 'positive' child.

I can add on many more points,but the message remains the same.

A society that discriminates against HIV positive persons is fuelling the epidemic in its midst.

Was I responsible for his death?

2009-06-13T02:09:00.002+05:30

"Sir, Please come fast your patient Mr K is gasping...."
By the time I reached the ICU the electrocardiographic monitor was showing a flat line. The Cardiologist was there and also the Urologist and a few others.They all were trying their best to revive the patient.I was summoned to talk to the relatives sitting outside. They gave me the hard job.
Yes it was a hard job.Mr K was my patient for a long time. He was suffering from Coronary Artery Disease and Chronic Obstructive Pulmonary Disease. He was in and out of ICU many times. But for the last few years he was doing fairly well.No Hospitalisation for 26 months. He was cheerful and pleasant Along with his Cardiac and Lung diseases he was also suffering from benign Prostatic enlargement. The Prostate was large enough to obstruct free flow of urine from the Urinary Bladder. He thus was able to pass Urine only through a permanent Catheter put inside his Bladder. 2 years ago he was evaluated for Prostatic surgery [so that he can pass Urine normally] but the procedure was deferred in view of his poor Lungs and Heart.
Seeing him come to my Out Patient Department every month with this urinary catheter I was tempted to rethink about Prostatic surgery. As his general condition seems to have improved during last few months,I had hope that the Prostate surgery could be done now. I referred him to Urologist. He did a complete evaluation and told me if I and the Cardiologist could give a certificate of fitness for surgery he will go ahead with the procedure. The Cardiologist gave a guarded certificate saying there is mild risk of complications including death due to the pre existing illness.I also gave such an opinion.
Some of the relatives were not willing for surgery.But his son was ready.He asked me again and again about the risks.I explained everything and said even though there is a risk it is negligible and you can give the consent. The patient was ready to comply with his son's and my decision. Finally all gave consent and surgery was fixed.

Today was the surgery day. All went all right till a few minutes ago when he suddenly suffered a cardiac arrest in the post operative ward. The attempts to revive was failing in front of my face.
What can I tell them? They believed in me and hoped the urinary catheter will go away and their father will be happy. But now the father is no more. Will they feel that I am responsible for his death.
I went out to see the anxious relatives. In a hushed tone I told them what all had happened. I told them that everything possible was done but unfortunately we could not save him.
Are their faces showing anger at me?
No only stunned disbelief.
I explained that his lungs and Heart suddenly gave away and even if it did not happen now it might have happened some days later. They took it well and there were no accusations.
But still I continue to ask the question again and again.
Was I responsible for his death? May be yes in an indirect way.

Can I get Swine flu? Facts you should know

2009-04-28T06:32:00.005+05:30

What is swine flu?

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people.

Will this swine flu virus spread from humans to humans?

It has now been determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people.
What are the signs and symptoms of swine flu in people?
The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.
How does swine flu spread?
Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

How can someone with the flu infect someone else?
Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

What should I do to keep from getting the flu?
First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.

Are there medicines to treat swine flu?
Yes. CDC and WHO recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses. Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms).

How long can an infected person spread swine flu to others?
People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods.

What surfaces are most likely to be sources of contamination?
Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk and then touches their own eyes, mouth or nose before washing their hands.

How long can viruses live outside the body?
We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks. Frequent handwashing will help you reduce the chance of getting contamination from these common surfaces.

What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against swine flu. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health:
Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
Avoid touching your eyes, nose or mouth. Germs spread this way.
Try to avoid close contact with sick people.
If you get sick with influenza, it is recommended that you stay home from work or school and limit contact with others to keep from infecting them.

What is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick, limit your contact with other people as much as possible. Do not go to work or school if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.

What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water. or clean with alcohol-based hand cleaner. we recommend that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.

What should I do if I get sick?
If you live in areas where swine influenza cases have been identified and become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea, you may want to contact their health care provider, particularly if you are worried about your symptoms. Your health care provider will determine whether influenza testing or treatment is needed.
If you are sick, you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others.
If you become ill and experience any of the following warning signs, seek emergency medical care.
In children emergency warning signs that need urgent medical attention include:
Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough
Fever with a rash In adults, emergency warning signs that need urgent medical attention include:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting

Can I get swine influenza from eating or preparing pork?
No. Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.
prepared from CDC/WHO documents and published here for spreading the information

Tuberculosis Control and Socio-economic factors

2009-03-24T20:03:00.008+05:30

World Tuberculosis Day, falling on 24 March each year, is designed to build public awareness that tuberculosis today remains an epidemic in much of the world, causing the deaths of several million people each year, mostly in the third world. 24 March commemorates the day in 1882 when Dr Robert Koch astounded the scientific community by announcing that he had discovered the cause of tuberculosis, the TB bacillus. At the time of Koch's announcement in Berlin, TB was raging through Europe and the Americas, causing the death of one out of every seven people. Koch's discovery opened the way toward diagnosing and curing tuberculosis.

Tuberculosis
Tuberculosis is a disease that is spread from person-to-person through the air. It is caused by Mycobacterium tuberculosis, a slowly growing bacterium that is resistant to most antibiotics and, thus, difficult to treat. Despite the availability of effective therapy since the 1950’s, there are more cases of tuberculosis in the world today than in recorded history.
Left untreated, tuberculosis can kill approximately one half of patients within five years and produce significant morbidity (illness) in others. It is estimated that one-third of all HIV-infected patients die from tuberculosis and that it kills more adults than any other infectious disease. Inadequate therapy for tuberculosis can lead to drug-resistant strains of M. tuberculosis that are even more difficult to treat; the drugs needed to treat these strains are associated with more drug toxicities and greatly increased costs.

WHO report 2009 - Global tuberculosis control
Although the total number of incident[new] cases of TB is increasing in absolute terms as a result of population growth, the number of cases per capita is falling. The rate of decline is slow, at less than 1% per year. Globally, rates peaked at 142 cases per 100 000 population in 2004. In 2007, there were an estimated 137 incident cases per 100 000 population. Incidence rates are falling in five of the six WHO regions. There were an estimated 13.7 million persons suffering from TB in 2007 (206 per 100 000 population), a decrease from 13.9 million cases (210 per 100 000 population) in 2006.
An estimated 1.3 million deaths occurred among HIV-negative incident cases of TB (20 per 100 000 population) in 2007. There were an additional 456 000 deaths among incident TB cases who were HIV-positive.

There were an estimated 0.5 million cases of multidrug-resistant TB (MDR-TB) in 2007. There are 27 countries (of which 15 are in the European Region) that account for 85% of all such cases. The countries that rank first to fifth in terms of total numbers of MDR-TB cases are India (131 000), China (112 000), the Russian Federation (43 000), South Africa (16 000) and Bangladesh (15 000). By the end of 2008, 55 countries and territories had reported at least one case of extensively drug-resistant TB (XDR-TB).

Multi-drug resistant tuberculosis (MDR-TB)
Multi-drug resistant tuberculosis (MDR-TB) is defined as TB that is resistant at least to isoniazid (INH) and rifampicin (RMP). Isolates that are multiply-resistant to any other combination of anti-TB drugs but not to INH and RMP are not classed as MDR-TB.
MDR-TB mostly develop in the course of the treatment of fully sensitive TB and this is the result of patients missing doses, doctors giving inappropriate treatment, or patients failing to complete a course of treatment.Once drug-resistant tuberculosis is created it can then be spread to other susceptible individuals. HIV-infected patients have helped to amplify the global drug resistance problem because HIV-infected patients with tuberculosis are more likely to acquire drug resistant tuberculosis (particularly rifampin-resistant) and are more likely to develop tuberculosis once infected.
Despite the availability of effective treatment regimens there are more drug-resistant cases of tuberculosis today than at any time in history. Ineffective tuberculosis control programs in resource poor areas have contributed to the spread of the disease.

XDR-TB
The world is also concerned now about XDR-TB or eXtensively Drug Resistant TB, a subset of MDR-TB also resistant to fluoroquinolones and one of the three injectibles, Kanamycin, Capreomycin and Amikacin. XDR-TB has been noted as an emerging health threat, especially in countries like India, with a high prevalence of HIV.

Why drug resistant TB?
Most experts believe that in India, the problem of drug resistance arises when patients stop taking the treatment prescribed to them. Dr. Chauhan says, in his article, “Contrary to popular belief I would like to say that many failures are due to failure to take treatment and not failure of treatment per se.”
A statement that is well borne out on the field. E. Subburam, State TB Officer, Tamil Nadu, says, “There are four main reasons why patients stop medication, leading to drug resistance. In our country, the primary reason is migration. Persons with alcohol and drug dependency are the second largest group of defaulters. Patients also stop treatment when after a month or two, the symptoms subside. In some cases, violent side-effects put the patient off the treatment.”

Stigma, however, continues to be an issue that comes in the way of effective treatment. Ratnam, a driver with the State-run transport corporation, works odd hours and therefore is unable to come to the DOTS [directly observed treatment strategy] centre to take his drugs. When his local DOTS centre offered to place the drugs in the bus terminus and appoint an employee there to give him the drugs, he refused. He did not want anyone to know he had TB, least of all his colleagues. So he dropped out, even as his treatment supervisor tried to find other ways of reaching the drugs to him.

In my experience too the fixed timings of DOTS centres is a big factor.Many working persons may not be able to reach the treatment centre which is usually open only on working days between 9am and 2pm.
Lack of awareness about the problems of default in taking medicines is another important factor.

Poverty and Tuberculosis

In Europe as society changed from predominantly rural to industrialized, crowding and poverty in metropolitan areas increased markedly, creating an environment in which M. tuberculosis was able to flourish. It is estimated that 20% of all deaths in London were due to TB during the late seventeenth century. This situation worsened, peaking in the UK in about 1780. This alarming state of affairs led to many social changes, and the incidence of TB started to decline in England from the mid 1800s, years before other infectious diseases, long before the discovery of M. tuberculosis and a century before the advent of antibiotics. This decline is attributed to an increased resistance in the population, better nutrition and improved housing and working conditions. In about 1870, food production exceeded population growth in Western Europe for the first time and higher wages from the industrial revolution allowed most citizens to purchase sufficient, nutritious food. The latter is a crucial factor, because it is known that a person who is 10% underweight has a threefold increased risk of developing TB after infection. Thus, the advent of antibiotics, although making a huge difference to individuals, had relatively little overall impact on the decline of TB in Europe.

Lesson for India

Europe in late 19th and early 20th century has proved that improved living conditions,better wages and good nutrition are the key factors that helps in arresting the TB epidemic. A strategy based purely on pharmoco therapy is destined to fail if we do not consider the larger socio-economic causes for the epidemic.

Tuberculosis is not just a medical problem, but also a problem of social inequality and poverty

Am I reassuring too much?

2009-03-23T02:27:00.002+05:30

A patient always like to hear reassuring words from their Doctor.
A doctor is also happy to see the smile of relief on patient's face.
I reassure my patients a lot.But some times I ask myself
Am I reassuring too much?

The other day in my practise it was a day of reassurance.

First patient was a 29 year old woman,in the last few weeks of Pregnancy.She was diagnosed to have Gestational Diabetes.She is working in one of our Metros and was under the care of a specialised Gestational Diabetic Clinic there. Now she has come home for delivery and wanted me to look after her Diabetes.

She was on Insulin, 3 injections per day and was monitoring her blood sugar every day 2 to 3 times at home with her glucometer. She was given a long list of dos and dont's and a detailed diet chart.She was following everything perfectly.

After reading her reports I looked in her face.She seemed to be distressed. I asked her what was troubling her. She said her blood sugar is fluctuating very much and is afraid her baby will be harmed. She also said instead of gaining, she was loosing little bit of weight and is worried about.

The blood sugars were fluctuating but with in a narrow range and was well acceptable. When ever a small rise in blood sugar happens she is much worried that she reduces food intake. Some of the diet restrictions told to her from her speciality clinic was extreme and had not much scientific basis. Her mother is also confused about what food her daughter should be given. All the home grown wisdom of what to give and what not to give for a pregnant daughter was set aside and they were religiously following the diet chart.

I smiled at her and said " You are worrying too much. Your blood sugars are excellent and I am sure you will have a healthy baby and a normal delivery. Yes, you should regularly check your sugars but eat more liberally. Tell me what you really like to eat and I will tell you what quantity and how often you can eat your favourite dish."
That reassurance visibly made her happy. By next visit she started gaining weight and more importantly was at ease. I hope she will deliver normally a healthy child.

Next patient was a retired Government Clerk. He came to me few weeks ago with features of Cirrhosis Liver,probably due to alcoholism. He was send to a Gastroenterologist for detailed evaluation and was found to have severe Liver disease. He has come back with the reports.
"Is it really bad doctor?"
"Your Liver is affected by your drinking".
"I stopped the day I first came to you. Will the Liver function improve?"
"If you do not drink again you will definitely improve, don't worry", I said looking in to his eyes.
That was really not the truth.The reports showed he have irreversible liver damage and his liver function may deteriorate over several months to years. But his symptoms will temporarily improve with medicines. That's why I could confidently reassure him.
My answer I am sure made him feel better.

Third patient was a 64 year old Rheumatoid Arthritis patient. Her knee joints were so much destroyed that she needs Total knee replacement for both knees. Her family was not very well off . I had discussed it with her son and the family was not very keen to find the money for the surgery.
"Will I be able to walk properly and climb steps doctor?" She usually ask me.
" Let us see. You are showing some improvement.So if you continue the treatment......let us see."
In my mind I was sure she will not be able to walk properly. I had hinted to her once about surgery which she refused immediately citing old age. Also the family may not be able to afford it. So she will most probably go on like that using a walking stick, moving very slowly,swaying her body to either side till her death.
But each time she leaves my room, she is satisfied with my reassurance.

Am I reassuring too much?
Some times I do, hiding the gravity of the illness so that the patient is not too much upset. Some time I reassure prematurely before arriving at the diagnosis to avoid unnecessary mental tension.
Making the patient fully aware of the situation may help in avoiding future surprises.It may also help in compliance with therapy. So should I change my method?

I am confident I did do the correct thing in all three instances.
As the great TB physician Dr Edward Trudeau said
"To cure sometimes, to relieve often, to comfort always,"
should be the motto of each Physician.

"I cannot tell this to my wife doctor".

2009-03-10T02:40:00.000+05:30

" I cannot tell this to my wife doctor.She will explode and may even take her own life".
A 43 year old man was telling this to me in my clinic.
He is HIV positive.He know about this for last 3 years.
I was asking him if he had tested his wife for HIV.
No he had not tested his wife.He had not told his wife yet. He is working in a far away place and visits his family only occasionally.

Are you using condom when you are with your wife? I asked.
'No' was his answer.

I did not know what to say.I had seen him 3 years ago when he was first found 'positive'.I had given a detailed lecture to him about what to do and what not to do.I had asked him to tell his wife about his 'positive' state.I had stressed on use of Condoms.
He had neither told his wife nor used condoms while having sex with her.

I was angry. "I can't treat you if you do not follow my advise". I threw his papers on the table. He and his friend who accompanied him started pleading.

" I cannot tell this to my wife doctor.She will explode and may even take her own life".

"What are you doing? You are now giving her infection and killing her.And you still say you are afraid she will commit suicide?"
I cannot ethically decline treating him. So what should I do?

I was confused. His CD4 cell counts are low and he should be started on ART. He is so afraid of stigma and discrimination that he is not willing to go to Government ART centre.

There is a law that says the doctor have to reveal the result to the spouse if she/he asks. I told him about it. From his face I could make out that he is mentally resolving never to bring his wife to me.

I had an idea.I should make him realise that telling his wife and testing her is also important for his health.

"I have to start you on anti viral medicines now.With in few months the number of viruses in your body will become very small.But if your wife is positive and you are having sex with her without condom the viral load will not decrease as your wife will transmit the virus to you."

He was confused first, I explained again to make him understand. Slowly he realised that it is important for his health that his wife is tested and given treatment if needed.Also the fact that having unsafe sex is unsafe not only for his wife but also for him.

He agreed to take his wife for testing. I gave prescription for 2 weeks and asked him to come back with the result of his wife's test. Will he do as I advised? I do not know.
But what a selfish man?

Slow melodious and soulful Music

2009-02-19T01:41:00.005+05:30

Nimmy has tagged me to list ten songs from two languages,those songs which are slow ,melodious and soulful. I am selecting ten Malayalam songs and five Hindi songs. These and many others are among my favourites.

Malayalam songs

1. Shyama sundara pushpame
Sung by Yesudas, Music K Raghavan,Lyric ONV Film Yudhakandam
2. Hridayathin romancham Sung by Yesudas,music by K Raghavan written by G.KumaraPillai for the film 'Utharayanam'

3. Kanner poovinte kavilil Sung by M.G.Sreekumar Lyrics Kaithapram,Music Johnson Film 'Kireedom'

4. Onnini Sruthi Thazhthi a non-film song sung by Jayachandran Lyrics ONV Music Devarajan

5. Mouname nirayum mouname Janaki sings Poovachal Kadher's lines tuned by M.G.Radhakrishnan in 'Thakara'
6.Chaithram Chayam chalichu Song from 'Chillu' Yesudas singing ONV's lines tuned by MBS
7.Ende Kadinjool Pranaya kathayile Yesudas sings ONV's lines tuned by MBS in Ulkaadal
8. Manasa Maine varu Manna Dey sings Vayalar's lines tuned by Saleel Choudary in 'Chemmen'
9. O Mridhule [sad version] Yesudas sings Sathyan Anthikad's lyrics tuned by M.G.Radhakrishnan in 'Njan ekananu"
10. Arikil nee undayirunenkil, Yesudas sings ONV's lyrics set to tune by Devarajan in 'Nee ethra dhanya"

Hindi Songs

1. ye rath bheegi bheegi

2.O duniya ke rakhwale

3.Poocho na kaise maine

4.Mere nasseb mein aye dost

5.Chupke Chupke raat din
Anyone reading this can do a similar exercise and share it.

Why I left Government Health Service

2009-02-18T23:33:00.002+05:30

As I said in my previous post I was happy and satisfied during my early years in Government service. Then why I left it? Let me try to explain my reasons.

As the days and months went by my workload began to increase. The number of patients crowding in to the Medicine out patient department of the hospital became too much to be handled by me alone. Most of the other doctors were also busy. A few were experts in shirking work and nobody could make them see patients.

A similar but smaller crowd waited for me at my house each afternoon. Slowly as the quantity of work increased the quality began to suffer. Knowingly or unknowingly the quality suffered more in the hospital. Attempt to take history from the patients was time consuming and was shelved. My examination became cursory and prescriptions mere symptomatic remedies. In my private practice [which gave me direct income] I was more careful. Being an ordinary human being it was natural for me to be more sincere in that part of my work where I get more incentive.

One day I realized the extend of loss of quality of my work in the Hospital. A patient with a Cardiac murmur came to the Hospital OP. I did not detect the murmur and gave a symptomatic prescription. Not satisfied with the way I examined him; he came to my house one day later. Then only I could find out my mistake.

I tried to be more careful in my Hospital work. It was time consuming and tiring. The rule in any Government Hospital was the more sincere you are the more work you get, with out any added incentive. Actually you will earn less as you spend less time for your private practice.

Later I was transferred to a bigger hospital. There I thought I would be able to do quality work. Here also the first year was good, with fewer crowds to see me, as I was new there. As years passed the quantity of work increased. I tried hard to maintain quality. I was careful in my examination of patients so as not to miss anything.

But my satisfaction level was low. I like to talk to patients. I usually explain the illness and also about the treatment I am planning to give in detail. I had to compromise on that as I could usually spend less than 5 minutes with each patient in the hospital. If I spend more time the patients waiting in the queue will suffer. The lab stops taking samples by 11am and the Pharmacy closes by 1 pm. So if my OP run late many will not be able to use those services provided free of cost by the Government.

The relatives of those admitted under me in the Hospital will come to my house during my private practice as if to enquire about the patient's condition. Then they will try to give me an envelope with money as a form of bribe [or 'gratitude/incentive']. As a rule I will not accept it. More smart among them will get themselves examined by me for vague complaints, get a prescription from me and then give me the envelope. I will be confused and may accept it. Soon I will question myself why I accepted that. One half of my mind will tell me it is only a token of gratitude. The other half will tell me it is unethical and against the law to accept such bribe.

Many of my patients who used to consult me at my house would need admission. They were not willing to get admitted under me in the Government Hospital because of poor infrastructure and cleanliness there. They used to urge me to look after them in the nearby private hospital. Then I used to say sorry, I can’t come there as it is against the rules. But the pressure continued.

The District Medical Officer used to send me to different parts of the district for various Government activities. I was always reluctant to say no. In a way it was a change from the monotony of Hospital work. But soon I realized that most of such activities were useless and a huge wastage of Government money. Once I was send on an emergency basis to a Tribal colony in a rural village to give a report about the typhoid outbreak there. The local MLA [member of legislative assembly] had given a written question about it in the State Assembly. I was not even allowed to complete my ward rounds as the authorities wanted immediate report. I reached there an enquired about the epidemic. Actually there was no such epidemic. A press report based on rumor was the reason for all this.
When a VVIP visits our District I was usually posted for duty. Waking up early in the morning the medical team will have to wait outside the Government Guest House. When VVIP is ready to travel we will be the last vehicles in the motorcade accompanying wherever the VVIP goes. The ordeal may end only late in the night.

All these increased my unhappiness and dissatisfaction in Government service. I realized that my character itself is changing. I was slowly becoming more and more rude to patients. Work quality was going down by each passing day. I stopped enjoying my work.

At the same time my ideological commitment to Government health service prevented me from getting out. One half of my mind was saying I should stay and fight the system to change it. The other half urged me to quit so that I can start enjoying my work again.
I was indecisive, not brave enough to decide either way. Fortunately a tiff with the authorities on a matter of ethics and quality helped me to decide. I quit.

Looking back I feel I did the right thing. I did not have the guts to fight it out to try to change the system. You can call me a selfish doctor who turned away from the poor. Still I am more happy and satisfied now than I would have been in Government service.

Why I joined Government Health Service?

2009-02-05T23:38:00.006+05:30

Walking out proud from the Medical College with a post-graduate degree in Internal Medicine I had the Government job waiting for me in my home District.

Did I had any second thoughts in joining the service?

Never.

Many of my friends were trying to pass the exam to get admission for further specialisation.

But by then I wanted to taste real work,not more and more knowledge about less and less[as sub specialisation is rightly termed].

During my post graduate days, watching the endless number of patients referred from peripheral hospitals to the Medical College, I realised that there was a serious shortage of quality hands in many Districts,especially in my own. Also I was a strong believer of equity in health and always raised my voice for more Government spending in health care. The right to healthy living free of illnesses is a fundamental right which should be ensured by the Government,that was my motto.

With all this background it was natural that I never entertained second thoughts on my decision to join Government Health Service. The low salary structure did not deter me from my decision.

The hospital where I started working was a Taluk[sub-District] Hospital. It had bare minimum facilities,was under-staffed and always overcrowded with poor patients. Being an Internal Medicine MD, the patients I looked after where mainly having chronic Lung diseases,Tuberculosis,Cardiac diseases,all kinds of fevers including Leptospirosis and Typhoid,Gastro intestinal infections,all complications of Diabetes,suicidal poisoning etc.In between I also had to do suturing of minor wounds,conduct deliveries when Gynecologist was on leave and do Post mortem in case of uncontroversial but unnatural deaths.

The crowd was not knew to me[as I faced similar crowd in Medical College OP] but the lack of facilities and inability to consult a senior member of my speciality was problematic in the beginning. Soon I settled down and took my work as a challenge. To come to a working diagnosis with barest possible examination time,do the minimum but essential and affordable investigations,and treat with least expensive but effective and available medicines is always a big challenge for any doctor working in Government Hospital in small towns and villages. I was up to the challenge and did reasonably well.

I was pleasant to patients, looked up to their face and tried to listen to their complaints. I tried to practise what I learned in Medical College. The ques of patients in front of me began to grow. I started my Private practise at my place of residence [as per the Government rules]. There also patients began to flock. Money started coming in and I was overall satisfied with my decision to join Government service.

I took part in many free medical camps during holidays serving the needy in remotest part of the District. I was given training in many subjects varying from HIV/AIDS to Torture Medicine.I also imparted training to my co-workers in many subjects.

Being a doctor in Government Service gives the satisfaction of serving the poor. At the same time one can earn more money in a legal way with our hard work through the private practise.
I felt only happiness and satisfaction during those early years.

Then why did I left the Government service? That I will tell in my next post.

It seemed they all wanted her to die.Part 3

2009-01-19T00:38:00.005+05:30

Yes, they all wanted her to die,may be even myself.And she died.
The girl I mentioned in 2 of my earlier posts [November,December]died few days ago. Not seeing her come for review for last 2 months, I called the cell number I had obtained from Hospital records again.The person who answered immediately gave it to the girl's mother.
Why you are not bringing her to me?How is she? I asked in an accusing tone.
She is no more,died few days ago', was the matter of fact reply.
I was shocked.
' Did you take her to any doctor?'
'No, She was better with your medicines'.
'Did she die in a hospital or home?'
'She died at home'.
I held the line for a few seconds not knowing what to do.Then I disconnected.
Sense of depression engulfed me.And guilt.May be I should have been more pro-active.Should have telephoned that number more regularly and threatened them of action if they did not bring the girl to me.Or I should have asked one of my acquaintance in the District Positive network[an NGO of Positive ppl] to go and find out where she lived and try to interact with the family.
I hid an important fact in my first posting about that girl.The fact was her father died few years ago due to HIV/AIDS and she might have been a victim of incestuous relationship[.Her mother was negative.]This was one of the most important factor that made her family want her to die.For them her death means an end to their humiliating secret.
She was severely ill,with her CD 4 count 20[indicating very advanced AIDS] at the time of diagnosis.Still with proper care there was a 40/60 or on the pessimistic side 20/80 chance that she will recover.
But they never wanted her to recover.Should I blame them? For them she was a dirty stain on the family,someone they wanted to forget fast.
May be I should have been able to ask some NGOs to take her under their wings.Take her out of the house where she is not wanted.If she was an orphan I might have done that before discharge from the hospital.But she was not an Orphan.She had a mother,sister and brother, and Uncles.
I wish she was an Orphan.Then she might have survived.

Why some Doctors discriminate against patients?

2009-01-16T01:20:00.005+05:30

He,let us call him Mr M, is 30 years old,single working in a Bank in one of India's big Cities.His native place is near my clinic and I know him for last 6 years. I know him because he is positive for Hepatitis B Virus.

I remember him coming to me in distress as the technician in the Blood Bank had rejected his donated blood and asked him to see a Physician.He was told he is having jaundice.
I understood what the technician meant.Such rejection meant the blood is positive for either Hepatitis B or Hepatitis C Virus.

I ordered a whole series of tests on his blood. Results showed he was harbouring Hepatitis B Virus in his blood,but all the other tests were negative.

Both Hepatitis B and C are transmitted by inoculation of infected blood and blood products or body fluids.Unprotected sex, unhygienic medical procedures and unsafe blood can cause transmission.Once the virus enters the body it lives and replicates in the Liver causing hepatitis which may or may not produce jaundice.In most patients the immune system kills the virus completely and the person becomes negative to the test for virus.
But in a minority of patients the virus persists in the Liver and blood in a dormant form.Such a person is called a carrier in whom the virus will not produce any problem but can potentially transmit it to others. Our Mr M was such a carrier.Later in life [may be after 10 or 20 years] in a small percentage of carriers,the virus may again become active producing severe permanent Liver damage and even Liver cancer.So Mr M will have to undergo periodic lab tests to assess the activity of the virus.

While I explained all this his face revealed a depressed mood.
'I never had any unprotected sex doctor.Also never received blood donation'.
Any major medical procedures or injections? I asked.
'I had a few shots for various reasons.Also few dental procedures'.

If he was speaking the truth, probably we the health care personnel might have carelessly passed the virus in to his blood.I stopped that discussion there.

From then on he had came to me every year doing a series of lab tests confirming that the virus is there but not doing any harm to him.

Today Mr M was before me again.After reviewing the lab tests I gave him a smile saying everything is all right except that he is continuing as a carrier. I asked him about plans for marriage.
'Family is after me, pushing for marriage',M said.'But I do not want to hide my carrier state'.

'You can immunise your future wife with vaccine.Then you need not worry about transmitting the virus', I reassured him.

'Will anybody willingly come for an arranged marriage with a Hep B carrier?' M asked.
'Then love somebody,that may solve your problem', I replied.He gave me a shy smile.

'I have another problem doctor',he hesitantly said.
'Tell me' I encouraged him.
'I need some dental procedure done.I went to 3 different dentists in the City where I work.When I revealed my Hep B positive status they became very hesitant in doing the procedure.They came with excuses like we do not have separate instruments,or we do not want to take a risk of transmission of virus to other patients etc..'M said.' I do not want anybody else to suffer like me,that's why I am revealing my Hep B positive status'he added.

I was ashamed but not shocked.
I have seen this behaviour many times in doctors[both dentists and other doctors] when confronted with Hep B or more often with HIV.These docs will do the procedure gleefully and pocket the fees if Mr M was not so truthful.And they are doing countless procedures on un tested or untruthful positive patients day in and day out.If the Universally accepted precautions are properly taken all procedures are safe.Why these doctors discriminate like this? Are they not confident about the safety measures they are taking in their clinics?
More over in case of M, he must have got the virus from an unsafe injection or procedure.So health professionals are even more to be held responsible.
I immediately send him to a Dentist friend, with a letter in such strong words that he will not even think about rejecting Mr M. I hope he will get the required treatment and will not ever be rejected again for being truthful.

Rheumatoid Arthritis a risk factor for Heart Attack and Stroke

2009-01-01T23:38:00.005+05:30

My Aunt died suddenly few years ago due to a massive Heart Attack[Myocardial Infarction]. She was suffering from Rheumatoid Arthritis[RA] for a long time.Her Arthritis was fairly under control and was active in life when she was suddenly taken away by death. Her sudden death was a shock to me.It made me research the literature to find out any connection between Rheumatoid Arthritis and Heart Attack.The findings were very revealing.
Several studies have found out that those who are suffering from RA has double the risk for Cardiovascular disease [which includes heart attack and stroke] than General Population.The risk is almost same as those who have Type2 Diabetes.
As more more and more such studies were published an expert committee was appointed by European League against Rheumatism[EULAR], the professional body of Rheumatologists in Europe.Now the Task Force has come out with its recommendations which can be read here. This was published at EULAR 2008 the Annual Congress of the European League Against Rheumatism in Paris, France in June 2008.

The EULAR Task Force’s multidisciplinary steering committee comprised 21 members, including rheumatologists, cardiologists, internists and epidemiologists, from across nine European countries.
This recommendations are applicable not only to RA patients but also to Ankylosing Spondylitis[AS] and Psoriatic Arthritis[PsA] patients.
What does this recommendations mean for RA,AS,PsA patients?
Persons suffering from RA,AS orPsA have very high risk of getting a Heart Attack or Stroke when compared to those who do not have RA,AS or PsA.
Any one having the above rheumatological diseases should undergo active screening for other Cardiovascular risk factors like Diabetes,High Blood Pressure,High Cholestrol etc.If any such risk factors are present they should be actively managed by lifestyle modification including diet and exercise,medicines and frequent monitoring. They should refrain from using tobacco.They should also undergo frequent screening for Coronary Artery disease by Electrocardiography[ECG/EKG],Exercise Stress Test[Treadmill Test] and or Angiography which ever is applicable in a particular patient.
Though the task force have not specified a target value,it can be inferred that the target values for Blood Pressure, HDL and LDL Cholesterol should be similar to the target for Type 2 Diabetes patients.
So RA patients should keep their
Blood Pressure below 130/80
LDL Cholesterol below 100mg/dL
HDL Cholesterol above 40mg/dL

It is hoped that the Task Force recommendations will directly contribute to improved clinical practice and better the life of Rheumatoid Arthritis patients.
I wish such recommendations were there 5 years ago.If so my Aunt might have been still alive.

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

2008-12-24T00:43:00.017+05:30

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.

Click here to calculate your Diabetes risk [for South Asian population]

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.

Acknowledgement
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.

Cost of gaining height

2008-12-16T23:20:00.004+05:30

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?

It seemed they all wanted her to die -Part 2

2008-12-09T01:11:00.005+05:30

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?

Non medical reason for referring a patient-Part 2

2008-12-04T01:10:00.003+05:30

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.

Questions and answers about HIV transmission

2008-11-30T21:59:00.007+05:30

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.
Courtesy- Avert.org
Click here if you want to know more

World AIDS Day December 1

2008-11-30T00:15:00.004+05:30

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

Non-Medical reasons for referring a Patient-Part 1

2008-11-25T23:33:00.005+05:30

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.

Life and Death

2008-11-20T00:04:00.005+05:30

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.

Is homeopathy good for Chickenpox?

2008-11-19T01:19:00.008+05:30

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

It seemed they all want her to die

2008-11-17T00:12:00.004+05:30

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

World Diabetes Day

2008-11-15T01:46:00.006+05:30

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
Tiredness
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.

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from International Diabetes Federation

Featured blog post

2008-11-02T02:22:00.004+05:30

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

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

2008-10-29T23:53:00.007+05:30

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!!!

How to know when you have a Major Depression

2008-10-28T00:23:00.005+05:30

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.

You:

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.

Circumstances
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.

Personality
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.

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

Gender
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.

Genes
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.

Sleep
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

How I got interested in HIV/AIDS?

2008-10-24T23:22:00.007+05:30

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.

Primary care Physician versus Sub specialist

2008-10-20T00:20:00.009+05:30

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'.

Sad News

2008-10-13T23:52:00.005+05:30

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

2008-10-13T00:26:00.003+05:30

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.

Thirty versus Forty

2008-10-08T23:44:00.006+05:30

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

2008-10-08T01:33:00.004+05:30

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.

Chronic severe Joint pain of Chikungunya

2008-10-05T23:46:00.007+05:30

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.

Smoking banned in public places from today

2008-10-03T00:41:00.004+05:30

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.

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

2008-09-24T00:17:00.002+05:30

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.

Obstinate Patient?

2008-09-23T23:31:00.004+05:30

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.

A Study in Contrast

2008-09-19T00:03:00.004+05:30

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
and
poverty,illiteracy and ignorance on the other side.

When will this huge divide go away?

Diabetes management in the Third World

2008-09-09T23:42:00.006+05:30

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.

Is it AIDS doctor?

2008-09-07T02:04:00.004+05:30

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.

Happy News

2008-09-06T00:10:00.003+05:30

The type 1 Diabetic I mentioned in A Strange Interview married that guy.I was specially invited for that marriage. It was on a working day and I excused myself.Send a greetings instead. I had 2 reasons for not attending the marriage. The obvious reason is I was busy as all doctors are. The other reason which I thought is some thing entirely different.I am not sure it is correct. Going to a gathering where I am invited because I am the doc treating the bride's illness may highlight the fact of her illness among even those who do not know it. I did not want that.
The marriage was almost a year ago. 10 days ago she called saying her blood sugars are unusually high.I asked her to come and see me. There was nothing wrong on examination.Then I asked her about her menstrual periods. She is late by few days.As her periods were irregular how late she did not know. I asked for a Urine Pregnancy test. It was positive.Yes she was Pregnant. I was happy but also worried that from now onwards extra care have to be taken to ensure a normal pregnancy and delivery. Her HbA1c was 6.9, which is fairly good.I am hoping for an uneventful pregnancy.

Fasting Season

2008-09-05T00:02:00.002+05:30

During the last week of August my out patients were mainly Muslims getting ready for traditional fasting during the month of Ramadan.As I was out of station also for some days my hands were full with patients.
Most of them are regular patients who wanted my guidance and approval before starting fasting. They want their blood sugar,Cholesterol and Blood pressure checked. They wanted my advise regarding timing of medication. As they fast from day break to Sunset medicines have to be taken late evening and early morning. Most of them are happy when I tell them they can fast. Some sick old people who may not be able to with stand fasting have to be told no. Some times they insist and then I will say try for few days, and if you feel sick stop.
Some patients I see only just before fasting season. They will be Diabetic or having high blood pressure. They never come for follow up visits even though they are taking medicines. They come during this time because they also want a reassurance that they can fast.Their face will show guilt as I ask where were you all this time. After hearing my lecture regarding the importance of frequent blood testing and follow up visits some may change their habits. But many in this group I am sure will come only next year.
From the experience of last 10 years I know that I cant change everybody.

A mood elevating patient

2008-09-01T23:59:00.002+05:30

It was Monday,the beginning of a busy week. My mood as I entered my consulting room was not good.May be the morning blues.Or depressed thinking about a week full of work ahead.
First 2 patients came in and went out.My mood remained the same.
Then walked in[or literally carried in by his son] a retired school teacher.He is above 80. He is a regular patient of mine for last 4 years.He is suffering from Type 2 Diabetes,Benign prostatic enlargement,Osteoarthritis etc etc. Regularly he becomes sick when I am out of station. This time it happened again. He tried to contact me for a trivial cold. He could not as I was away for a week.This made him restless.His sleep was reduced.Then he started running a temperature.The son took him to another doc the next day. Medicines were prescribed.The symptoms were reduced but he was not satisfied.
He held my hand and told me he is so happy seeing me. He said he do not feel good.There is no appetite or sleep. He was afraid he will die before I came back.The son remarked that the illness actually started when his Dad heard I am out of station and now he will become all right soon.
I examined him and then reassured him that he is only having a mild cold.I also told him I won't go anywhere next 2 months. He did not leave my hand for a long time.

The faith and love that the old man had for me made me happy and I began smiling again.My blues were forgotten.

A strange interview

2008-08-31T00:05:00.005+05:30

It happened some time ago. She is a 31 yr old Type 1 Diabetic patient of mine. She called me up one day saying a guy will come to see me asking about her health condition. He is her prospective bride groom. The families contacted through a matrimonial ad. He had met her and her family. Now he wants to know how healthy she is.

In India most of the time it is the family/parents who search and find partners for their sons and daughters.[Things are changing but slowly] The parents of my Type 1 patient were in search of a bridegroom for some years now. She had called me before also, saying a guy or his parents may come and ask about her. But nobody had come to me yet.She had a stable and well paying Govt job and this had attracted many suitors.Still her T1 status might have dissuaded her prospective grooms. As far as I know she had said no to one or two suitors too.

He called me 2 or 3 times on phone before fixing a suitable time to see me. He was a serious looking guy, little bald may be around 35 years. He introduced himself and mentioned the name of my patient[his proposed bride].
We were silent for sometime.Then I started interviewing him.He is only having a temporary job in a Company,but his family had some agricultural land and according to him are financially stable.
He did not knew how to start his questions.I helped him by asking what he want to know.
How serious is her Diabetes?
Will she need Insulin through out her life?
Can she become pregnant and deliver children?
Will the children inherit her Diabetes?

Some how I thought this Guy is nice and dependable. I wanted my patient to get a good partner.So the picture of her health status that I presented to him was very positive.

Yes, she needs Insulin through out her life.Her body is not producing Insulin,a hormone essential for Sugar metabolism. We are injecting it so that she can live normally.
She have no other defect.
She can become and pregnant deliver normal children.
Finally I also added that she is having the best blood sugar control among my Type 1 patients.

I had a feeling that he was satisfied and happy. She came the next day and wanted to know everything.I told her in detail.Then she asked me 'How you feel about him?' I said I felt he is nice and dependable. She looked at my face intently and I gave her a reassuring smile.

Who profits from illness?

2008-08-30T01:08:00.002+05:30

The other day I was travelling with an Indian guy settled in US.He is a retired person aged about 60 years.He has been in US for last 35 years. He had come to India for attending a marriage of one his nephews.After the customary lamentations about the 'dismal' situation in India our chat turned to the subject of health care in USA.
He said recently he had to do an emergency surgery for Piles in USA and it cost him about 20000 US dollars. I first thought I heard him wrongly.In India for 20000$ a person can replace both his knees and do a coronary bypass surgery.I asked him again and he said Yes the bill was for twenty thousand dollars.He also added that his Insurance Company payed only 6000$.He is paying the rest from his pocket in instalments.
Then I said the doctors in US must be having handsome earnings as the patients have to pay so much. He said only a few docs have good savings. He revealed that his son is a Doctor and is still paying off his debts incurred while studying even though he passed out 5 years ago.
So who profits from the illness among common people? May be Insurance companies,Drug Companies,Corporate Hospitals etc. Is there any way out so that quality health care is easily affordable to all?

Type 2 or Type 1 Diabetes? Not sure yet

2008-08-22T14:09:00.003+05:30

The 12 yr old girl with Diabetes about whom I posted few days ago came with her lab reports. The C peptide level was in the upper range of normal.It means considerable amount of Insulin is being secreted from her Pancreas.

Does it mean she is having Type 2 Diabetes? We cannot be sure yet. There is something called 'honey moon' period in Type 1 Diabetes where the patient's requirement of Insulin injections will be less or even nil. That does not mean the patient is not suffering Type 1 Diabetes. After such honey moon period which lasts for few months the Insulin requirement will increase and the patient will show all features of Type 1 Diabetes.

Let us hope it is not Type 1 Diabetes but only time will tell.Meanwhile I have started her on Oral tablets in addition to Insulin.Let us see the response.

Patient loyalty

2008-08-16T01:37:00.006+05:30

Some patients are very loyal to their doctor. They hate seeing another doctor. They will believe only if their favourite doctor tells them, but their loyalty land them into trouble sometimes.
A patient of mine, a 50-year-old diabetic, developed sweating and mild chest pain. As I was away for a day, he consulted another doctor. An Electrocardiogram (ECG/EKG) was done and the doctor found some changes suggestive of early heart attack. The patient was asked to get admitted in an Intensive care Unit. Not believing the doctor, the patient waited for a day to see me. That night the patient became worse and he died on way to Hospital.
Being a one man practise, many a time it is difficult for me to arrange substitute medical care when I am out of station. Though I tell them to see the nearest available doctor in case of emergency, many are reluctant. When I come back from a break of few days many of these loyal patients accuse me of orphaning them. Their affection make me feel good ,but at the same time the accusation make me feel guilty.