Wednesday, December 2, 2009

A very 'Positive' news from Pakistan

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
AIDS Portal

World AIDS Day 2009.A statistical update

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.

Saturday, November 14, 2009

What Diabetic patients should know

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.

Friday, November 13, 2009

Mass drug prophylaxis against filariasis

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.

Wednesday, November 11, 2009

H1N1 Flu 2009 - Epidemiological and Clinical data from India

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.

Saturday, November 7, 2009

Chronic cough and Alternative medicine

"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?

Thursday, October 29, 2009

Avoid Pregnancy during this flu season

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.

Thursday, October 15, 2009

Effect of climate change on Health

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.


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.


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 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.

Thursday, October 8, 2009

Latest update on Novel H1N1 influenza pandemic 2009

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.


Sunday, September 27, 2009

What is the cause of his respiratory distress?

                     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?

Monday, September 14, 2009

What could be her diagnosis? Part 2

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.

Sunday, September 6, 2009

What could be her diagnosis?

"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?

Thursday, August 20, 2009

Indian Government Guidelines for management of Novel H1N1 flu cases

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.

Wednesday, August 19, 2009

Is my son having 'swine' flu?

' 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.

Sunday, August 9, 2009

How serious is the Novel H1N1 influenza infection?

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
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.

Wednesday, August 5, 2009

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

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?

Sunday, August 2, 2009

"Never do such blood tests on your own"

"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. 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.

Sunday, July 19, 2009

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

" 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

Friday, July 10, 2009

Feverish Rainy Season

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.

Sunday, June 21, 2009

Discrimination against 'positive' persons.Another shocking story

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.