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.
Saturday, August 8, 2009
Tuesday, August 4, 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?
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?
Saturday, August 1, 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.
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.
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.
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
......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.
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.
Saturday, June 20, 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.
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.
Friday, June 12, 2009
Was I responsible for his death?
"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.
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.
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