Today October 15th is the Blog Action Day and this year's theme is climate change.
What are the effects of climate change on health?
Rapidly changing Climate is a major challenge to public health together with poverty, inequity, and infectious and non-communicable diseases. Furthermore, the poorest countries will suffer the greatest consequences of climate change even though they contributed the least for emissions.
Patterns of disease and mortality
Global temperature rise will directly affect health. The heat waves of 2003 in Europe caused up to 70 000 deaths, especially from respiratory and cardiovascular causes. Rising temperatures are likely to generate heat-related stress, increasing the short-term mortality rate due to heatstroke. Regions that are heavily urbanised will be more adversely affected than rural ones.
Rising temperatures will also affect the spread and transmission rates of vector-borne and rodent-borne diseases. Temperature affects rate of pathogen maturation and replication within mosquitoes, the density of insects in a particular area, and increases the likelihood of infection. Therefore, some populations who have little or no immunity to new infections might be at increased risk. Vector reproduction, parasite development cycle, and bite frequency generally rise with temperature; therefore, malaria, tick-borne encephalitis, and dengue fever will become increasingly widespread. In some cases, extreme events, such as heavy rains, will wash away eggs and larvae and decrease vector populations.
Mosquitoes responsible for malaria will grow, by accessing warm high altitudes, in places once free of the disease. It is estimated that 260—320 million more people will be affected by malaria by 2080 as a consequence of new transmission zones.
Dengue fever is sensitive to climate. The disease is prominent in urban areas because of inadequate water storage that affects about 100 million people worldwide. Climate change will increase the number of regions affected by arbovirus, such as Australia and New Zealand. Heavy rainfall and a rise in temperature increase the rate of infection. By 2080, about 6 billion people will be at risk of contracting dengue fever as a consequence of climate change, compared with 3·5 billion people if the climate remained unchanged.
Schistosomiasis, fascioliasis, alveolar echinococcosis, leishmaniasis, Lyme borreliosis, tick-borne encephalitis, and hantavirus infections are all projected to increase as a result of global climate change.
As ocean temperatures rise with global warming and more intense El Niños, cholera outbreaks might increase as a result of more plankton blooms providing nutrients for Vibrio cholerae. In 1998, increased rainfall and flooding after hurricane Mitch in Nicaragua, Honduras, and Guatemala caused a leptospirosis outbreak, and an increased number of cases of malaria, dengue fever, and cholera.
Food
Climate change threatens human health through its effect on under nutrition and food insecurity. Chronic and acute child malnutrition, low birth weights, and sub optimal breastfeeding are estimated to cause the deaths of 3·5 million mothers and young children every year. Furthermore, one in three children under the age of 5 years born in developing countries suffer from stunting due to chronic under nutrition. Climate change will compound existing food insecurity.
A study suggests that half of the world's population could face severe food shortages by the end of the century because rising temperatures take their toll on farmers' crops. Harvests of staple food crops, such as rice and maize, could fall between 20% and 40% as a result of increased temperatures during the growing season in tropical and subtropical regions.
Water and Sanitation
Safe and reliable access to clean water and good sanitary conditions are essential for good health. In 2002, 21% of people living in developing countries did not have sustained access to an improved water source, and 51% did not have access to improved sanitation.
Changing rainfall and temperature over the next decades are likely to make provision of clean water, good sanitation, and drainage even more complicated than it is now. Average annual rainfall is forecast to decrease in some regions and increase in others, and droughts and floods are likely to become more frequent and intense. Regional temporal patterns of rainfall might also be altered: the problem is not simply sustained drought, but also severe rainfall all at once followed by less rainfall, thus annual rainfall might rise, but still cause drought.
More than a sixth of the world's population currently live in glacial-fed water catchments, which are vulnerable to climate change. Increasing rates of glacial melting are predicted to lead to great reductions of water availability. In the near future, high peak flows in glacial-fed rivers are expected, as the rate of glacier-mass loss increases, followed by dramatic reductions in river flow and freshwater availability as glaciers progressively disappear. Rising temperatures are also likely to result in earlier snow thawing and increased rain relative to snow precipitation, bringing peak river flows earlier in the year, potentially exacerbating dry season water scarcity.
Reduced river flows and increased water temperature will lead to declining water quality as the dilution of contaminants is reduced, less oxygen is dissolved in water, and microbiological activity increases. These effects could lead to major health problems for vulnerable people, especially during drought, and might increase the risk of conflict and major population migration.
Poverty
Many of the most serious public health consequences of climate change will be experienced by the world's poorest nations, increasing global health inequities. Basic infrastructure for much of the world's population is inadequate to meet essential health care needs, and our ability to cope effectively with the aftermath of natural disasters is insufficient. Overall, all the underlying social, economic, and ecological determinants of global illness and premature death will be exacerbated by climate change. Progress towards the Millennium Development Goals and achievement of the 2015 targets might be impaired or reversed. Because climate change acts mostly as an amplifier of existing risks to health, poor and disadvantaged people will experience greater increments in disease burden than rich, less vulnerable populations.
Gender
Gender inequity is another important factor. In developing countries, women are among the most vulnerable to climate change; they not only account for a large proportion of the agricultural workforce but also have few alternative income opportunities. Women manage households and care for family members, which limit their mobility and increase their vulnerability to natural disasters and other local sudden climate changes. Efforts to keep the adverse effects of climate change to a minimum should ensure that policies address issues of women's empowerment.
Climate change is not just an environmental issue but also a health issue. The ability to adapt to the health effects of climate change depends on measures that reduce its severity—i.e., mitigation measures that will drastically reduce carbon emissions in the short term, but also increasing the planet's capacity to absorb carbon. This is a crucial issue that must be acted upon urgently.
Source: The report of The Lancet Commission on health effects of climate change published in The Lancet dated 16th May 2009.
Wednesday, October 14, 2009
Wednesday, October 7, 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.
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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.
.
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.
.
Saturday, September 26, 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?
" 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?
Sunday, September 13, 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.
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.
Saturday, September 5, 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?
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?
Wednesday, August 19, 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.
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.
Tuesday, August 18, 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.
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.
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