It seemed they all wanted her to die.Part 3

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

Why some Doctors discriminate against patients?

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

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

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

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

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

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

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

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

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

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

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

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

Rheumatoid Arthritis a risk factor for Heart Attack and Stroke

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

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

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

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

Each year 7 million people develop diabetes and the most dramatic increases in type 2 diabetes have occurred in populations where there have been rapid and major changes in lifestyle, like India, demonstrating the important role played by lifestyle factors and the potential for reversing the global epidemic.

A person with type 2 diabetes is 2 – 4 times more likely to get cardiovascular disease (CVD), and 80% of people with diabetes will die from it. Premature mortality caused by diabetes results in an estimated 12 to 14 years of life lost.
India leads the global top ten in terms of the highest number of people with diabetes with a current figure of 40.9 million, followed by China with 39.8 million. Behind them come USA; Russia; Germany; Japan; Pakistan; Brazil; Mexico and Egypt. Developing countries account for seven of the world’s top ten.

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

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

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

People forming blue circle on World Diabetes day

Kathmandu Declaration and Life Circle approach

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

Prevention before bearing your child [Pre Conception Period]
You can try to prevent you and your yet to be born children getting Type 2 Diabetes.

You can do this by

1. Maintaining a BMI of less than 23 [for Indians and other South Asians; less than 25 for Caucasians]

and a waist circumference of less than 90 for males and less than 80cm for females.

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

2.Regular physical activity of at least 30 minutes a day for 5 days a week.[more if you need to loose weight]

3. Check your blood sugar to rule out Diabetes or pre-diabetes before becoming pregnant

4.Good dietary habits which includes increased amount of vegetables and fresh fruits and minimum high calorie foods.

Prevention of type 2 Diabetes in childhood and adolescence

Make sure that your child is not over weight.Actively discourage sedentary habits and over eating.Do your workouts with your kids if possible.Too much stress on studies will make your child highly paid but an unhealthy professional.

Prevention of type 2 Diabetes in adulthood

To find out your risk for type 2 diabetes, check each item that applies to you.

1. My BMI is more than 23 or my waste circumference is more than 90cm[males] or 80cms[females]
2. I have a parent, brother/ sister Uncles/Aunts, Cousins with diabetes.
3. I am from South Asia.
4. I have had gestational diabetes, or I gave birth to at least one baby weighing more than 3.5 kilograms.
5. My blood pressure is 140/90 mm Hg or higher, or I have been told at least once that my blood pressure is more than normal.
6. My cholesterol levels are not normal.

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

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

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

The more items you checked, the higher your risk.

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

How can I reduce my risk?
You can do a lot to lower your chances of getting diabetes. Exercising regularly, reducing fat and calorie intake, and losing a little weight can help you reduce your risk of developing type 2 diabetes. Lowering blood pressure and cholesterol levels also helps you stay healthy.

If you are overweight
Then take these steps:
Reach and maintain a reasonable body weight.
Make wise food choices most of the time.
Be physically active every day.

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

If your blood pressure is too high
Then take these steps:
Reach and maintain a reasonable body weight.
Make wise food choices most of the time.
Reduce your intake of sodium and alcohol.
Be physically active every day.
Talk with your doctor about whether you need medicine to control your blood pressure.

If your cholesterol or triglyceride levels are too high
Then take these steps:
Make wise food choices most of the time.
Be physically active every day.
Talk with your doctor about whether you need medicine to control your cholesterol levels.
Making Changes to Lower My Risk
Making big changes in your life is hard, especially if you are faced with more than one change. You can make it easier by taking these steps:
Make a plan to change behavior.
Decide exactly what you will do and when you will do it.
Plan what you need to get ready.
Think about what might prevent you from reaching your goals.
Find family and friends who will support and encourage you.
Decide how you will reward yourself when you do what you have planned.
Your doctor, a dietitian, or a counselor can help you make a plan. Consider making changes to lower your risk of diabetes.

Reach and Maintain a Reasonable Body Weight
Your weight affects your health in many ways. Being overweight can keep your body from making and using insulin properly. Excess body weight can also cause high blood pressure.
Body mass index (BMI) is a measure of body weight relative to height. You can use BMI to see whether you are underweight, normal weight, overweight, or obese. Use the Body Mass Index Table to find your BMI.
Find your height in the left-hand column.
Move across in the same row to the number closest to your weight.
The number at the top of that column is your BMI. Check the word above your BMI to see whether you are normal weight, overweight, or obese.

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

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

Acknowledgement
Compiled and edited from IDF and NIH websites. A big thanks to Dr C.S.Yagnik,Pune for his inputs.
The series of meetings leading to the Kathmandu declaration is supported by an educational grant from Merck Sharp & Dohme.

Cost of gaining height

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

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

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

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

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

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

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

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

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

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

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

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

It seemed they all wanted her to die -Part 2

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

Now the bad news.

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

Non medical reason for referring a patient-Part 2

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