Sunday, August 29, 2010

Swine flu revised guidelines - India

So far, the present guidelines stipulate that a person suspected of influenza A H1N1 need to be referred to an identified govt. health facility. He/she needs to be kept in an isolation facility in that hospital and if found positive, is treated accordingly. 
In order to make the testing facility for H1N1 more accessible at large and due to the onset of the Influenza season in the country, it has been decided to revise the existing guidelines.
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. 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.

Thursday, August 19, 2010

TB: Why you should not discriminate

Impact of Stigma and Discrimination

Tuberculosis is an infectious disease caused by bacteria that any person can get. It is not a hereditary disease or a curse of God. It can be completely cured by taking regular and complete treatment. Stigma and discrimination against people diseased with TB can occur in many settings at the workplace, health care facilities, or within the community. Its manifestation can be as dramatic as physical violence or as subtle as avoidance. However, it is totally unnecessary and primarily based on myths. Stigma is as old as history. Stigma and discrimination against people infected with TB can occur in many settings at the workplace, healthcare facilities, or within the community. Its manifestation can be as dramatic as physical violence or as subtle as avoidance. However, it is totally unnecessary and primarily based on myths. Beyond the economic consequences, stigma and discrimination against people with TB have a devastating social and psychological impact. Such attitudes obstruct health care providers in delivering effective treatment. Stigma often prevents people from seeking health care attention, which constitutes a direct public health threat to the community. Even when patients attend treatment, social disapproval of their family or community members decreases compliance with treatment. Proper adherence, however, is critical to avoid the development of multi-drug resistant TB (MDR-TB). Social isolation, experienced rejection, shame and blame due to TB diagnosis can lead to psychosomatic stress, loneliness and feelings of hopelessness.


Some of the causes of stigma & discriminationinclude:
•Lack of knowledge about TB transmission, diagnosis and treatment.
•Association with conditions already stigmatized particularly HIV/AIDS, poverty, malnutrition, migration and poor hygienic living conditions.
•People with TB are often seen as being responsible for becoming infected.
• People living with TB are seen as guilty of infecting others.
• Lack of protective equipment for health care workers.
• Lack of access to treatment.

TB related stigma and discrimination can be minimized!

It is important that employees and healthcare professionals understand the determinants and dynamics of stigma to ensure that they prevent the violation of human rights, that patients seek timely advice and achieve good treatment adherence. It is suggested that company management implement the following strategies to minimize TB related stigma and discrimination at the workplace:

•Provide a supportive work environment, where people can disclose their TB status without the threat of being stigmatized and risk losing their jobs. Have in place a policy that addresses this so that workers don’t lose their jobs because of being diagnosed as TB; rather such TB patients are provided proper care and access to DOTS services.

• Influence people’s attitudes through awareness about TB, to provide up to date information on TB epidemiology, diagnosis, transmission, treatment and address TB related stigma and discrimination. Increasing factual knowledge should be followed by experiential learning, which helps employees reflect their own attitude about TB and understand individuals affected by TB stigma and discrimination.

•Involve those with personal experience with TB and set up “Support Groups”. Such groups can encourage the exchange of experiences related to TB and address issues concerning social and workplace support.

• Initiate workplace campaigns to change attitudes. The aim of these campaigns is to provide accurate, up-to date information on TB (‘TB is curable’).

• Develop sustainability of TB anti-stigma campaigns through partnerships with private and public national and international companies.

• Respect confidentiality. Risks of disclosure might include negative responses, such as rejection, isolation and loss of employment. This can result in poor treatment adherence and/or the spread of TB to other employees.

•Link with existing HIV/AIDS anti-stigma workplace initiatives.

•Ensure occupational safety for health care staff and appropriate working conditions for all, e.g. ensuring good ventilation of premises and/ or applying air filtration. TB anti-stigma interventions should be in place in every company.

Source: Adapted from ICN Document: TB/MDR TB Related Stigma and Discrimination.


Tuesday, July 27, 2010

Contents in tobacco smoke

Just have a look at what a tobacco smoke contains and the relevance of those contents in our lives!

The real facts about tobacco

  • Tobacco smoke has negative effects on nearly every organ of the body and reduces overall health.[1]
  • Tobacco smoke contains over 4,000 chemicals, including at least 50 that cause, initiate or promote cancer such as tar, ammonia, carbon monoxide, oxides of nitrogen and benzopyrene.[2]
  • In 2001, over 40 billion cigarettes (42,301 billion) were sold in Canada.[3]
  • Child labour is widespread in all major tobacco producing countries.[4]
  • Smoking in movies is thought to be the most powerful pro-tobacco influence on teens today, accounting for 52% of adolescents who start smoking, an effect even stronger than cigarette advertising.[5]
  • The prevalence of smoking in Canada is declining among youth.  In 2008, across the country, 15% of youth 15 – 19 years old reported that they were regular smokers.  This number has not changed from the same period one year before.[6] 
  • In Ontario, youth are smoking even less.  Only 11.9 % of students in grades 7 – 12 reported that they smoked daily in 2007.  This number is down from 22% in 1999.[7]
  • Breathing in second-hand smoke causes over 1,000 deaths in Canadian non-smokers from lung cancer and heart disease every year.[8]
  • A non-smoker in a smoky room is inhaling the same chemicals as a smoker.[9]
  • The earlier you start smoking, the higher your chances are of becoming addicted to nicotine and continuing to smoke as an adult.[10]
  • Most youth who smoke want to quit but few succeed.[11] One study found that among youth who smoke, 77 percent have made one or more serious quit attempts in the last year but few of these are successful.[12]
  • If you are caught supplying or selling tobacco to youth you can be fined hundreds or even thousands of dollars for breaking the law.
  • Your choice to smoke is affected by factors such as your beliefs and attitudes, your culture, the communities you live in, your friends and family and even whether you are stressed or feel unsafe.[13]
  • Cannabis smoke is potentially carcinogenic in the same way that cigarette smoke is. Cannabis smoke contains over 400 chemicals, many of them carcinogenic.[14]
  • Youth who smoke are more likely to be depressed during their teens and even into their twenties.[15]
  • Teens who smoke cigarettes may be less like­ly to eat a healthy diet and exercise regularly.[16]
  • People who smoke are less likely to exercise.[17]
  • Smokers who want to become more physically active may find it difficult to get past the early stages of exercise because they have trouble breathing.[18]   As a result they often become discouraged and give up.
  • According to researchers at Stanford University if you are next to a person smoking outdoors, you can breathe in smoke that is much more concentrated than normal air pollution levels.  In fact, being within a few feet of a smoker outdoors may expose you to air pollution levels that are similar to levels measured in homes and bars.[19]
  • In 2008, 33% of Canadian youth ages 15-19, tried little cigars or cigarillos and 10% had smoked a little cigar or cigarillo in the past 30 days. [20]
  • A larger number of young adults ages 20-24 (50%) tried little cigars or cigarillos and 13% reported smoking a little cigar or cigarillo in the past 30 days. [20] 
Health Canada Website, Accessed March 15, 2007:
Health Canada Website, Accessed March 15, 2007:
CCTC Website: Industry Watch FAQs Accessed March 16, 2007.
World Health Organization Website:  Accessed March 16, 2007,
Dalton, M.A., (2003). Effect of smoking in movies on adolescent smoking initiation: a cohort study. Published by the Lancet, online June 10, 2003. Accessed March 17, 2007
Canadian Tobacco Use Monitoring Survey: Health Canada Website
Centre for Addiction and Mental Health. (2007). Drug Use Among Ontario Students 1977 – 2007. The results of the Ontario Student Drug Use and Health Survey.  Released November 20, 2007. OSDUHS2007_DrugDetailed_final.pdf
Makomaski Illing, E.M., & Kaiserman, M.J. (2004). Mortality attributable to tobacco use in Canada and its regions, 1998. Canadian Journal of Public Health, Jan-Feb:95(1):38-44.
United States Environmental Protection Agency. (1992). Respiratory health effects of passive smoking: lung cancer and other disorders (p 3-2). Washington, DC: Indoor Air Division, Office of Atmospheric and Indoor Air Programs, Office of Air and Radiation.
Milton, M.H., Maule, C.O., Yee, S.L., Backinger, C., Melarcher, & A.M., Husten, C.G. (2004) Youth Tobacco Cessation:  A Guide for Making Informed Decisions. Atlanta:  U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Sussman S. (2002). Effects of sixty six adolescent cessation use trials and seventeen prospective studies of self-initiated quitting. Tobacco Induced Disease, 1, 35-81.
Hollis J.F., Polen MR, Lichtenstein E, & Whitlock EP. (2003). Tobacco use patterns and attitudes among teens being seen for routine primary care, American Journal of Health Promotion 17(4): 231-9.
Kaczynski AT, Manske SR, Mannell RC, Grewal K. Smoking and physical activity: A systematic review. American Journal of Health Behaviour. 2008;32(1):93-110.
Conwell, L.S., O'Callaghan, M.J., Andersen, M.J., Bor, W., Najman, J.M., & Williams, G.M. (2003). Early Adolescent Smoking and a Web of Personal and Social Disadvantage. Journal of Paediatrics and Child Health, 39, 580-585.
Centre for Addiction and Mental Health (CAMH) Understanding the Effects and Risks of Cannabis Use: Frequently Asked Questions and Answers. Cannabisfactsheet4effects.pdf
Chaiton M, Zhang B. Environment modifies the association between depression symptoms and smoking among adolescents. Psychology of Addictive Behaviors 2007 Sep;21(3):420-424. Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Larson NI, Story M, Perry CL, Neumark-Sztainer D, Hannan PJ. Are diet and physical activity patterns related to cigarette smoking in adolescents? Findings from project EAT. Preventing Chronic Disease 2007 Jul;4(3):A51. – pdf full text
Costakis CE, Dunnagan T, Haynes G. The relationship between the stages of exercise adoption and other health behaviors. American Journal of Health Promotion. 1999;14:22-30.
Klepeis NE, Ott W, Switzer P. Real-time measurement of outdoor tobacco smoke. Journal of the Air and Waste Management Association 2007 May;57(5):522-34. See also:
Canadian Tobacco Use Monitoring Survey:  Health Canada Website Ref:

Tuesday, July 13, 2010



Fat embolism
It is a common pathological finding following long bone fracture especially with lower limb fractures e.g. Femur and Pelvis. It is common in fractures that have not been immobilized.
It can also occur after:
- Prosthetic joint replacement
- Cardiac massage
- Liver trauma
- Burns
- Marrow transplant
- Marrow biopsy
- Rapid high altitude decompression and liposuction
- Non traumatic etiology: Fatty liver, prolonged corticosteroid therapy, acute pancreatitis, osteomyelitis, conditions causing bone infarcts such as sickle cell disease.
It may occur in previously young and healthy individuals. More common 24 – 72 hours post fracture.


Marrow fat enters the circulation and lodges in the lungs causing mechanical obstruction.

Clinical features:
1. Hypoxia
2. Coagulopathy with transient petechial rash on neck, axilla and skin folds.
3. Neuro disturbance: confusion, disorientation, coma.
4. Clinically stable patients may deteriorate with low grade fever, petechial rash, hypoxia and confusion.
5. Jaundice and renal dysfunction are possible.

GURD’S criteria for diagnosis of Fat pulmonary embolism:
1. Axillary or subconjunctival petechial
2. Hypoxemia (PaO2<60 mm Hg, FiO2 110/min)
2. Pyrexia (Temperature >38.5 degree celcius)
3. Emboli present in retina on fundus examination
4. fat present in urine
5. Sudden unexplained drop in hemotocrit or platelet values
6. Fat globules present in sputum
7. Increasing sedimentation rate
Diagnosis requires at least 4 major and 1 minor criteria.

-Clinical suspicion in patients with lower limb fractures presenting with tachypnoea and hypoxia.
-Fat globules in urine.
Chest radiograph: Bilateral alveolar infiltrates. ARDS can develop.

CT Thorax: ground glass opacities / nodular opacities- centrilobular, subpleural
V/Q SCAN: perfusion scan shows multiple peripheral subsegmental defects.
Echocardiographic findings: Fat embolism can be identified in real time during orthopedic procedure.
Imaging recommendations:
Chest radiograph is usually adequate for detection of lung disease and monitoring disease course.

ARDS, Hydrostatic pulmonary edema, neurogenic pulmonary edema, Infection, Pulmonary hemorrhage, Acute venous thrombo embolic disease, Pulmonary contusion, Aspiration.

1. Immobilization of fracture site.
2. Fluid replacement
3. Oxygen
4. Supportive care.

Wednesday, May 5, 2010

You Can Control Your Asthma

4th May 2010 is the World Asthma Day. The theme of World Asthma Day 2010 is "You Can Control Your Asthma". On this occasion it is important for all of us to be well informed about the various aspects of asthma and spread awareness about the same.
A very important fact about asthma is that it cannot be cured but can definitely be controlled. People with asthma can live normal active life provided their asthma is controlled. Thus asthma does not have to necessarily limit one’s life.
Nowadays we have specialist doctors who specialize in treatment of respiratory diseases (Chest Physicians) and it’s better to have a specialist opinion right at the onset before the disease progresses.
People have asthma for many years. The main complaint an asthmatic faces is trouble in breathing. During asthmatic attacks (Acute severe asthma) chest tightness, coughing and wheezing episodes are the main clinical complaints. Patients might be absolutely normal in between two asthmatic attacks. Asthmatic attacks vary in severity from mild to very severe cases which can turn out to be fatal. Most of the times these patients wake up at night due to coughing or breathlessness.
What is asthma?
Asthma is a disease involving the airways in the lungs. The main function of the airways is to carry air in and out of the lungs. In asthma airways become smaller and smaller and also more thickened (Airway remodeling). When asthma is under control, the airways are clear and air flows easily in and out. When asthma is not under control, the sides of the airways in the lungs are always thick and swollen. In such a situation, an asthma attack can happen easily. During an attack, the airways get squeezed and also make mucus. Thus during an asthma attack, less amount of air can get in and out of the lungs. This is manifested coughing and wheezing in asthmatic patients.  The chest feels tight during such attack.
The airway function is measured objectively by spirometry or the so called pulmonary function test which helps in the diagnosis of asthma.
You can get asthma at any age however you cannot catch asthma from other people. Many times it runs in families.
How to control your asthma and keep asthma attacks from starting:
1. Take asthma medicines regularly and as per the instructions of your doctor.
2. Stay away from things that start your asthma attacks (triggers).
3. Go to the doctor 2 or 3 times in a year for check-ups. Go even when you feel fine and have no breathing problems.
4. Know the signs to predict your asthma is getting worse and how to respond (consult your doctor).
Most people with asthma need two kinds of medicine.
1. Quick-relief medicines (“relievers”) are used to stop asthma attacks.
2. Preventive medicines (“controllers”) are used every day to protect the lungs and keep asthma attacks from starting.
Now a days SMART therapy is available and both type of medicines are available in the same inhaler. Ask  the doctor to write down what asthma medicines to take and when to take them.
The medicine plan provided by your doctor helps you :
• to know what quick-relief medicines to take when you have an asthma attack.
• to help remember what preventive medicines to take every day.
• to see if you should take asthma medicine just before sports or working hard.
It is important to stress that preventive medicines for asthma are safe to use every day.
• You do not become addicted to preventive medicines for asthma even if you use them for many years.
• Preventive medicine makes the swelling of the airways in the lungs go away.
The doctor may tell you to take preventive medicine every day:
• If you cough, wheeze, or have a tight chest more than twice a week
• If you wake up at night because of asthma
• If you have many asthma attacks
• If you have to use quick-relief medicine more than twice a week to stop asthma attacks.
Asthma medicine can be taken in different ways. When asthma medicine is breathed in, it goes right to the airways in the lungs where it is needed.
Inhalers for asthma come in many shapes. Most are sprays (Metered Dose Inhalers) and some use powder (Dry Powder Inhalers). A spacer or a holding chamber makes it easier to use a spray inhaler. Asthma medicine also comes as pills and syrups.
The important points which need to be stressed are that, always have asthma medicines, always keep a part of your monthly budget for your medicines and buy medicine well in advance before you run out of medicines. Always carry your quick-relief asthma medicine with you when you leave home.
Risk factors:
Many things can start asthma attacks. These things are called “ risk  factors”: Animals ,Cigarette ,Smoke, Dust in beds with fur, Dust from Strong Pollen from the weather, sweeping smells and trees and  sprays ,flowers ,Colds ,Running, sports, and working hard.
Different people with asthma respond to different risk factors. Know which ones start asthma attacks for you. Keep risk factors that start your asthma attacks out of your home.
The following are some household measures that could help the asthmatic patients.
• Many people with asthma are allergic to animals with fur.  Keep animals outside. Give away pets.
• No smoking inside. Get help to quit smoking.
• Keep strong smells out of the home.  No soap, shampoo, or lotion that smells like perfume. No incense. Make special changes to the room where the person with asthma sleeps.
• Take out rugs and carpets. They get dusty and moldy.
• Take out soft chairs, cushions and extra pillows. They collect dust.
• Do not let animals on the bed or in the bedroom.
• No smoking or strong smells in the bedroom.
•Keep the bed simple. 
Dust collects in the mattress, blankets and pillows. This dust bothers most people with asthma.
• Put special dust-proof covers with zippers on the mattress and pillow.
• Do not use a pillow or a mattress made of straw.
• A simple sleeping mat may be better than a mattress.
• Wash sheets and blankets often in very hot water.  Dry them in the sun.
Use windows to keep the air fresh and clean.
• Open windows wide when it is hot or stuffy, when there is smoke from cooking, and when there are strong smells.
• If you heat with wood or kerosene, keep a window open a little to get rid of fumes.
• Close windows when the air outside is full of exhaust from cars, pollution from factories, dust, or pollen from flowers and trees.
Plan to do these chores when the person with asthma is not there:
• Sweep, vacuum, or dust
• Paint
• Spray for insects
• Use strong cleaners
• Cook strong smelling foods.
• Air out the house before the person with asthma returns.
• If there is no one to help, people with asthma can use a mask or scarf when they sweep or dust.
Running, sports, or working hard can also cause asthma symptoms. But these activities are good for you and need not be stopped. Your doctor may tell you to take asthma medicine before doing these activities. Thus the quality of life need not be affected.
When you know there is asthma in the family, you may be able to keep your baby from getting asthma.
• When you are pregnant, do not smoke.
• Keep tobacco smoke away from the baby and out of your home.
• Put a special dust-proof cover on the baby’s mattress. 
• Keep cats and other animals with fur out of your home.
Health check ups:
Go to the doctor 2 or 3 times a year for check- ups. Go even if you feel fine and have no breathing problems.
• Tell the doctor about any problems with your asthma medicines. The doctor can change the asthma medicine or change how much you take. There are many asthma medicines.
• Ask questions. Your doctor is your partner in controlling your asthma.
• Asthma may get better or it may get worse over the years. Your doctor may need to change your asthma medicines.
Know the signs that your asthma is getting worse and how to respond.
• Be alert for asthma symptoms: Cough, wheeze, tight chest and waking up at night. Act fast if an asthma attack starts.
• Move away from the risk factor that started the attack.
• Take a quick-relief asthma medicine.
• Stay calm for 1 hour to be sure breathing gets better.
Get emergency help from a doctor if you do not get better. Get help if you see any of these asthma danger signs.
• Your quick-relief medicine does not help for very long or it does not help at all. Breathing is still fast and hard.  
• It is hard to talk.
• Lips or fingernails turn grey or blue.
• The nose opens wide when the person breathes.
• Skin is pulled in around the ribs and neck when the person breathes.
• The heartbeat or pulse is very fast.
• It is hard to walk.
Be careful!  Using too much quick- relief medicine for asthma attacks can hurt you.
Quick-relief medicine for asthma makes you feel better for a little while.  It may stop the attack. With some attacks, you may think you are getting better but the airways are getting more and more swollen. Then you are in danger of having a very bad asthma attack that could kill you. A bad asthma attack may be recognized;
• If you use quick-relief medicine more than twice a week to stop asthma attacks, this means you need a preventive medicine for asthma. 
• If you need quick-relief medicine more than 4 times in 1 day to stop asthma attacks, you need help from a doctor today.
Monitoring asthma:
A peak flow meter can be used at a clinic or at home to measure how well a person is breathing.
• It helps the doctor decide if someone has asthma.
• It helps to see how bad an asthma attack is.
• It helps the doctor see how well asthma is controlled over time.
If a peak flow meter is used every day at home, people can find breathing problems even before they start to wheeze or cough.  Then people know when more asthma medicine is needed. There are many kinds of peak flow meters (Consult your doctor for details on this).
Thus on this world asthma day let us all resolve to spread this awareness about asthma and let everyone know that "You Can Control Your Asthma".

Monday, February 15, 2010

The Pickwickian syndrome

Today we look into an interesting syndrome in which obesity decreases ventilation!

The pickwickian syndrome, or obesity hypoventilation syndrome, was first described by Burwell and associates in 1956 and named for a character described in Charles Dickens' The Posthumous Papers of the Pickwick Club. Marked obesity, somnolence, cyanosis, periodic breathing, secondary erythrocytosis, and right ventricular heart failure were the initially described clinical characteristics of this syndrome.
Morbid obesity decreases total lung capacity (TLC), functional residual capacity (FRC), and tidal volume because of increased adipose tissue in the chest wall and elevation of the diaphragm caused by increased intra-abdominal adipose tissue. The reduced lung volumes lead to atelectasis, which alters ventilation-perfusion (V/Q) matching and causes hypoxia. There is also evidence that respiratory muscles become less effective in morbid obesity. Most patients also have OSA, which further increases ventilatory work in a system already predisposed to hypoventilation. Finally, hypoxic and hypercapnic responses are diminished in most patients, either secondary to chronic hypoxia and hypercapnia or, perhaps, congenitally. Even though the exact sequence of events is not always clear, it is easy to conceptualize that affected patients with reduced lung volumes, atelectasis, noncompliant chest walls, ineffective respiratory muscles, upper airway obstruction,and altered metabolic control of breathing are prone to develop hypoventilation, especially during sleep.

Nasal continuous positive airway pressure (nCPAP) is now clearly established as the most effective therapy for OSA. nCPAP is also effective in the majority of patients with obesity hypoventilation, not only resolving upper airway obstruction during sleep, but also increasing the ventilatory response to CO2 while awake and improving awake hypercapnia. However, there are many patients with severe OSA and hypercapnia who are only partially responsive to CPAP alone and continue to demonstrate sleep associated hypoventilation and elevated PaCO2 during wakefulness.

Friday, January 29, 2010

Yousaytoo Awards - a bit offtopic! to break the monotony.

Friends today I am going a bit off topic in my bid to break the monotony and also put forward my optimistic side!
I am extremely glad to share information regarding the "yousaytoo awards". This award is given in the category of internet blogs. I am extremely hopeful and the optimism in myself comes to its its full bloom , the moment i think of a $1,000 holiday dream gift coming my way. It could be a clinic utility with which I could serve my patients.I being a Chest Physician a simple spirometer would be a dream gift for me which I could utilise for my patients. The fun gifts are really funny and the one that interests me the most is the digital photoframe keyring to put the keys of my two wheeler and carry my most memorable pics with me.I know that there are many competitors in the competition and my chances are a lot dependent on luck. Still I am an optimistic person and will continue to enrich my blog with some very useful sites that will definitely be resourceful to everyone.

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