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History & Evolution of Intensive (Critical) Care Units


              The English nurse Florence Nightingale pioneered efforts to use a separate hospital area for critically injured patients. During the Crimean War in the 1850s, she introduced the practice of moving the sickest patients to the beds directly opposite the nursing station on each ward so that they could be monitored more closely.  In 1923, the American neurosurgeon Walter Dandy created a three-bed unit at the Johns Hopkins Hospital. In these units, specially trained nurses cared for critically ill postoperative neurosurgical patients.

           The Danish anaesthesiologist Bjørn Aage Ibsen became involved in the 1952 poliomyelitis epidemic in Copenhagen, where 2722 patients developed the illness in a six-month period, with 316 of those developing some form of respiratory or airway paralysis. Some of these patients had been treated using the few available negative pressure ventilators, but these devices (while helpful) were limited in number and did not protect the patient’s lungs from aspiration of secretions. Ibsen changed the management directly by instituting long-term positive pressure ventilation using tracheal intubation, and he enlisted 200 medical students to manually pump oxygen and air into the patients’ lungs round the clock. At this time, Carl-Gunnar Engström had developed one of the first artificial positive-pressure volume-controlled ventilators, which eventually replaced the medical students. With the change in care, mortality during the epidemic declined from 90% to around 25%. Patients were managed in three special 35-bed areas, which aided charting medications and other management.

        In 1953, Ibsen set up what became the world’s first intensive care unit in a converted student nurse classroom in Copenhagen Municipal Hospital. He provided one of the first accounts of the management of tetanus using neuromuscular-blocking drugs and controlled ventilation.

         The following year, Ibsen was elected head of the department of anaesthesiology at that institution. He jointly authored the first known account of intensive care management principles in the journal Nordisk Medicin, with Tone Dahl Kvittingen from Norway.

      For a time in the early 1960s, it was not clear that specialized intensive care units were needed, so intensive care resources were brought to the room of the patient that needed the additional monitoring, care, and resources. It became rapidly evident, however, that a fixed location where intensive care resources and dedicated personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital. In 1962, in the University of Pittsburgh, the first critical care residency was established in the United States. In 1970, the Society of Critical Care Medicine was formed.

How an epidemic led to development of Intensive Care Unit

How an epidemic led to development of Intensive Care Unit

The number of hospital admissions was more than the staff had ever seen. And people kept coming. Dozens each day. They were dying of respiratory failure. Doctors and nurses stood by, unable to help without sufficient equipment.

It was the polio epidemic of August 1952, at Blegdam Hospital in Copenhagen. This little-known event marked the start of intensive-care medicine and the use of mechanical ventilation outside the operating theatre — the very care that is at the heart of abating the COVID-19 crisis.

In 1952, the iron lung was the main way to treat the paralysis that stopped some people with poliovirus from breathing. Copenhagen was an epicentre of one of the worst polio epidemics that the world had ever seen. The hospital admitted 50 infected people daily, and each day, 6–12 of them developed respiratory failure. The whole city had just one iron lung. In the first few weeks of the epidemic, 87% of those with bulbar or bulbospinal polio, in which the virus attacks the brainstem or nerves that control breathing, died. Around half were children.

Desperate for a solution, the chief physician of Blegdam called a meeting. Asked to attend: Bjørn Ibsen, an anaesthesiologist recently returned from training at the Massachusetts General Hospital in Boston. Ibsen had a radical idea. It changed the course of modern medicine.

Student saviours                                    

The iron lung used negative pressure. It created a vacuum around the body, forcing the ribs, and therefore the lungs, to expand; air would then rush into the trachea and lungs to fill the void. The concept of negative-pressure ventilation had been around for hundreds of years, but the device that became widely used — the ‘Drinker respirator’ — was invented in 1928 by Philip Drinker and Louis Agassiz Shaw, professors at the School of Public Health in Boston, Massachusetts. Others went on to refine it, but the basic mechanism remained the same until 1952.

Iron lungs only partially solved the paralysis problem. Many people with polio placed in one still died. Among the most frequent complications was aspiration — saliva or stomach contents would be sucked from the back of the throat into the lungs when a person was too weak to swallow. There was no protection of the airway.

Ibsen suggested the opposite approach. His idea was to blow air directly into the lungs to make them expand, and then allow the body to passively relax and exhale. He proposed the use of a trachaeostomy: an incision in the neck, through which a tube goes into the windpipe and delivers oxygen to the lungs, and the application of positive-pressure ventilation. At the time, this was often done briefly during surgery, but had rarely been used in a hospital ward.

Ibsen was given permission to try the technique the next day. We even know the name of his first patient: Vivi Ebert, a 12-year-old girl on the brink of death from paralytic polio. Ibsen demonstrated that it worked. The trachaeostomy protected her lungs from aspiration, and by squeezing a bag attached to the tube, Ibsen kept her alive. Ebert went on to survive until 1971, when she ultimately died of infection in the same hospital, almost 20 years later.

The plan was hatched to use this technique on all the patients in Blegdam who needed help to breathe. The only problem? There were no ventilators.

Very early versions of positive-pressure ventilators had been around from about 1900, used for surgery and by rescuers during mining accidents. Further technical developments during the Second World War helped pilots to breathe in the decreased pressures at high altitudes. But modern ventilators, to support a person for hours or days, had yet to be invented.

What followed was one of the most remarkable episodes in health-care history: in six-hour shifts, medical and dental students from the University of Copenhagen sat at the bedside of every person with paralysis and ventilated them by hand. The students squeezed a bag connected to the trachaeostomy tube, forcing air into the lungs. They were instructed in how many breaths to administer each minute, and sat there hour after hour. This went on for weeks, and then months, with hundreds of students rotating on and off. By mid-September, the mortality for patients with polio who had respiratory failure had dropped to 31%. It is estimated that the heroic scheme saved 120 people.

Major insights emerged from the Copenhagen polio epidemic. One was a better understanding of why people died of polio. Until then, it was thought that kidney failure was the cause. Ibsen recognized that inadequate ventilation caused carbon dioxide to build up in the blood, making it very acidic — which caused organs to shut down.

Three further lessons are central today. First, Blegdam demonstrated what can be achieved by a medical community coming together, with remarkable focus and stamina. Second, it proved that keeping people alive for weeks, and months, with positive-pressure ventilation was feasible. And third, it showed that by bringing together all the patients struggling to breathe, it was easier to care for them in one place where the doctors and nurses had expertise in respiratory failure and mechanical ventilation.

So, the concept of an intensive-care unit (ICU) was born. After the first one was set up in Copenhagen the following year, ICUs proliferated. And the use of positive pressure, with ventilators instead of students, became the norm.

In the early years, many of the safety features of modern ventilators did not exist. Doctors who worked in the 1950s and 1960s describe caring for patients without any alarms; if the ventilator accidentally disconnected and the nurse’s back was turned, the person would die. Early ventilators forced people to breathe at a set rate, but modern ones sense when a patient wants to breathe, and then help provide a push of air into the lungs in time with the body. The original apparatus also gathered limited information on how stiff or compliant the lungs were, and gave everyone a set amount of air with each breath; modern machines take many measurements of the lungs, and allow for choices regarding how much air to give with each breath. All of these are refinements of the original ventilators, which were essentially automatic bellows and tubing.

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Mental Health- Depression


Mental health conditions are increasing worldwide. Mainly because of demographic changes, there has been a 13% rise in mental health conditions and substance use disorders in the last decade (to 2017). Mental health conditions now cause 1 in 5 years lived with disability. Around 20% of the world’s children and adolescents have a mental health condition, with suicide the second leading cause of death among 15-29-year-olds. Approximately one in five people in post-conflict settings have a mental health condition.

Mental health conditions can have a substantial effect on all areas of life, such as school or work performance, relationships with family and friends and ability to participate in the community. Two of the most common mental health conditions, depression and anxiety, cost the global economy US$ 1 trillion each year.

Despite these figures, the global median of government health expenditure that goes to mental health is less than 2%. 

Depression

Depression

Key facts

  • Depression is a common mental disorder. Globally, it is estimated that 5% of adults suffer from depression.
  • Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease.
  • More women are affected by depression than men.
  • Depression can lead to suicide.
  • There is effective treatment for mild, moderate, and severe depression.

Overview

Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years (1). Approximately 280 million people in the world have depression (1). Depression is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. Especially when recurrent and with moderate or severe intensity, depression may become a serious health condition. It can cause the affected person to suffer greatly and function poorly at work, at school and in the family. At its worst, depression can lead to suicide. Over 700 000 people die due to suicide every year. Suicide is the fourth leading cause of death in 15-29-year-olds.

Although there are known, effective treatments for mental disorders, more than 75% of people in low- and middle-income countries receive no treatment (2).  Barriers to effective care include a lack of resources, lack of trained health-care providers and social stigma associated with mental disorders. In countries of all income levels, people who experience depression are often not correctly diagnosed, and others who do not have the disorder are too often misdiagnosed and prescribed antidepressants.

Symptoms and patterns

During a depressive episode, the person experiences depressed mood (feeling sad, irritable, empty) or a loss of pleasure or interest in activities, for most of the day, nearly every day, for at least two weeks. Several other symptoms are also present, which may include poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling especially tired or low in energy. 

In some cultural contexts, some people may express their mood changes more readily in the form of bodily symptoms (e.g. pain, fatigue, weakness).  Yet, these physical symptoms are not due to another medical condition. 

During a depressive episode, the person experiences significant difficulty in personal, family, social, educational, occupational, and/or other important areas of functioning. 

A depressive episode can be categorised as mild, moderate, or severe depending on the number and severity of symptoms, as well as the impact on the individual’s functioning. 

There are different patterns of mood disorders including:

  • single episode depressive disorder, meaning the person’s first and only episode);
  • recurrent depressive disorder, meaning the person has a history of at least two depressive episodes; and
  • bipolar disorder, meaning that depressive episodes alternate with periods of manic symptoms, which include euphoria or irritability, increased activity or energy, and other symptoms such as increased talkativeness, racing thoughts, increased self-esteem, decreased need for sleep, distractibility, and impulsive reckless behaviour.  

Contributing factors and prevention

Depression results from a complex interaction of social, psychological, and biological factors. People who have gone through adverse life events (unemployment, bereavement, traumatic events) are more likely to develop depression. Depression can, in turn, lead to more stress and dysfunction and worsen the affected person’s life situation and the depression itself.

There are interrelationships between depression and physical health. For example, cardiovascular disease can lead to depression and vice versa.

Prevention programmes have been shown to reduce depression. Effective community approaches to prevent depression include school-based programmes to enhance a pattern of positive coping in children and adolescents. Interventions for parents of children with behavioural problems may reduce parental depressive symptoms and improve outcomes for their children. Exercise programmes for older persons can also be effective in depression prevention.

Diagnosis and treatment

There are effective treatments for depression. 

Depending on the severity and pattern of depressive episodes over time, health-care providers may offer psychological treatments such as behavioural activation, cognitive behavioural therapy and interpersonal psychotherapy, and/or antidepressant medication such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Different medications are used for bipolar disorder. Health-care providers should keep in mind the possible adverse effects associated with antidepressant medication, the ability to deliver either intervention (in terms of expertise, and/or treatment availability), and individual preferences. Different psychological treatment formats for consideration include individual and/or group face-to-face psychological treatments delivered by professionals and supervised lay therapists. Antidepressants are not the first line of treatment for mild depression. They should not be used for treating depression in children and are not the first line of treatment in adolescents, among whom they should be used with extra caution.

WHO response

WHO’s Mental Health Action Plan 2013-2030 highlights the steps required to provide appropriate interventions for people with mental disorders including depression. 

Depression is one of the priority conditions covered by WHO’s Mental Health Gap Action Programme (mhGAP). The Programme aims to help countries increase services for people with mental, neurological and substance use disorders through care provided by health workers who are not specialists in mental health. 

WHO has developed brief psychological intervention manuals for depression that may be delivered by lay workers to individuals and groups. An example is the Problem Management Plus manual, which describes the use of behavioural activation, stress management, problem solving treatment and strengthening social support. Moreover, the Group Interpersonal Therapy for Depression manual describes group treatment of depression. Finally, the Thinking Healthy manual covers the use of cognitive-behavioural therapy for perinatal depression.

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Sale of breast milk- Ayush licence- Dairy product -Lucrative business- Any Ethical Question?


Commercial sale of mother’s milk under Ayush licence has thrown up ethical questions.  You can buy literally anything these days, even human breast milk. India is home to the only company in Asia that sells mother’s milk for profit, Bengaluru-based Neolacta Lifesciences Pvt Ltd. After activists objected to the commercialization of mother’s milk, the Food Safety and Standards Authority of India (FSSAI) cancelled the company’s licence stating that sale of mother’s milk was not permitted under its regulations. However, an FSSAI inspection revealed that the company continues to sell mother’s milk by obtaining an Ayush licence in November 2021 for its product dubbed ‘Naariksheera’ (breast milk). Neolacta, which was established in 2016, had originally obtained a licence from the Karnataka office of the FSSAI in the category of dairy products. “It is absolutely shocking that a company is being allowed to collect breast milk from young mothers and sell it like a dairy product with a huge price tag claiming to have added value to it,” said Nupur Bidla of the Breastfeeding Promotion Network of India (BPNI), which had alerted the government to this in 2020.

       Saurabh Aggarwal, MD of Neolacta, told TOI that the company has significant experience in the human milk space supplying technology to set up the first milk bank in Australia. He said that NeoLacta had, over the past five years, “benefited over 51,000 plus premature babies across 450 hospitals.” Donated breast milk is mainly used to feed premature or sick babies when mothers are unable to nurse them for a variety of reasons. Usually, the milk is sourced through milk banks set up as non-profits. Milk collected from donors (healthy lactating mothers) is pasteurised, analysed for nutrient content and checked for contamination of any kind and is then frozen and stored. In most milk banks, especially those attached to government hospitals, the donated milk is given free of cost. However, in many others it might be free for a few poor patients but those who can afford it are usually charged a few hundred rupees for 50 ml of donated breast milk. There are over 80 non-profit human milk banks in India. Neolacta charges Rs 4,500 for 300 ml of frozen breast milk. A pre-term baby could require about 30 ml per day while a baby on full feed could need as much as 150 ml per day. It also sells human milk-derived powder that is readily available on ecommerce sites as well as its own. President of the National Neonatology Forum (NNF).

     Dr Siddarth Ramji told TOI that “as a principle we do not support commercialisation of breast milk” but pointed out that NNF was not a regulatory body. Dr Satish Tiwari, national convenor of the Human Milk Banking Association of India, described it as a shame. “Does the company pay the mothers who are donors? Do they take it free and sell it at such a high cost? No one knows. The government should look into this.” In a research article published in December 2020 titled, ‘Nurture commodified? An investigation into commercial human milk supply chains’, social scientist Dr Michal Nahman and economist Prof Susan Newman from the UK examined the way Neolacta functioned. Speaking to TOI, Prof Newman said their research consultants had found evidence that women, mainly in rural areas, were actively being pursued by NGOs and associated ‘health workers’ and paid either with cash or with food packets. She pointed out that in the initial news reports on Neolacta, they freely admitted to collecting milk from women across four states but have since become more cagey about how they source the milk. The article adding that in 2016, an attempt by NeoLacta to collect breast milk from the largest government hospital for women and children in Bengaluru, Vani Vilas, was abandoned after serious concerns over the “commercial exploitation of breast milk”. “It was evident from our interviews with NeoLacta donors, intermediaries such as NGOs and community health workers and NeoLacta employees,  donor milk is not framed as a commodity in spite of the marketisation of NeoLacta product. Rather, the way in which donor milk is operationalised as a ‘gift’ (or ‘daan’ in the Indian context) is built in to how it is commodified,” stated the article. Remuneration would depend upon the volume that women provide and 80% of the revenue would be paid to the mother with the NGO worker taking a 20% cut, it added.

 At the time of going to press, the Ayush ministry had not responded to this reporter’s queries. BPNI wrote to the health ministry in February 2020 that “Neolacta has been involved in commercializing human milk” even though the guiding principles for using donor human milk in India in the health ministry’s ‘National Guidelines on Lactation Management Centers in Public Health Facilities’ clearly states, “DHM (donated human milk) cannot be used for any commercial purpose”. With the ministry not responding, BPNI wrote to FSSAI asking how the licence was issued. Neolacta was established in 2016, a year after Cambodia banned selling of breastmilk after a public outcry about an American for-profit company Ambrosia sourcing breast milk from poor women in Cambodia and selling it in the US. A letter from the Cambodian government was quoted as stating: “Although Cambodia is poor and (life is) difficult, it is not at the level that it will sell breast milk from mothers.” In the context of Cambodia, UNICEF had said in a statement that the trade in breastmilk was “exploiting vulnerable and poor women for profit and commercial purposes”. Most countries do not allow the commercial sale of breastmilk.

    Dr Arun Gupta of BPNI alleges that Neolacta aggressively markets its products on social media. “It is using the tactics of the infant formula industry in the way it is targeting healthcare providers to gain legitimacy. Infant formula companies harp on mothers not having enough milk and Neolacta goes on about mothers producing ‘excess breastmilk’ which they can donate. It claims that its products do not come under the IMS Act, which regulates the marketing of infant milk substitutes, but it does,” said. BPNI complained to the National Neonatology Forum (NNF) in February 2021. The NNF responded in April 2021 to state that the NNF had already taken a decision in its executive board meeting to abstain from providing any form of encouragement to Neolacta Lifesciences and that a letter communicating this decision had been sent to all the members of the forum. Officials from the Bengaluru branch of FSSAI inspected the Neolacta unit on April 22 and found stocks of packing materials bearing the suspended FSSAI License, which they seized. The local FSSAI office has also asked the company to recall from the market all its products which have used the FSSAI licence and to disable online selling of such products. The company was also issued a notice for carrying out food business without a valid FSSAI license. A commercial company selling breast milk would court healthcare providers including doctors and hospitals to become their suppliers, which would increase the cost to the healthcare system and create ethical dilemmas, warned public health researcher Sarah Steele of the University of Cambridge in a piece she wrote about commercial human milk banks in October 2021. She added that if mothers moved from donating to non-profit milk banks to such companies, healthcare providers would be forced to enter into contracts with such companies and this could result in the privatization of a previously public service. Dr Sushma Nangia, professor and head of the neonatology department in Lady Hardinge Medical college who established a human milk bank, explained that donated breast milk might be better than infant formula but was inferior to mother’s own milk. “Even for pre-term babies their own mother’s milk is best for them to thrive. Donated human milk is inferior to mother’s milk as milk from different sources is pooled and vital nutrients are lost when it is pasteurized. Obviously, there are cases where donated breast milk is needed and that is why we started a bank but we do not prescribe it for all pre-term or sick babies. Neonatologists and the increase in the business of neonatal ICUs in the private sector are behind the push for donated breastmilk. It has become a lucrative business. This menace (push for commercial donor milk) can be curbed if neonatologists invest time and resources in ensuring mother’s own milk for her baby rather than going for commercial donor milk and also providing unambiguous information to families that donor milk is not the same as their own mother’s milk. The government needs to step in and enquire where the milk is being sourced from,” said Dr Nangia.

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NAIROBI FLY DERMATITIS- Spreading at Sikkim-Paederus dermatitis


Nairobi fly is a common name for two species of rove beetle also called Dragon Bug.

Paederus dermatitis is a peculiar, irritant contact dermatitis characterized by a sudden onset of erythematobullous lesions on exposed areas of the body. The disease is provoked by an insect belonging to the genus Paederus. This beetle does not bite or sting, but accidental brushing against or crushing the beetle over the skin provokes the release of its coelomic fluid, which contains paederin, a potent vesicant agent.

 The fluid contains paederin, a potent vesicant agent. If not immediately washed off, the chemical leads to a linear dermatitis composed of erythematobullous lesions.

NAIROBI FLY DERMATITIS: AROUND 8-10 CASES REPORTED DAILY AT RANGPO PHC

 

NAIROBI FLY DERMATITIS: AROUND 8-10 CASES REPORTED DAILY AT RANGPO PHC

GANGTOK,: Blister Bee Dermatitis, also known as Nairobi Fly Dermatitis, has been spreading rapidly at different places in Sikkim with Sikkim Manipal Institute of Technology, Duga, IBM and Rangpo being the worst-affected.

Nairobi fly is a common name for two species of rove beetle in the genus Paederus, native to East Africa. The beetle contains a toxic hemolymph known as pederin which can cause chemical burns if it comes into contact with skin. Because of these burns, the Nairobi fly is sometimes referred to as a dragon bug. The symptoms include skin inflammation, rashes and blisters in severe cases.

The rash usually affects body parts not covered by clothing; healing time ranges from 7 to 28 days, usually with permanent skin discoloration.

A local guardian of a student at SMIT stated that, “Nairobi fly is reportedly spreading in and around SMIT campus like wildfire and has already infected almost hundred students with its poisonous acid among which one had to undergo a minor hand operation.”

Rangpo PHC, the main health centre in the region, has been receiving around 8-10 cases daily.

“We have getting around 8 to10 cases per day from Duga, Tamatar, IBM and Rangpo areas. I learnt about the cases at SMIT on June 30. I stay in SMIT itself in the staff quarter and almost 60 students from SMIT boys’ hostel have been infected by Nairobi Fly Dermatitis,” sadi Dr. Sandhya Rai.

“The beetle breeds on mushy areas and SMIT boys’ hostel is located along the riverside and maybe the cases are more there because the Nairobi fly breeds on mushy and humid areas,” she added.

Dr. Rai maintained that the infection is not fatal and treatable with oral treatments. She further informed that the beetle, like any other insect and bug, is attracted to light and urged people to use dim lights at night. The beetle does not bite or sting, but the burn is caused when the beetle is slightly or completely squashed, she added.

“The preventive measures include typical anti-vector precautions, including bed nets, long-sleeve clothing, and avoiding fluorescent lights. If the beetles are found on the skin, brushing them off, rather than crushing them, avoids producing dermatitis and spraying pesticides from time to time.”

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Most Unethical Medical Study Ever- Tuskegee Study for Syphilis


One of the ugliest and unethical human studies in the history, Tuskegee Study raised a host of ethical issues such as informed consent, racism, paternalism, unfair subject selection in research, maleficence, truth telling and justice, among others.   It is really unbelievable to understand the heinous nature of the Tuskegee study.

    The Public Health Service started the study in 1932 in collaboration with Tuskegee University (then the Tuskegee Institute), a historically Black college in Alabama. In the study, investigators enrolled a total of 600 impoverished African-American sharecroppers from Macon County, Alabama.

Tuskegee syphilis study

     Tuskegee syphilis study

The goal was to “observe the natural history of untreated syphilis” in black populations. But the subjects were unaware of this and were simply told they were receiving treatment for bad blood. Actually, they received no treatment at all. Even after penicillin was discovered as a safe and reliable cure for syphilis, the majority of men did not receive it.

In 1932, the USPHS, working with the Tuskegee Institute, began a study to record the natural history of syphilis. It was originally called the “Tuskegee Study of Untreated Syphilis in the Negro Male” (now referred to as the “USPHS Syphilis Study at Tuskegee”).

The study initially involved 600 Black men – 399 with syphilis, 201 who did not have the disease. Participants’ informed consent was not collected. Researchers told the men they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance.

By 1943, penicillin was the treatment of choice for syphilis and becoming widely available, but the participants in the study were not offered treatment.

The purpose of the study was to observe the effects of the disease when untreated, though by the end of the study medical advancements meant it was entirely treatable. The men were not informed of the nature of the experiment, and more than 100 died as a result.

None of the infected men were treated with penicillin despite the fact that, by 1947, the antibiotic was widely available and had become the standard treatment for syphilis.

    .

Of these men, 399 had latent syphilis, with a control group of 201 men who were not infected. As an incentive for participation in the study, the men were promised free medical care. While the men were provided with both medical and mental care that they otherwise would not have received,  they were deceived by the PHS, who never informed them of their syphilis diagnosis and provided disguised placebos, ineffective methods, and diagnostic procedures as treatment for “bad blood”.

The men were initially told that the experiment was only going to last six months, but it was extended to 40 years.  After funding for treatment was lost, the study was continued without informing the men that they would never be treated.

The study continued, under numerous Public Health Service supervisors, until 1972, when a leak to the press resulted in its termination on November 16 of that year.  By then, 28 patients had died directly from syphilis, 100 died from complications related to syphilis, 40 of the patients’ wives were infected with syphilis, and 19 children were born with congenital syphilis.

The 40-year Tuskegee Study was a major violation of ethical standards, and has been cited as “arguably the most infamous biomedical research study in U.S. history.”  Its revelation has also been an important cause of distrust in medical science and the US government amongst African Americans.

Later in 1973, a class-action lawsuit was filed on behalf of the study participants and their families, resulting in a $10 million, out-of-court settlement in 1974.

On May 16, 1997, President Bill Clinton issued a formal Presidential Apology for the study.

On May 16, 1997, President Bill Clinton formally apologized on behalf of the United States to victims of the study, calling it shameful and racist. “What was done cannot be undone, but we can end the silence,” he said. “We can stop turning our heads away. We can look at you in the eye, and finally say, on behalf of the American people, what the United States government did was shameful and I am sorry.”

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Typhoid bacteria (Salmonella) contamination found in world’s largest chocolate-making plant


After several countries reported cases of salmonellosis following the consumption of Kinder brand of chocolates, the company has decided to recall its products. Contamination with salmonella was found following the consumption of the Belgium-based Kinder brand of chocolate, the World Health Organization (WHO) informed that the brand has decided to recall its candy.

   The incident has brought forth the need for attention and strict regulation, which is required to regulate hundreds and thousands of ready to eat products, fast foods, especially chocolates. They may carry deadly infections, if procedure to manufacture them is not up to mark and if the authorities are lax to check them periodically.

    The major development came after 150 suspected cases of salmonellosis were found in Belgium (26), France (25), Germany (10), Ireland (15), Luxembourg (1), the Netherlands (2), Norway (1), Spain (1), Sweden (4), the United Kingdom (65) and the United States of America (1). According to the statement released by WHO on Wednesday, children under the age of 10 years have been most affected. Although nine children are still in hospital, no fatalities were reported until now.

“The risk of spread in the WHO European region and globally is assessed as moderate until the information is available on the full recall of the products,” the UN agency said in a statement. According to WHO, salmonella bacteria matching the current human cases of infection were found last December and January in the buttermilk tanks at a factory run by chocolate makers Ferrero, in the Belgian city of Arlon.

In a  chocolate-making plant in Belgium  salmonella bacteria have been found. Chocolate plant after receiving the news of bacteria in the plant (Chocolate Plant) production has been stopped. The sale of products sent for sale from the plant has been banned. All dealers associated with the plant have been prohibited from selling the product. Belgium ( BelgiumThe plant in which bacteria have been found is the world’s largest chocolate-making plant. Even before this salmonella bacteria (salmonella bacteria) has been confirmed.

The company also supplies products to Nestle.

The plant of the world’s largest company, Barry Callebaut, is located in the city of Vieze, Belgium. This company makes liquid chocolate, which supplies its products to many big brands. Company Liquid Chocolate Nestle ( Nestlé), Unilever (Unilever), Harshi (hershey), supplies to large companies such as Mondelez. Even before this, information about the presence of Salmonella bacteria in the products of other companies has come to the fore. This was confirmed in the product of Ferrero company based in Arlon, South Belgium.

A company spokesperson said that the sale of products made after June 25 has been banned. However, the company’s spokesperson also said that most of the products in which it has been confirmed are present in the company itself. After getting the bacteria, the company has informed the Food Safety Agency of Belgium. On behalf of the company, it has been said that the Food Safety Agency is investigating the matter. It was said on behalf of the company that the investigation process may take time, due to which there is a possibility of a decrease of 2.6 percent in the company’s stock. After the completion of the investigation, all the production lines of the company can be started for production.

Salmonella bacteria give rise to deadly diseases like typhoid and salmonellosis. Apart from this, this bacteria affects the intestine of humans and animals. This bacteria is spread by eating contaminated food or food items. Salmonella bacteria are also spread in humans by eating dirt, eggs, raw meat. Young children and the elderly are at greater risk from this bacteria.

It has been said in a media report that the effect of salmonella infection starts showing in 6 to 36 hours. Due to this, the infected person may have problems like abdominal pain, vomiting, fever, diarrhea. A research report states that there are about 40,000 infected cases of Salmonella bacteria in the United States every year.

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The Family Doctor – A Dear Friend Lost in era of Medical Consumerism


      Until a few decades back, a family physician used to be the right answer for most healthcare situations, right from the toddler in the house to the octogenarians. Medical emergencies always have been an exception.  The family physician could offer expert comprehensive medical care to people of all ages and genders, making them a preferred choice, a dear friend for the common needs of the entire family. He was a great support to all family members at almost all stages of their lives.

Unlike other medical specialists who focus on a specific medical condition, one part of the body or just an organ, a family physician has the expertise and knowledge to provide comprehensive healthcare as well as emotional support to patients of all ages. He was a health guide from infancy to late adulthood and in old age as well. That made him the go-to doctor at any point for the family.

A major role of the family physician was to educate the patients about disease prevention and health maintenance. It included focussing on both physical and emotional health, which may include stress relief, anger management, fertility counselling, weight management and nutritional counselling.  For day-to-day common ailments like flu, ear infection, common allergy, draining small abscess, the family physician was the preferred go-to medical resource for the treatment.

The family doctor could help recognise potential red flags for any emerging conditions that may require prompt attention, such as diabetes, heart disease, or cancer – especially if there was a family history of the condition. If there was any need for specialist medical treatment, the family physician would refer to an appropriate specialist.

But now, with increasing medical commercialisation and consumerism, primary care is at the crossroads. The primary care delivery systems are becoming unsustainable and lack the resiliency to survive in new changing environments.  In an era of specialisation, the primary care has to struggle to remain relevant and viable.

There has been an increasing inclination of patients to have opinions from specialist even for minor issues. In last few years, with greater smartphone ownership, internet connections – a bevy of apps, online medical service aggregators have started operating brazenly, advertised by superstars and celebrities, aggressively pushing for tests and surgeries – have made the ‘family doctor’ look like ‘Dr Minimalist’. There are a number of reasons why more doctors want to become specialists: competitive pressures, greater income potential, higher status among peers, greater prestige in society and patients’ demand. These factors drive the preference for specialisation. The final result is being lot of specialists, who treat an organ but too few “doctors” to treat the human body as a whole. The media insinuation against doctors has created an environment of mistrust against doctors in the community and rift in doctor-patient relationship.

In addition to basic medical services, the family physician used to act as health advisors, guiding anxious patients to the appropriate healthcare facility. In today times, one of the most effective healthcare interventions is to advise the person to “when to see a specialist doctor and when not to go”. But that friendly advice with in comfort of homely atmosphere is getting distant gradually.

The family doctor – a helping hand, a dear friend and an all-time support of is getting far away from patients in this era of medical consumerism.

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How to Prevent/ Manage Mountain Sickness or Altitude Sickness?


If you’ve ever hiked up a mountain and felt yourself getting nauseous or lightheaded, you may have experienced altitude sickness, also called mountain sickness. This condition happens when you travel to a high altitude (elevation) too quickly.

It doesn’t happen only to hikers. Just visiting a high-altitude location can cause problems for some. Symptoms happen when your body tries to adjust to the lower air pressure and lower oxygen levels at high altitudes.

  Altitude sickness symptoms can range from uncomfortable to life-threatening. But with some planning and precautions, you can avoid this condition. The best way to prevent it is to move at a slower pace and let your body adjust. If you notice symptoms at high elevation, don’t push yourself to go farther. Get back down to a lower elevation and let your body adjust before moving up, slowly and carefully.

Who is at risk for altitude sickness?

Anyone can get altitude sickness. Your age, sex and general health don’t seem to affect your risk. You may be at higher risk if you:

  • Have a lung or heart condition: Your healthcare provider may recommend avoiding high altitudes if possible.
  • Are pregnant: Talk to you provider before traveling to a high-altitude location.
  • Live at low elevation: Since your body isn’t used to higher altitudes, you have a greater risk for symptoms. If you’re planning a trip to a high-altitude location, be aware of the symptoms of altitude sickness and how to treat it.
  • Previously had altitude sickness: Talk to your provider about prevention and treatment before your next trip.

What is considered a “high elevation” in terms of getting altitude sickness?

Climbing to these elevations can bring on symptoms of altitude sickness:

  • High altitude: 8,000 to 12,000 feet above sea level.
  • Very high altitude: 12,000 to 18,000 feet.
  • Extremely high altitude: 18,000+ feet.

The summit of Mount Everest is over 29,000 feet.

How common is altitude sickness?

Altitude sickness may occur in up to half of people who climb to elevations above 8,000 feet.

What are the different forms of altitude sickness?

Most people who get altitude sickness get AMS, acute mountain sickness. Higher than 10,000 feet, 75% of people will get mild symptoms . There are three categories of AMS:

  • Mild AMS: Symptoms, such as mild headache and fatigue, don’t interfere with your normal activity. Symptoms improve after a few days as your body acclimates. You can likely stay at your current elevation as your body adjusts.
  • Moderate AMS: Symptoms start to interfere with your activities. You may experience severe headache, nausea and difficulty with coordination. You’ll need to descend to start to feel better.
  • Severe AMS: You may feel short of breath, even at rest. It can be difficult to walk. You need to descend immediately to a lower altitude and seek medical care.

Two severe forms of altitude illness occur less frequently but are more serious. Both can be life-threatening. You need to descend immediately and receive medical treatment for:

  • HAPE (High-altitude pulmonary edema): HAPE produces excess fluid on the lungs, causing breathlessness, even when resting. You feel very fatigued and weak and may feel like you’re suffocating.
  • HACE (High-altitude cerebral edema): HACE involves excess fluid on the brain, causing brain swelling. You may experience confusion, lack of coordination and possibly violent behaviour

SYMPTOMS AND CAUSES

What causes altitude sickness?

Altitude sickness results from a rapid change in air pressure and air oxygen levels at higher elevations. You may have symptoms if you travel to a high elevation without giving your body time to adjust to less oxygen. Even if you’re physically fit, you can still experience altitude sickness.

In addition, high altitude and lower air pressure can lead to fluid leaking from blood vessels. Researchers don’t understand exactly why this happens. This leakage causes fluid to build up in your lungs and brain. Ignoring moderate or severe symptoms can lead to a life-threatening situation. What are the symptoms of altitude

Symptoms of altitude sickness?

You’ll likely feel nauseous and lightheaded. You may vomit and have a headache. Different levels of altitude sickness have different symptoms:

Symptoms of mild, short-term altitude sickness usually begin 12 to 24 hours after arriving at high altitude. They lessen in a day or two as your body adjusts. These symptoms include:

  • Dizziness.
  • Fatigue and loss of energy.
  • Shortness of breath.
  • Loss of appetite.
  • Sleep problems.

Symptoms of moderate altitude sickness are more intense and worsen instead of improve over time:

  • Worsening fatigue, weakness and shortness of breath.
  • Coordination problems and difficulty walking.
  • Severe headache, nausea and vomiting.
  • Chest tightness or congestion.
  • Difficulty doing regular activities, though you may still be able to walk independently.

Severe altitude sickness is an emergency. The symptoms are similar to moderate AMS, but more severe and intense. If you start experiencing these symptoms, you must be taken to a lower altitude immediately for medical care:

  • Shortness of breath, even when resting.
  • Inability to walk.
  • Confusion.
  • Fluid buildup in the lungs or brain.

HAPE, when fluid builds up in the lungs, prevents oxygen from moving around your body. You need medical treatment for HAPE. Symptoms include:

  • Cyanosis, when your skin, nails or whites of your eyes start to turn blue.
  • Confusion and irrational behavior.
  • Shortness of breath even when resting.
  • Tightness in the chest.
  • Extreme fatigue and weakness.
  • Feeling like you’re suffocating at night.
  • Persistent cough, bringing up white, watery fluid.

HACE happens when the brain tissue starts to swell from the leaking fluid. You need medical treatment for HACE. Symptoms include:

  • Headache
  • Loss of coordination.
  • Weakness.
  • Disorientation, memory loss, hallucinations.
  • Psychotic behavior.
  • Coma.

DIAGNOSIS AND TESTS

How is altitude sickness diagnosed?

If you get a headache and at least one other symptom with 24 to 48 hours of moving to a higher elevation, it’s most likely altitude sickness. If you’re climbing, a more experienced climber may recognize symptoms of altitude sickness and guide you to get help.

If you have severe altitude sickness, a healthcare provider will ask about your symptoms, activities and location. The provider may perform a physical exam, including listening to your chest.

Will I need tests to diagnose altitude sickness?

You may need a chest X-ray to see if there is any fluid in your chest. In severe cases, your healthcare provider may order a brain MRI or CT scan to check for fluid in the brain.

MANAGEMENT AND TREATMENT

How is altitude sickness treated?

The main treatment for altitude sickness is to move to a lower elevation as quickly

and safely as possible. At the very least, do not go higher. If symptoms are mild, staying at your current elevation for a few days might be enough to improve the symptoms.

Other treatments depend on how severe the symptoms are:

  • Mild altitude sickness: Over-the-counter medicines can relieve headaches. Other symptoms will improve once your body adjusts or you move to a lower altitude.
  • Moderate altitude sickness: Symptoms should improve within 24 hours once you are 1,000 to 2,000 feet lower than you were. Within three days, you should feel completely better.
  • Severe altitude sickness, HACE and HAPE: If you have severe symptoms, you must be taken immediately to an elevation that’s no higher than 4,000 feet. Get to a healthcare provider as soon as possible. You may need hospitalization.

What treatments are available for severe altitude sickness?

Treatments depend on your symptoms:

  • For fluid in the brain (HACE), you may need dexamethasone, a steroid that helps reduce swelling in the brain. Dexamethasone is sometimes prescribed as a preventive medication.
  • For fluid in the lungs (HAPE), you may need oxygen, medication, a lung inhaler or, in severe cases, a respirator.
  • If you need more oxygen, a provider might prescribe acetazolamide, which increases your breathing rate, so you take in more oxygen. The medicine helps your body adjust faster to the higher elevation and reduces symptoms of altitude sickness.

PREVENTION

How can altitude sickness be prevented?

The best way to prevent altitude sickness is to go slow — called acclimatization. This process allows your body time to adjust to the change in oxygen levels. Take your time when traveling up. For instance, spend a day at a point midway up before continuing to ascend.

You can also talk to your healthcare provider about taking acetazolamide before your trip. Taking it 24 hours before traveling to a high altitude and continuing for five days can help prevent altitude sickness. Dexamethasone can also be used preventively, but it can have serious side effects. Talk to your provider before your trip.

OUTLOOK / PROGNOSIS

What’s the outlook for someone with altitude sickness?

Most people who get altitude sickness get the mild form. Once you return to a lower elevation (or stay at your current elevation without climbing higher), symptoms improve.

Are there long-term effects of altitude sickness?

If you take care and move to a lower elevation when you feel symptoms, altitude sickness has no long-term negative effects. You’ll recover within a few days. Once you feel better, you can continue to travel to higher elevations, as long as you do so slowly and carefully.

Can altitude sickness be fatal?

In rare cases, altitude sickness can be life-threatening. If you develop HAPE or HACE, you are at risk for complications such as coma or even death. Get treatment as soon as possible to reduce your risk.

Can altitude sickness be cured?

Altitude sickness is temporary. Once you return to a lower altitude, you’ll feel better. When you begin your ascent again (or on your next climb), make sure to travel slowly to let your body acclimate.

If I’m planning a hike to a very high elevation, how can I hike safely without getting altitude sickness?

These steps can help your body acclimate:

  • Walk up: Start below 10,000 feet and walk to a high altitude instead of driving or flying. If you drive or fly to an elevation higher than 10,000 feet, stay at your first stop for at least 24 hours before going higher.
  • Go slow: Once above 10,000 feet, don’t increase your altitude more than 1,000 feet a day.
  • Rest: Build a rest day into your schedule for every 3,000 feet you climb.
  • “Climb high and sleep low”: If you climb more than 1,000 feet in a day, come down to sleep at a lower altitude.
  • Know your body: Recognize the signs and symptoms of altitude sickness. Move to a lower altitude (or avoid climbing higher) if you notice any symptoms.
  • Stay hydrated: Drink 3-4 quarts of water per day.
  • Avoid alcohol: Alcohol can dehydrate your body. It also has stronger effects at higher elevations, which can impair judgment.
  • Eat carbs: Eat a diet that’s more than 70% carbohydrates.
  • Know the “don’ts”: Avoid tobacco and depressant drugs, such as sleeping pills and tranquilizers.

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The Book- A Midnight Adieu during Indo-Pak Partition 1947


           My second book has been released on Amazon worldwide. The book ‘A Midnight Adieu during Indo-Pak Partition 1947’ is a story of Dr Paras Ram family. Today story  is about the book, so it is little different from  usual medical topics of this blog.

The Massive Betrayal- No One to Blame

           In this book, Narain has narrated the true incidents of his life during Indo-Pak partition in 1947.  His story depicts the tragedy of millions during riots amidst celebrations for independence by others. Innocent Hindus and Sikhs, who had nothing to do with politics, went through a nightmare and the worst phase of their life because of weak statesmanship and poor capabilities of their leaders. It was highly impractical to assume that Muslims in Pakistan would remain neutral to Hindu minority, who were left behind.

         The painful truth that his father, Dr Paras Ram was killed by Baloch’s own army and not by rioters still burns Narain inside. How human greed intertwined with religious fanaticism and communalism changed life of millions of families overnight, still haunts him. With no serious policing, coupled with Government indifference, the partition turned out to be unthinkable nightmare for the masses.

    The book is a kaleidoscope of Narain’s  pained soul where he only  has one unanswered question for his countryman far and near; were these atrocities borne by minorities worth their unanimous dark lives. Why masses  as humans refuse to take lessons from such inhumane religious conflicts and never take refuge in any recourse for alleviating inhuman act and conflicts for our generations to grow with.

    For the victims, neither religion nor Government was helpful. The differences over faith and religion had put people through beastly times. If this was all in the name of religion, one would say it is better not to have religion at all.

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Time to Regulate Health Administrators & Pharmaceuticals like Doctors #CBI- arrests-Joint-Drugs-Controller


  CBI has arrested Joint Drugs Controller for allegedly taking a ₹4 lakh bribe to clear injections made by  Biocon Biologics .The CBI has arrested Joint Drugs Controller S Eswara Reddy for allegedly receiving a Rs 4 lakh bribe from a conduit to waive the Phase 3 clinical trial of the ‘Insulin Aspart’ injection, an under development Biocon Biologics product to manage Type 1 and Type 2 diabetes, officials said on Tuesday.

        The incident may be just a tip of the iceberg, to indicate collusion between administrators and various industries. It is the time to regulate all important components of health industry including health administrators as doctors are regulated – to achieve real cost effective health care.

          In last few decades, as doctor-patient relationship has been getting more complex and medical industry has controlled the financial interaction, the medical costs have become expensive. Hence the health insurance industry is gradually becoming indispensable. As doctors are at the front and remain the visible component, they are blamed for the expensive medical treatments.  The tremendous rise in health care expenses is usually borne by the government, taxpayer, insurance or patient himself.  Therefore there has been an increasing dependence on investors in health care, along the lines of an industry to ensure its financial viability. 25 factors- why health care is expensive

      Complex interplay of various industries  like pharmaceutical, consumable industry and other businesses associated with  health care  remain invisible to patients. Various important components for example pharma industry, suppliers, biomedical, equipment, consumables remain unregulated.  There is large number of administrators involved in such processes.  Although doctors are strictly regulated and kind of over-regulated but such administrators and financial controllers who play important part in medicine, cost, sale and purchase, remain largely unregulated. Because of such undeserved criticism, doctors have actually been alienated from financial aspect but still they are often perceived as culprits for cost escalation.

CBI has arrested Joint Drugs Controller for allegedly taking a ₹4 lakh bribe to clear injections

       The CBI has arrested Joint Drugs Controller S Eswara Reddy for allegedly receiving a ₹4 lakh bribe to waive the phase three clinical trial of the Insulin Aspart injection, a product of Biocon Biologics under development to manage Type 1 and Type 2 diabetes, officials said on Tuesday.

CBI has arrested Joint Drugs Controller for allegedly taking a ₹4 lakh bribe to clear injections made by  Biocon Biologics

Biocon Biologics is a subsidiary of the  Biocon. The company has denied allegations.The agency has also arrested  director at Synergy Network India Private Limited, who was allegedly giving Reddy a bribe, they said.

After completing the necessary paperwork, the CBI has arrested Reddy and Dua, nabbed during a trap operation on Monday while the alleged bribe exchange was going on, the officials said.

The CBI has also booked Associate Vice President and Head-National Regulatory Affairs (NRA), Biocon Biologics Limited, Bangalore, L Praveen Kumar, as well as Director, Bioinnovat Research Services Private Limited, Delhi, Guljit Sethi in the case under IPC sections of criminal conspiracy and corruption. 

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     25 factors- why health care is expensive

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 21 occupational risks to doctors and nurses

Covid paradox: salary cut for doctors other paid at home

   Medical-Consumer protection Act- Pros and Cons

Expensive Medical College  seat- Is it worth it?

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