Updated guidelines for treatment for patients with ventricular arrhythmias

Updated guidelines for treatment for patients with ventricular arrhythmias

Dr KK Aggarwal

The American College of Cardiology (ACC), American Heart Association (AHA) and the Heart Rhythm Society (HRS) have jointly published new guidelines for the management of adults who have ventricular arrhythmias or who are at risk for sudden cardiac death, including diseases and syndromes associated with a risk of sudden cardiac death from ventricular arrhythmias.

According to the guidelines, patients considering implantation of a new ICD or replacement of an existing one should be informed of their individual risk of sudden cardiac death and nonsudden death from heart failure or noncardiac conditions, and the effectiveness and potential complications of the ICD. In patients nearing the end of life from other illness, clinicians should discuss ICD shock deactivation as they reassess their patients’ goals and preferences.

Emphasizing on the role of shared decision making between patients and their doctors, the guidelines say that treatment decisions should also take into consideration, the health goals, preferences, and values of the patients.

The “2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death” have been published online October 30, 2017 in the Journal of the American College of Cardiology, Circulation and HeartRhythm.

(Source: ACC News Release, October 30, 2017)

Draft guidelines for prosecution under 304 A

Draft guidelines for prosecution under 304 A

Guidelines for protecting doctors from frivolous or unjust prosecution against medical negligence

WHEREAS, the Hon’ble Supreme Court in Jacob Mathew vs. State of Punjab [AIR 2005 SC 3189] had observed that statutory rules or executive instructions incorporating certain guidelines need to be framed and issued by the Government of India and/or the State Governments in consultation with the Medical Council of India;

WHEREAS, the Hon’ble Supreme Court had, “so long as it is not done”, proceeded to lay down certain guidelines which should govern the prosecution of doctors for offences for which criminal rashness or negligence is as ingredient. The following guidelines were laid down:

“A private complaint may not be entertained unless the complainant has produced prima facie evidence before the Court in the form of a credible opinion given by another competent doctor to support the charge of rashness or negligence on the part of the accused doctor. The investigating officer should before proceeding against the doctor accused of rash or negligent act or omission, obtain an independent and competent medical opinion preferably from a doctor in government service qualified in that branch of medical practice who can normally be expected to give an impartial and unbiased opinion applying Bolam’s test to the facts collected in the investigation. A doctor accused of rashness or negligence, may not be arrested in a routine manner [simply because a charge has been leveled against him]. Unless his arrest is necessary for furthering the investigation or for collecting evidence or unless the investigating officer feels satisfied that the doctor proceeded against would not make himself available to face the prosecution unless arrested, the arrest may be withheld.”
WHEREAS, the Government of India, Ministry of Health and Family Welfare, vide its letter dated 11.07.2012 has asked the Medical Council of India to suggest guidelines, which need to be framed for protecting doctors against frivolous complaints/prosecution;

THEREFORE, the Medical Council of India proposes the following guidelines to be observed by the prosecuting agencies for protecting doctors against frivolous complaints/prosecution:-
1. The Prosecuting Agency on receipt of any complaint of which criminal rashness or negligence is an ingredient against a registered medical practitioner under the Indian Medical Council Act, 1956 prior to making arrest refer the complaint to the Chief Medical Officer of a District who shall place it before the District Medical Board for its recommendations as regards the merit of the allegations of criminal rashness or negligence, contained in the complaint.
2. The District Medical Board on receipt of such reference examine the allegation contained therein in a time-bound manner, preferably within two-weeks, and thereafter forward its recommendation to the Prosecuting Agency through the Chief Medical Officer of the District.
3. The District Medical Board that has examined the complaint must ensure a Doctor qualified in that branch of medical science is part of the Board.
4. The Prosecuting Agency, in case, it is dissatisfied with the recommendation of the District Medical Board may stating the reasons for such dissatisfaction refer the matter to the Divisional Medical Board for its recommendation within a period of three-weeks from the date of receipt of recommendation of the District Medical Board.
5. The Divisional Medical Board, on receipt of any such reference from the Prosecuting Agency would examine the matter within a period of three-weeks from the date of receipt of such reference. The Divisional Medical Board shall provide reason for endorsing or rejecting the recommendation of the District Medical Board. The decision of the Divisional Medical Board shall expeditiously be conveyed to the prosecuting agency, and in any case not later than four-weeks from the date of receipt of reference made by the prosecuting agency.
6. The Prosecuting Agency, in case, it is it is dissatisfied with the recommendation of the Divisional Medical Board may stating the reasons for such dissatisfaction refer the matter to the State Medical Board for its recommendation within a period of four-weeks from the date of receipt of recommendation of the Divisional Medical Board.
7. The State Medical Board, on receipt of any such reference from the Prosecuting Agency would examine the matter within a period of four-weeks from the date of receipt of such reference. The State Medical Board shall provide reason for endorsing or rejecting the recommendation of the Divisional Medical Board. The decision of the State Medical Board shall be expeditiously conveyed to the prosecuting agency, and in any case not later than five-weeks from the date of receipt of reference made by the prosecuting agency.
8. The Prosecuting Agency on the receipt of Recommendation of the District/Divisional/State Medical Board further proceed in the matter in accordance with law. However, in case arrest of a registered medical practitioner in the employment of State/Central Government is being made, the Controlling Officer of such Medical Practitioner would be informed by the Prosecuting Agency. Likewise, in case, the registered medical practitioner is engaged in private practice, the concerned State Medical Council, or in case there is no State Medical Council in that State/Union Territory, the Medical Council of India be informed.
The above-said guidelines may if deemed appropriate be notified by the Union of India under the Code of Criminal Procedure, 1973.

New guidelines on diabetes self-management education and support

New guidelines on diabetes self-management education and support Management of diabetes is multidisciplinary and a team approach is the basis of care of the patient with diabetes, who is at the center of this team. Diabetes self-management education (DSME) is a very important aspect of management in all patients with diabetes, including those with prediabetes. Optimal control of blood sugar is important; but, it is also important to control other risk factors such as hypertension, dyslipidemia in order to prevent the macrovascular and microvascular complications of diabetes. Because of the need for lifestyle modifications, patients with diabetes are themselves responsible for the day to day management of diabetes, but with the support of the doctor. For the first time, the American Diabetes Association (ADA) and American Association of Diabetes Educators (AADE) have combined education and support (DSMES) and released new standards to help diabetes educators and medical providers establish and sustain patient care models, programs and teams for people with diabetes and their caregivers. These guidelines will be published in the September 2017 issues of Diabetes Care and The Diabetes Educator. These standards relate to organizational structure, participation of community stakeholders, access, program coordination, instructional staff, individualizing diabetes education to the need of each patient, monitoring of patient progress and quality improvement. An up-to-date, evidence-based, and flexible curriculum provides education. These standards emphasize that DSME alone does not translate into effective self care. Ongoing support is very important to improve patient outcomes. The standards defined in these recommendations can be applied to both small solo practices, as well as large, multicenter facilities. (ADA Press Release, July 28, 2017) Dr KK Aggarwal National President IMA & HCFI

Do clinical practice guidelines have legal implications?

Do clinical practice guidelines have legal implications? Call guidelines as guidance or advisories Dr KK Aggarwal National President IMA Clinical practice guidelines are becoming an increasingly common feature of the health care. The government has developed Standard Treatment Guidelines under the Clinical Establishments Act (CEA), for example, for critical care, orthopaedics, cardiovascular diseases, general surgery etc. There are 21 such guidelines. “To ensure compliance with Standard Treatment Guidelines as may be determined and issued by the Central Government or State Government, as the case may be, from time to time” is one of the conditions to be fulfilled for registration and renewal of a clinical establishment under CEA (Clinical Establishments Act FAQs). The government has three functions to perform • Administrative through bureaucracy • Regulatory through Medical Council of India and state councils • Legislative through law ministry Developing guidelines and updating them therefore is not the job of the Govt; instead it should be the job of professional bodies such as medical associations, which represent the collective consciousness of the medical fraternity. Unlike the Medical Associations, the Expert Panel enlisted by the Govt. to develop the guidelines does not represent the collective consciousness medical fraternity. In UK, the guidelines are regularly developed by the National Institute of Clinical Excellence (NICE), Royal medical colleges and the universities. Clinical practice guidelines are recommendations and suggestions that are evidence-based and show potential benefit or harm. They standardize treatment and improve quality of care. But they are not without their limitations. They cannot be generalized i.e. applied on each and every individual. Each patient is different and hence treatment has to be individualized. Also, western data cannot be extrapolated to our Indian settings. There is a need for a balanced perspective. Lawyers should really have no part to play in the development of clinical guidelines, as they are not clinicians. The basic legal premise to work from in designing clinical guidelines is the “Bolam principle”, which would be applied in any dispute about the correctness or otherwise of a clinical guideline. Basically, a clinical guideline would be viewed as proper if it satisfied the Bolam test. Lord Browne-Wilkinson stated in Bolitho v City and Hackney HA [1998] Lloyd's Rep Med 26 the test: "The locus classicus of the test for the standard of care required of a doctor or any other person professing some skill or competence is the direction to the jury given by McNair J, in Bolam v Friern Hospital Management Committee [1957] 1WLR 583,587. “I myself would prefer to put it this way, that he is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of men skilled in that particular art ... Putting it the other way round, a man is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion who would take a contrary view.” There are many ways to treat patients and any court would look to experts in the medical or nursing professions to help them assess whether the clinical guideline used in the case was proper or not. The views of experts are however not definitive; they may show that a reasonable body of medical opinion may have designed and used a clinical guideline in a certain way, but the judge in the case will have the final say. Issues to be considered when developing clinical guidelines: • The objectives for the clinical guidelines need to be clear, and clearly stated. This will affect their subsequent legal standing. • The intended use and applicability of clinical guidelines should be spelt out clearly, in the introduction. • The guidelines must make clear for whom they are intended. • Clinical guidelines that no longer reflect best practice might conceivably become actionable, and developers need to incorporate specific statements about their validity and review procedure. • They should be constructed in such a way that allows deviation and does not suffocate initiative that might bring about further improvements. • The development of clinical guidelines must involve all the relevant professionals and managers. In Jacob Mathew vs State of Punjab & Anr on 5 August, 2005, the Hon’ble Supreme Court of India has acknowledged that neither the investigating officer or the complainant or judges are experts as they do not have knowledge of medicine. It also held that “one man clearly is not negligent merely because his conclusion differs from that of other professional men … Differences of opinion and practice exist, and will always exist, in the medical as in other professions. There is seldom any one answer exclusive of all others to problems of professional judgment. A court may prefer one body of opinion to the other, but that is no basis for a conclusion of negligence." “Non-adherence to established guidelines does not necessarily bode an adverse outcome for the defendant. Adherence to guidelines may not exonerate the defendant” (J R Soc Med. 2003 Mar;96(3):133-8). So, differ with a reason. You should be able to justify your action or inaction and explain to the Court as to why you took the decision that you did. To remove the confusion and possible legal implications, do not call guidelines as guidelines but as ‘Advisory’ or ‘Guidance’. Dr KK Aggarwal National President IMA & HCFI

WHO confirms three Zika cases in India

WHO confirms three Zika cases in India The first three cases of Zika virus infection were confirmed on Friday from Ahmedabad, Gujarat by the World Health Organization (WHO). In its report dated May 26, 2017, the WHO said, “On 15 May 2017, the Ministry of Health and Family Welfare-Government of India (MoHFW) reported three laboratory-confirmed cases of Zika virus disease in Bapunagar area, Ahmedabad District, Gujarat, State, India. The routine laboratory surveillance detected a laboratory-confirmed case of Zika virus disease through RT-PCR test at B.J. Medical College, Ahmedabad, Gujarat. The etiology of this case has been further confirmed through a positive RT-PCR test and sequencing at the national reference laboratory, National Institute of Virology (NIV), Pune on 4 January 2017 (case 2, below). Two additional cases (case 1 and case 3), have then been identified through the Acute Febrile Illness (AFI) and the Antenatal clinic (ANC) surveillance." (Source: WHO, May 26, 2017) Zika virus disease was declared as a Public Health Emergency of International Concern (PHEIC) by the WHO in February last year. And, in November 2016, the WHO declared an end to its global health emergency over the spread of the Zika virus. Guidelines on the Zika virus disease were issued by the Ministry of Health and Family Welfare last year. NCDC, Delhi and National Institute of Virology (NIV), Pune were designated as the apex laboratories to support the outbreak investigation and for confirmation of laboratory diagnosis. According to the WHO report, an Inter-Ministerial Task Force has been set up under the Chairmanship of Secretary (Health and Family Welfare) together with Secretary (Bio-Technology), and Secretary (Department of Health Research). The Joint Monitoring Group, a technical group tasked to monitor emerging and re-emerging diseases is regularly reviewing the global situation on Zika virus disease. In addition to National Institute of Virology, Pune, and NCDC in Delhi, 25 laboratories have also been strengthened by Indian Council of Medical Research for laboratory diagnosis. In addition, 3 entomological laboratories are conducting Zika virus testing on mosquito samples. The Indian Council of Medical Research (ICMR) has tested 34 233 human samples and 12 647 mosquito samples for the presence of Zika virus. Among those, close to 500 mosquitoes samples were collected from Bapunagar area, Ahmedabad District, in Gujarat, and were found negative for Zika. However, this report has highlighted India’s vulnerability to vector-borne diseases due to its huge population, climate and people traveling into the country in large numbers. These cases provide evidence on the circulation of the virus in India suggesting low level transmission of Zika virus and chances of more cases occurring. Dengue and Chikungunya are already endemic in the country. All these three diseases – Dengue, Chikungunya and Zika – are viral infections and share a common vector, the Aedes mosquitoes. Dengue or Chikungunya-like symptoms with red eyes, fever with a rash or joint pain should not be ignored. Such cases could be Zika. Eliciting a travel history in such patients is very important. There is no specific treatment. Patients should be advised to take paracetamol to relieve fever and pain, plenty of rest and plenty of liquids. Aspirin, products containing aspirin, or other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should be avoided. In view of the detection of Zika in India, the need of the hour is enhanced surveillance: community-based and at international airports and ports to track cases of acute febrile illness. While awareness needs to be created about the disease, the public needs to be reassured that there is no cause for undue concern. There is no vaccine for Zika virus infection. Protection against mosquito bites is very important to prevent Zika infection. People traveling to high risk areas, especially pregnant women, should take protections from mosquito bites. • Stay inside when the Aedes are most active. They bite during the daytime, in the very early morning, and in the few hours before sunset. • Buildings with screens and air conditioning are safest. • Wear shoes, long-sleeved shirts, and long pants when you go outside. • Ensure that rooms are fitted with screens to prevent mosquitoes from entering. • Wear bug spray or cream that contains DEET or a chemical called picaridin. Dr KK Aggarwal National President IMA & HCFI

New guidelines for ‘deprescribing’ PPIs

New guidelines for ‘deprescribing’ PPIs Proton pump inhibitors (PPIs) are a very commonly prescribed class of drugs for patients with acid peptic disorders. They have been generally regarded as safe and well tolerated. And, their long-term use is common. However, recently, there have been concerns about the use of PPIs, especially long-term use. PPIs have been linked to increased risk of osteoporotic fractures, pneumonia, Clostridium difficile infection and rebound acid hypersecretion, especially in the older population. Long-term use may also affect patient compliance to the prescribed treatment. Evidence-based recommendations published in the May 2017 issue of Canadian Family Physician to help the physician decide when and how to safely stop the PPIs or reduce their dose, called ‘deprescribing’ PPIs. This can be done in three ways: • Reducing the dose by ‘intermittent’ use for a fixed duration; ‘on-demand’ use or using a lower ‘maintenance’ dose. • Stopping the drug can be done by abruptly discontinuing the drug or via a tapering regime. • Stepping down means abrupt discontinuation or PPI tapering followed by an histamine-2 receptor antagonist (H2RA) These guidelines recommends deprescribing PPIs in adults who have completed a minimum of 4 weeks of PPI treatment for heartburn or mild to moderate gastroesophageal reflux disease (GERD) or esophagitis, and whose symptoms are resolved. • Decrease the daily dose or stop and change to on-demand use. This has been given a strong recommendation. • Or, an H2RA can be considered as an alternative to PPIs. This alternative has been given a weak recommendation due to the higher risk of symptoms recurring. These recommendations are not applicable to patients who have severe esophagitis grade C or D, or a documented history of bleeding gastrointestinal ulcers or have Barrett esophagus. (Source: Can Fam Physician. 2017 May;63(5):354-364) Dr KK Aggarwal National President IMA & HCFI

ACP releases new guidelines on the treatment of osteoporosis

ACP releases new guidelines on the treatment of osteoporosis The American College of Physicians (ACP) has released new guidelines on the treatment of osteoporosis, which have been published in the Annals of Internal Medicine. The recommendations for treating osteoporosis were last published in 2008. • Physicians should treat women with osteoporosis with bisphosphonates (alendronate, risedronate, or zoledronic acid) or denosumab, a biologic agent for five years. Continuing treatment after the initial five years may be beneficial for some patients and may be appropriate after reassessing the risks and benefits of continuing therapy. • Bisphosphonates are also recommended in men with osteoporosis to reduce fracture risk. • Bone density monitoring during the five-year treatment period is not recommended due to lack of evidence of the benefit of monitoring. • Use of hormone-replacement therapy (HRT), either estrogen alone or estrogen + progestin or raloxifene for the treatment of osteoporosis in women is not recommended. The serious adverse effects of estrogen treatment such as increased risk for cerebrovascular accidents and venous thromboembolic events outweigh the potential benefits. • The decision to treat osteopenic women 65 years of age or older at a high risk for fracture should be based on fracture risk profile; and the benefits, harms, and costs of medications and patient preference. • Most women with normal bone density measurements do not progress to osteoporosis within 15 years; hence, ACP does not support frequent monitoring of women with normal bone density for osteoporosis At the same time, the ACP does not recommend physicians use, (Source: ACP Press Release, May 9, 2017)

IMA guidelines: Preventing dementia and cognitive decline

IMA guidelines: Preventing dementia and cognitive decline Simple lifestyle modifications can help reduce your risk of Alzheimer’s and related dementias. New Delhi, March 15, 2017: Nearly 4 million people are living with some form of dementia, in India. Promising research shows that you can reduce your risk of dementias through a combination of simple but effective lifestyle changes. No matter what your age, it's not too late to take steps to prevent memory loss.Brain- healthy lifestyle measures starting as early as young adulthood, can significantly prevent the onset of age induced Alzheimer’s and related dementias later in life. In addition, good health habits can reduce the risk for illnesses that might affect your memory as well as the likelihood that you'll need medications that could have damaging side effects. Padma Shri Awardee Dr K.K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement said that, “Alzheimer’s is a very complex disorder and has multiple risk factors. Risk factors like genetics and your age are beyond your control, however, some of these factors are modifiable and form the basis of a brain- healthy lifestyle. These include stress management, regular exercise, good sleep, healthy diet, mental stimulation and social engagement. A low-fat, high-fibre diet including plenty of fresh fruit and vegetables and whole grains can help reduce your risk of some kinds of dementia”. Along with diet and exercise, it is important that you engage in regular mentally stimulating activities to keep those brain cells up and running. This is particularly beneficial for those who have crossed their 40s. “Try doing light brain stimulating tasks like crossword puzzles, quizzes, daily reading or anything similar that interests you. For older individuals, it is advised that they engage their mental reserves through social engagement and exercise. For most people, a minimum of 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity each week, such as cycling or fast walking, is recommended.Good sleep should supplement these activities to obtain their full benefit”, adds Dr. K.K Aggarwal. Following are the some crucial protection strategies against dementia and cognitive decline. • Maintain a healthy weight. • Check your waistline. • Eat mindfully. Emphasize colorful, vitamin-packed vegetables and fruits; whole grains; fish, lean poultry, tofu, and beans and other legumes as protein sources; plus healthy fats. Cut down on unnecessary calories from sweets, sodas, refined grains like white bread or white rice, unhealthy fats, fried and fast foods, and mindless snacking. Keep a close eye on portion sizes, too. • Exercise regularly. Aim for 2½ to 5 hours weekly of brisk walking (at 4 mph). Or try a vigorous exercise like jogging (at 6 mph) for half that time. • Keep an eye on important health numbers. In addition to watching your weight and waistline, keep a watch on your cholesterol, triglycerides, blood pressure and blood sugar numbers. • Smoking increases your risk of developing cardiovascular diseases, cancer and dementia. • When possible, walk instead of driving or riding. • Try keeping up with current affairs, learning a new hobby, and playing challenging games to exercise your mind.

New American Thyroid Association guidelines on hyperthyroidism

New American Thyroid Association guidelines on hyperthyroidism The American Thyroid Association (ATA) has issued new guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Published online August 17, 2016 in the journal Thyroid, these guidelines include 124 evidence-based recommendations. Some recommendations are as below: • “Hyperthyroidism” has been defined as a form of thyrotoxicosis due to inappropriately high synthesis and secretion of thyroid hormones by the thyroid gland. And, “thyrotoxicosis" is a clinical state resulting from inappropriately high thyroid-hormone action in tissues generally due to inappropriately high tissue thyroid hormone levels. • Serum TSH is recommended as an initial screening test. When thyrotoxicosis is strongly suspected, diagnostic accuracy improves when a serum TSH, free T4 and total T3 are assessed at the initial evaluation. • Medical therapy of any comorbid conditions should be optimized prior to radioactive iodine (RAI) therapy. • Free T4, total T3, and TSH should be measured on follow-up within the first 1–2 months after RAI therapy for Graves’ disease and should be repeated at 4–6 week intervals for 6 months, or until the patient becomes hypothyroid and is stable on thyroid hormone replacement. • Methimazole is the drug of choice for Graves’ disease, except during the first trimester of pregnancy (propylthiouracil is preferred), thyroid storm, and in patients with minor reactions to methimazole who do not opt for RAI or surgery. • All patients should be informed about the adverse effects of antithyroid drugs, preferably in writing. • Patients on antithyroid drugs should get a differential white blood cell count done during febrile illness and at the onset of pharyngitis. • Thyroid receptor antibodies (TRAb) should be measured to guide treatment decisions for e.g. whether stop or continue with the antithyroid drugs; normal levels indicate greater chance for remission. • In pregnant women, TRAb level should be measured first during the first trimester and, if elevated, again at 18–22 weeks of gestation. If the level is still high, the fetus or neonate should be evaluated for thyroid dysfunction after birth. • Near-total or total thyroidectomy is the procedure of choice for Graves’ disease. The surgery should preferably done by a high-volume thyroid surgeon.

IMA and HCFI release guidelines on dengue and chikungunya management

IMA and HCFI release guidelines on dengue and chikungunya management

New Delhi, 18 August 2016: In an attempt to dispel myths and create awareness about the ongoing dengue and chikungunya outbreak in the city, IMA and HCFI today released a set of guidelines on the management of the disease.

Speaking about the issue, Padma Shri Awardee KK Aggarwal – President HCFI and Honorary Secretary General IMA said,” The incidence of dengue and chikungunya will continue to exist this month and instead of creating unnecessary chaos and panic, it is essential that awareness is created about its prevention and timely steps are taken towards disease management. One must remember that only 1% of the dengue cases are life-threatening. Most dengue cases can be handled on an outpatient basis and do not require hospitalization. Chikungunya is not fatal and does not require hospitalization. Wearing long sleeved clothes, wearing mosquito repellent with permethrin and checking for breeding in and outside one’s house is key“

Whenever Dengue or Chikungunya Case is suspected: do the followings:

• RWA should come into action and inform everyone in their colony to check for breeding in and around their houses
• Treating doctor of the dengue or chikungunya patient should inform the local IMA President and Secretary about the disease incidence so that they can send a message to all doctors in that area to stay alert
• The local MLA/MP should be informed about the outbreak of dengue in a particular area so that the necessary Vector Control Programme is put to action by the respective Municipal body.

                                                                                                                              

Dengue pointers released:

• Over ninety five percent people suffer from simple dengue fever, which is not as threatening as severe dengue fever.
• In simple dengue fever there is no capillary leakage, the person requires only oral fluids, 100 ml per hour, and is advised to visit local doctor. Additionally, the patient is recommended to drink 500 ml water at the time of diagnosis
• Only those patients with dengue fever who have vomiting should consume intravenous fluids
• Those suffering from severe dengue develop capillary leakage and intra-vascular dehydration.  Also, they suffer from a rapid fall in the platelet count along with rapid rise in their hematocrit levels
• They will have rapid fall in platelets along with rapid rise in hematocrit levels
• Persistent vomiting, nausea, extreme exhaustion and lethargy are some of the symptoms of dengue. Along with these symptoms, a victim might suffer unrelieved abdominal pain and mental irritability and confusion.
• These people require close daily observation
• Dengue patients are kept under close observation and are recommended to consume 1500 ml fluids (20 ml per kg) immediately
• And in case, when they cannot consume liquids orally, then intra venous fluids are a must

Chikungunya pointers released:

• Chikungunya fever is a non fatal debilitating viral illness
• Common symptoms of Chikungunya develop 3-7 days after being bitten by an infected mosquito include fever and joint pain.
• Classical triad is skin rash, joint pains and high fever.
• Most patients will recover within a week. 
• At present, there is no vaccine to prevent or medicine to treat Chikungunya virus.\
• Patients are advised to get plenty of rest and drink fluids to prevent dehydration. 
• It is important to note that aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS) should not be taken until dengue is ruled out to reduce the risk of bleeding since both the ailments present similar symptoms.
• Joint involvement seen with Chikungunya fever usually subsides in one to two weeks’ time.
• In 20% cases joint involvement may persist for weeks and in less than 10% cases, they tend to persist for months. 
• In about 10 % cases, the swelling disappears; the pain subsides, but only to reappear with every other febrile illness for many months. 
• Each time the same joints get swollen, with mild effusion and symptoms persist for a week or two after subsidence of the fever. 
• Cold compression may easy pain.
• Non weight bearing exercises may be suggested. e. g. slowly touching the occiput (back of the head) with the palm, slow ankle exercises, pulley assisted exercises, milder forms of yoga etc.

Do not ignore 2nd attack of dengue

Do not ignore 2nd attack of dengue New Delhi, August 03, 2016: If you have suffered from dengue in the past be more careful as the second attack of dengue may be more dangerous than the first attack, said Padma Shri Awardee Dr KK Aggarwal – President Heart Care Foundation of India (HCFI) and Honorary Secretary General IMA. There are four different strains of dengue and one can, suffer with dengue four times during lifetime. Subsequent dengue infections are more likely to end up with deadly complications. A person with dengue can also simultaneously suffer from malaria. Malaria and dengue together can lower platelet counts to a dangerous level leading to complications. In a dengue season nobody should take aspirin for fever as it can precipitate bleeding, he added. In dengue most complications occur within two days of subsiding of fever and most people are careless during this period. Any abdominal pain, giddiness or weakness after the fever has subsided should be attended to, by a doctor. Dengue complications during this period are due to shift of blood volume and patient requires rapid infusion of oral or intravenous fluids in large quantity. There is no need for giving platelets unless the counts have fallen lower than 2% of original platelet counts