Think before you prescribe

Consider a more convenient option when prescribing antiviral drug for herpes zoster

Herpes zoster or shingles is a viral infection characterized by pain followed by a vesicular rash. It is caused by reactivation of the varicella zoster virus (VZV). The aim of treatment is to hasten healing, reduce the severity and duration of pain and also to reduce the chances of complications such as post-herpetic neuralgia.

Timely administration of antiviral drugs - acyclovir, valacyclovir and famciclovir – decreases viral shedding and reduces the acute pain in patients with uncomplicated infection. These clinical benefits have been demonstrated in various clinical trials.

Acyclovir has to be administered five times daily, which may hinder patient compliance to prescribed treatment. This is especially of concern in the elderly, in whom herpes zoster is most prevalent.

The prodrug of acyclovir, valacyclovir, is administered thrice daily as treatment for herpes zoster and the serum levels achieved are 3 to 5 times higher than those obtained with oral acyclovir.

Famciclovir is a prodrug of penciclovir and is also administered thrice daily as treatment for herpes zoster.

Therefore, when compliance is a concern or convenience of dosing is required, valacyclovir and famciclovir are useful and convenient alternatives to acyclovir as treatment for herpes zoster. 

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Entertainment vs Ananda

All of us crave for and seek happiness. But do we know what true happiness actually is?

‘Feel-good’ movies, a tasty dish, a pleasant or delightful fragrance, a melodious song, a tender touch, seeing a beautiful thing – all these give pleasure and make us feel more upbeat. And, we often confuse or mistake these feelings as happiness.

But, these feelings are not true happiness; they fulfill or satisfy our worldly desires as they are at the level of the senses. This is entertainment, which is temporary or short-lived. A tasty meal will stay with you only until your next meal.

True bliss or happiness is ananda, which is at the level of soul. For example, you watch a movie that stays with you for long after the movie is over. You keep on thinking about it for days to come. Or, you watch a dance drama and your expressions or emotions become one with those enacted on the stage. This is ananda. You become one with the character. You lose track of time.

This is the rasa theory of natya shastra, which establishes a relationship between the actor and the audience. The two are connected at the level of the soul.

According to the Rasa theory of the Natya Shastra, entertainment is a desired effect of performance arts but not the primary goal, and the primary goal is to transport the individual in the audience into another parallel reality, full of wonder and bliss, where he experiences the essence of his own consciousness, and reflects on spiritual and moral questions (Wikipedia).

This is the difference between ananda and entertainment.

Krishna has used the word ‘prasanna’ in Bhagwat Gita, which is inner happiness and not just happiness.

Ananda can be achieved only if you live in the present and not in the past or the future.

Take ‘anand’ in whatever you do; do your duty with devotion and discipline, which means, to be more productive, lose track of time…

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Modern day doctor patient relationship. | Dr K K Aggarwal | TEDxMansarov...

A three-drug combo pill lowers BP more than usual care

A new low-dose antihypertensive combination drug, containing medications belonging to different class, may have the potential to revolutionize treatment of hypertension globally. This ‘triple pill’ contains three antihypertensive drugs: Telmisartan (20 mg), amlodipine (2.5 mg) and chlorthalidone (12.5 mg).

A randomized clinical trial, the TRIUMPH trial, which was conducted in Sri Lanka compared once-daily low-dose triple antihypertensive combination drug with usual care in 700 patients with  with mild to moderate hypertension, who needed either initiation (untreated patients) or escalation (patients on monotherapy) of antihypertensive therapy.  In usual care, patients received their doctor's choice of blood pressure-lowering medication.

Among 700 randomized patients (mean age, 56 years; 58% women; 29% had diabetes; mean baseline systolic/diastolic BP, 154/90 mm Hg), 675 (96%) completed the trial.

In the study published August 14, 2018 in JAMA, 70% patients in the triple pill group achieved the BP targets of systolic/diastolic BP of less than 140/90 mm Hg (or <130/80 mm Hg in patients with diabetes or chronic kidney disease [CKD]) compared with 55% patients receiving usual care.

The maximum difference between the two treatment groups was observed at six weeks after starting treatment, when 68% of those receiving the triple pill had achieved their target BP vs 44% of those receiving usual care. The average reduction in blood pressure was 8.7 mm Hg for participants receiving the triple pill and 4.5 mm Hg for those receiving usual care. The benefits of triple pill were maintained until six months. No significant between-group differences were observed in the proportion of patient withdrawal from BP-lowering therapy due to adverse events; 6.6% for triple combination pill vs 6.8% for usual care.

Based on these findings, the study concluded that use of medication, such as the ‘triple pill’ used in this study, as initial therapy or to replace monotherapy may be an effective way to improve BP control. It was also safe.

Hypertension is a common and most important risk factor for cardiovascular disease. The low and middle income countries, in particular, bear a significantly high global burden of hypertension, making it a major public health problem these countries.

There are several barriers to effective control of high BP, including lack of adequate resources, limited access to treatment and most importantly, poor patient compliance to treatment due to the need to take multiple pills daily.

The triple pill offers a useful strategy to control the high burden of hypertension, especially in the low and middle income countries. Combining the anti-hypertensive drugs in a single pill would make it easier both for doctors to prescribe treatment and more importantly for patients to adhere to the prescribed treatment.

(Source: JAMA, ACC)

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Kerala battles its worst floods in 100 years: Long-term health effects of floods

Continuing with our discussion on the health effects of floods, today we talk about the long-term health effects of flood.

It’s not just the sick, who are vulnerable to these health effects, the healthy people too are at risk of adverse health effects due to polluted air, contaminated water, infected wounds, mold, infectious diseases, carbon monoxide and mosquitoes.

·         Mold in the walls of homes damaged by water is common and is a potential irritant to people who suffer from asthma or COPD or respiratory problems. Exposure to molds causes allergic reactions leading to nasal stuffiness, throat irritation, coughing or wheezing.

·         Carbon monoxide poisoning may occur due to the use of portable devices like electric generators and cooking stoves.

·         Destruction or damage to the health care infrastructure or hospital buildings. This is of concern, especially for patients who have chronic illnesses like heart disease or respiratory illness or those who are undergoing dialysis because of lack of required medications/equipments and loss of access to essential care, including continuing health care.

·         Mental health problems: Depression, increase in suicidal thoughts, post traumatic stress disorder (PTSD)

·         Stagnant water is a breeding ground for mosquitoes, with increased chances of outbreaks of chikungunya, dengue, Zika, leptospirosis

·         Contaminated water due to damage to water and sanitation infrastructure is a public health hazard leading to shortage of drinking water

·         Population displacement

·         Disruption of food supplies

·         Destruction of homes

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Kerala battles its worst floods in 100 years: Acute health effects of floods

Floods waters not only take a toll of human life, they also leave an aftermath of illnesses. The health effects of floods can be immediate as well as long-term.  Today we discuss the immediate or acute health effects of flood.

Drowning

Floods create an immediate risk of drowning for everyone. It has been postulated that two thirds of flood-related deaths worldwide are from drowning and one third from physical trauma, heart attacks, electrocution, CO poisoning or fire.

Drowning may occur by falling into fast-flowing water, at times of unknown depth, including open manholes, crossing flooded rivers or streams, standing on bridges that might be washed away or driving through flood-water. Driving through floodwater is risky. Vehicles do not provide adequate protection from flood waters. They can be swept away or may stall in moving water. As per the CDC, people in vehicles are at greatest risk for drowning, while according to the UK health protection agency, 6 inches of fast-flowing water can knock over an adult, and 2 feet of standing water will float a car.

Injuries

Walking through floodwater is dangerous. Sharp objects submerged in the water can cause injury. Standing waters can hide open manholes and drains, or holes in the roads or other trip/fall hazards. Flood waters can displace vehicles, trees and other material, which can cause injury. Building collapse or damage may also cause injury. Chances of injuries are more when people are trying to evacuate and move away from the fast approaching water. Types of injuries include wounds caused by sharp objects and fractures.

Electrocution

There is a risk of electrocution if water is present anywhere near electrical circuits and electrical appliances. Submerged fallen power lines or live wires can electrically charge the standing water.

Communicable diseases

Although in the short term, there is limited risk of transmission of communicable diseases, floods can potentially increase the transmission of:

• Water-borne diseases, such as typhoid fever, cholera, leptospirosis and hepatitis A
• Vector-borne diseases, such as malaria, dengue, yellow fever, Zika

The major risk factor for water-borne diseases is drinking from potentially contaminated water sources. Leptospirosis, a zoonotic bacterial disease can also be transmitted directly from contaminated water and may cause epidemic. Infection may be acquired by wading in floodwater or contaminated fresh water, especially if there is open wound or scratch.

Direct contact with polluted waters can cause wound infections, dermatitis, conjunctivitis and ear, nose and throat infections.

Hypothermia may occur, particularly in children, if trapped in floodwaters for long periods of time.

Chemical contamination

Industrial chemical leaks, gasoline and diesel spills from vehicles, fuel supplies, pesticides, including household items can contaminate flood water. Carbon monoxide poisoning may occur due to the use of portable generators or pumps to remove collected water.

Stress

Psychological stress manifesting as tearfulness, numbness, tearfulness, numbness, lethargy, low mood is common.

Other health effects

• Trench foot, also known as immersion foot, caused by prolonged exposure of the feet to wet, unsanitary, and cold conditions.
• Animal and insect bites may occur as flood waters can displace animals, insects, and reptiles from their home.

In addition, health risks are also associated with the evacuation of patients to safer grounds, loss of health workers and/or health infrastructure including essential drugs and supplies and damage to equipments.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Differences between Alzheimer's dementia and vascular dementia

Dementia is an umbrella term for a syndrome marked by deterioration in memory, other cognitive abilities and the ability to perform everyday activities. Although dementia mainly affects older people, it is not a normal part of aging. It is one of the major causes of disability and dependency among older people worldwide (WHO). There are several types of dementia. The most common is Alzheimer’s disease. Vascular dementia is another type of dementia.

While Alzheimer’s disease and vascular dementia are both types of dementia, their causes, symptoms and prognosis differ.

·         Vascular dementia is caused by an acute event such as stroke or transient ischemic attack (TIA), while the cause of Alzheimer’s disease still remains unknown.

·         Diabetes, hypertension, coronary artery disease, high cholesterol levels are risk factors for vascular dementia. Alzheimer’s disease is an irreversible, degenerative disease of the brain. Age is the best known risk factor for Alzheimer’s disease. Genetics may also have a role.

·         In vascular dementia, cognitive impairment occurs more suddenly and then remains stable for some time (step-like decline) and is related to an acute event like stroke or TIA. Whereas, in Alzheimer’s disease, memory problems are characteristically one of the first warning signs of cognitive loss and memory gradually declines over time.

·         Physical disability occurs at the same time as cognitive impairment in vascular dementia. In Alzheimer’s, cognitive impairment occurs first followed by physical disability.

·         A CT scan or MRI can detect an area of brain affected by stroke or TIA (infarcts). Alzheimer’s disease, on the other hand, is a diagnosis of exclusion. All other causes of dementia such as B12 deficiency (reversible) need to be ruled out before diagnosing a person with Alzheimer’s disease.

·         Prognosis of vascular dementia depends on the extent of damage in brain. Alzheimer’s disease progresses over the years. Survival after a diagnosis of Alzheimer’s disease is usually 8.4 years.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA