My Lockdown on blogging

My Lockdown on blogging

Dear Friends,

How are you doing with lockdown (I call it shutdown, computer terminology) in ? Wherever you are, US, China, Canada or Ceylon?

It may be a treat for you to avoid US, China, Canada or Ceylon traffic (I forget most of the landmarks of the world, now)!

? Your better half must be busy replanting ? is it daffodil or is it looking after grand children?

With rain coming I will have a break, let my rooftop garden go wild.

It is only 20 by 30 feet has 5 types of lilies and 25 water plants and many banzai plants.

Mind you the 20 odd palm trees I planted only three survived and are very tall now.

I have some seeds too.

Mind you I do not watch cricket or play hockey.

I keep my one and my  daughter’s hockey sticks as souvenirs.

I lost my billiard sticks and ques.

Somebody had used them as firewood, I believe in my absence abroad. 

You may not be hearing or getting my rants from now onwards.

I am getting bit lazy and lot of typos and grammatical mistakes.

I do not want to kill the queen’s language.

Besides satire has no place in this country.

By the way, keep me posted of life and things dear to heart.

List of Medical Stuff one Needs in an Emergency

List of Medical Stuff one Needs in an Emergency

Things are not good as it is, and I wake up exactly 8 hours after a good sleep without bad dreams.

Nothing else to do, this is a way to ease my pent up anger of incarceration.

No anxiety at all!

But I must thank late Professor Senake Bibile, who was probably assassinated by CIA cohorts and Drug conglomerate of America.

This is dedicated to him.

Having said that, I have met bizarre medical personnel in Ceylon, UK and New Zealand where I have worked for considerable length of time and finally settle downed as a teacher and a research pathologist.

I used to say, I can run any hospital with minimum of facilities and of course, I did not have many when I was managing a D.M.O station with Cholera epidemic in this country.

My memory is failing and I start with a incident in a private nursing home in Negambo.

I had an 84 four year old male admitted to this nursing hospital for last rights by his relations.

I had a good technician who was a navel officer with whom I worked during 1989 in Digana village (IMMI) where the 15 or bodies and body parts scattered DJV guys/ girls dumped by our army, then active.

I did have a camera (as a pathologist I photograph some cases for posterity) but never ventured into hysterical photo record but the local journalists took some photographs and they were the first to appear in daily papers.

I told my private technician (he was not employed to save money) to make a blood film (I generally have a look at them after my clinical rounds) and look at it in detail.

He came running to me to report malaria and I told him not a surprise he had hepatosplenomegaly.

My in depth examination revealed even malaria gametes.

Caveat was he had appendicitis in addition.

 

I went and told the owner of the the institution for approval of intravenous chloroquine which I had to purchase from a local pharmacy.

We did not keep a stock and it has cardiac-suppressant effects.

With a ECG monitor standing by, I infused first the antibiotics (we have decided not to operate him immediately) and then the chloroquine slowly.

To my surprise he woke up from his slumber (he had thought he is going to die) and I asked him what he wants me to do.

He said he wish to go home immediately (to write his will or something to that effect).

I said nothing doing for 3 weeks (good for our hospital account) and I will tell him when.

Then I told him his kith and kin wished him dead already and not to trust them when they visit him.

furthermore, pretend you are in deep sleep (coma to be precise) and listen to them to confirm my above affirmations.

Malaria gone and primaquine (double dose) given to prevent relapse, he was by tenth day full of spirit and his ruptured appendix was forming into an abscess walled off (fat guy with lot of omental fat to ward of septicaemia) by the antibiotic treatment.

If my memory was right I gave a single dose of chloramphenicol which was followed by Rocephin IV.

On a similar note on malaria I diagnosed a malaria case in New Zealand clinically and asked the chief technician blood (malaria) film.

He said no malaria in New Zealand (I did not tell him the patient is a visitor from Malaysia).

I took a bet for a large chocolate slab and won it but we shared the spoils in good spirit.

He was the best technician I have ever worked with in my life.

In a similar case a patient was brought in moribund state (after writing his will) with a rollicking double pneumonia.

We treated him with Rocephin and he started recovering but my basal tests included Serum typhoid antibody titre.

He had typhoid too (confirmed) and Rocehin was enough to cure both pneumonia and typhoid.

I am not sure typhoid causes pneuminia.

He had two doses of chloramphenicol IV.

Mind you chloramphenicol is now banned in Ceylon.

 

In a lighter note all my engineer friends (only one girl) who did the Mahaweli Project including surveying came to me within 9 to 12 months with malaria.

The symptoms were variable (like Dengue) in addition to fever (by the way, not typical of malaria in textbooks).

I had eight Cesarean babies dying in my first month of internship.

We did not have a bacteriology unit and sent all blood and stool sample to Colombo confirmed typhoid epidemic in the hospital.

Thankfully midwife feeding the babies was a typhoid carrier, including few other nurses.

 

Closed the Unit and send the acting consultant guy back to base in Colombo.

I reported to the DHS that he was not in base on duty and was recuperating in Colombo.

MS was also transferred.

These were the times when Public Service Commission had teeth without political intervention.

Coming to my list.

My List

1. Saline and Dextrose saline

2. Blood.

3. Hyperimmune serum

4. Morphine

5. Frusemde and simple oral diuretics

6. Oxygen cylinder with mask to make 20-30% oxygen saturation.

7. Prednisolone

8. Isoprenaline with ventolin nebulizer

9. Insulin preferably with an insulin pump

10. Thyroxin

11. ECG

12. X-Ray

13. Emergency Blood film (malaria, ureamia, liver failure, anaemia, leukaemia and even metastatic cancer)

14. Blood sample for basic investigations virology not included.

15. Blood Pressure apparatus and appropriate treatment.

16 to 20 is optional depending on the initial cues.

That include, cholera, typhoid, hepatitis and now Coronavirus testing kit.

My approach to any clinical problem at hand (POMR- Problem Oriented Medical Records)

My approach to any clinical problem at hand (POMR- Problem Oriented Medical Records)

There is some overlay and interplay of terminology.

Even after going through the list throughly, only 60% of the problems can be sorted out with impunity (40% already known and another 20% solved leaving behind 40% a mystery).

When I see journalists’ questions and presentations, Dr. Sanjaya Gupta is having a torrid time and trying hard to keep abreast but mildly skeptical of political overtures.

I hope this list will give some comfort (40% a mystery)1

1. Aetiology

2. Definitions

3. Classification of Diseases

4. Epidemiology

Incidence

Prevalence

5. Pathogenesis

6. Pathology (after the fact at postmortem or biopsy)

7. Microbiology

8. Virology (globally neglected including WHO)

9. Immunology

10. Clinical Findings

11. Laboratory Findings (relevant and incidental)

12. Differential diagnosis (my specialty of trying to delineate subtle differences)

13. Treatment modalities including life support

14. Complications (disease as well as treatment itself including ventilator support)

15. Prognosis

16. Prevention

17. Research

18. Outcome

19. Outlook

20. Philosophical Perspective (ability to stay calm in adversity and leave no stone unturned nevertheless for ABSOLUTE clarity)

Update on Coronavirus

Reproduction

Update on Coronavirus

This retrospective case series includes adults 18 years of age or older with confirmed Covid-19 who were consecutively admitted between March 5 (date of the first positive case) and March 27, 2020, at an 862-bed quaternary referral center and an affiliated 180-bed nonteaching community hospital in Manhattan. Both hospitals adopted an early-intubation strategy with limited use of high-flow nasal cannulae during this period. Cases were confirmed through reverse-transcriptase–polymerase-chain-reaction assays performed on nasopharyngeal swab specimens. Data were manually abstracted from electronic health records with the use of a quality-controlled protocol and structured abstraction tool (details are provided in the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

Table 1. Characteristics of the Patients.

Among the 393 patients, the median age was 62.2 years, 60.6% were male, and 35.8% had obesity (Table 1). The most common presenting symptoms were cough (79.4%), fever (77.1%), dyspnea (56.5%), myalgias (23.8%), diarrhea (23.7%), and nausea and vomiting (19.1%) (Table S1 in the Supplementary Appendix). Most of the patients (90.0%) had lymphopenia, 27% had thrombocytopenia, and many had elevated liver-function values and inflammatory markers. Between March 5 and April 10, respiratory failure leading to invasive mechanical ventilation developed in 130 patients (33.1%); to date, only 43 of these patients (33.1%) have been extubated. In total, 40 of the patients (10.2%) have died, and 260 (66.2%) have been discharged from the hospital; outcome data are incomplete for the remaining 93 patients (23.7%).

Patients who received invasive mechanical ventilation were more likely to be male, to have obesity, and to have elevated liver-function values and inflammatory markers (ferritin, d-dimer, C-reactive protein, and procalcitonin) than were patients who did not receive invasive mechanical ventilation. Of the patients who received invasive mechanical ventilation, 40 (30.8%) did not need supplemental oxygen during the first 3 hours after presenting to the emergency department. Patients who received invasive mechanical ventilation were more likely to need vasopressor support (95.4% vs. 1.5%) and to have other complications, including atrial arrhythmias (17.7% vs. 1.9%) and new renal replacement therapy (13.3% vs. 0.4%).

Among these 393 patients with Covid-19 who were hospitalized in two New York City hospitals, the manifestations of the disease at presentation were generally similar to those in a large case series from China¹; however, gastrointestinal symptoms appeared to be more common than in China (where these symptoms occurred in 4 to 5% of patients). This difference could reflect geographic variation or differential reporting. Obesity was common and may be a risk factor for respiratory failure leading to invasive mechanical ventilation.³ The percentage of patients in our case series who received invasive mechanical ventilation was more than 10 times as high as that in China; potential contributors include the more severe disease in our cohort (since testing and hospitalization in the United States is largely limited to patients with more severe disease) and the early-intubation strategy used in our hospitals. Regardless, the high demand for invasive mechanical ventilation has the potential to overwhelm hospital resources. Deterioration occurred in many patients whose condition had previously been stable; almost a third of patients who received invasive mechanical ventilation did not need supplemental oxygen at presentation. The observations that the patients who received invasive mechanical ventilation almost universally received vasopressor support and that many also received new renal replacement therapy suggest that there is also a need to strengthen stockpiles and supply chains for these resources.

Parag Goyal, M.D.
Justin J. Choi, M.D.

My approach to any clinical problem at hand

My approach to any clinical problem at hand

There is some overlay and interplay of terminology.

Even after going through the list throughly, only 60% of the problems can be sorted out with impunity (40% already known and another 20% solved leaving behind 40% a mystery).

When I see journalists’ questions and presentations, Dr. Sanjaya Gupta is trying hard to keep abreast but mildly skeptical of political overtures.

I hope this list will give some comfort (40% a mystery)

1. Aetiology

2. Definitions

3. Classification of diseases

4. Epidemiology

Incidence

Prevalence

5. Pathogenesis

6. Pathology (after the fact at postmortem or biopsy)

7. Microbiology

8. Virology (globally neglected including WHO)

9. Immunology

10. Clinical Findings

11. Laboratory Findings (relevant and incidental)

12. Differential diagnosis (my specialty of trying to delineate subtle differences)

13. Treatment modalities including life support

14. Complications (disease as well as treatment itself including ventilator support)

15. Prognosis

16. Prevention

17. Research

18. Outcome

19. Outlook

20. Philosophical Perspective (ability to stay calm in adversity and leave no stone unturned for clarity)

Conspiracies in Science.

You won't here the unlucky 13 from me, since I am retiring from the Fake Seeking Internet and digital Media

Number 12 is Viral Flu ( my last in the Mystery List to ponder in my retirement)

Conspiracies in Science.

I thought I could make 10 easily!

It does not look like preset day scientists are bent on conspiracies.

I lost count at EIGHT of course I left out the minor events.

Have you thought about any?
 
Well I have found 11, NOW.

It is all due to my memory failing.

Conspiracies in Science in my List.

1. Microsoft’s Strategy
Bulldoze other operating systems with Fear, Uncertainty and Doubt (FUD).
 
2. Drug Companies
Demise of Professor Bible
 
3. AIDS Epidemic
Germans in Mid Africa
 
4. UFOs
America's Blue Book
 
5. Big Bang Theory
This is the biggest for me to satisfy the Church.
 
6. Global Warming
America aided by Oil Companies headed the misinformation campaign
 
7. Mad Cow Disease
Late British PM headed it.
 
8. Coconut Theory
America's peanut industry.

9. Chip Conspiracy
Silicon Valley kept the chip technology their copyright.

10. Solar Cells

We could have (96% of the solar energy is wasted) been a better country without coal power.

If, Ceylon/ Sri-Lankan invested on SOLAR 40 years ago, we won't have power cuts now.

11. Lithium Dry Cell battery

Is the biggest conspiracy.
The dry cell and lithium battery for the electric car was designed in the sixties but Americans shelved it.
I wrote about it many moons ago but I have lost the original references.

Jumbo Predators

Reproduction 

Jumbo Predators

Leave jumbos alone!

April 16, 2020, 9:38 am
The worldwide halt in travel has brought about some big changes for animals used in Sri Lanka's tourism industry. Elephants, who are forced to work day after day in the nation's tourist camps, have had a brief reprieve from their toil, as the camps have been forced to close and the trekking chairs have been removed from their backs.

 International watchdogs have documented that wild elephants are captured to perpetuate this lucrative tourist industry. Taken from their home and family, these intelligent and social animals will spend most of their lives in chains, living in fear of being whacked with a sharp metal-tipped weapon. Ultimately, tourists, who pay to ride or bathe an elephant, are responsible for this cycle of abuse.
 Captivity robs elephants of everything that gives their lives meaning: foraging for food, constantly being on the move, taking dust baths, swimming, and, most importantly, socializing with their families and other elephants. Long after visitors go home with their photos and memories, elephants continue to suffer through their interminable days.

 Now, handlers are reportedly not feeding the elephants they use and blaming the COVID-19 pandemic for this. It's never been clearer that these multiton wild animals deserve to be cared for properly, and live out their lives free from having chains around their legs and being beaten with bullhooks. As always, PETA - People for Ethical Treatment of Animals - will transfer any elephants surrendered to us to a sanctuary.

 When the world gets past the Coronavirus crisis, life will slowly return to normal. But for the elephants in Sri Lanka's elephant camps, going back to servitude is no life at all.Please, never book an interaction with an elephant and always be sure that one is not included on your tour.

 JASON BAKER
 Senior Vice President, People for the Ethical Treatment of Animals

Stupid Education Ministers

Stupid Education Ministers

Our current education minister is stupid to open the universities soon after the New Year celebrations.

Similar thing happened in China (with their new year celebrations).

We have had many stupid ministers of educations.

1. Badu Deen Mahamud was on top of that list.

His time no convocations (under Sirima) and no degree certificates for undergraduates.

2. Then there was Iriyagolla (was very god with Kunu Haruha or FOUL Words, just like Badu Deen Mahamud) who was policemen by trade and had a torrid time (even his son who was an alcoholic joined the protests in our times) under his belt (my euphemism- university students).

One of them (naming is shaming even after death) had venereal diseases and I have seen that suppressed report myself (one of his contact victims) in a VD Clinic.

3. Then came Ranil who was famous for enhanced interrogation (American euphemism for water barding or torture) at Batalanda.

4. The current one is famous for lying through his Arxxxx for his master!

Either we follow the trends in 1918-19 epidemic (we do not have much valid data) or we have to follow known enteric (not respiratory) virus infectious hepatitis.

It has six weeks incubation period and convalescence is six months to two years
This virus is enteric (this information is suppressed by China and WHO) as opposed to respiratory and that is why its incubation period (three weeks or more; we really do not know; is longer than 3-5 days of normal for seasonal flu) is long.

With the rain season starting with Bak Maha Akunu (New year Flu is my description of it) normal flu will spread in all universities by default along with a delay (an ample time to spread) the Coronavirus (6 weeks to six months in universities).

Then we have to close universities indefinitely.

By the way, I do not mind few of the dons who bum suck politicians dying as a byproduct.

My advice for university students is to send a medical certificates to the medical officer saying one is disposed and sit the examination second time which is much easier by default.

I am no longer in the university and won’t accept a visiting lecture even if they pay me 100 times as an incentive.

COVID-19: Ceylonese Response

My Comments

I have made adequate entries on this virus (not the epidemic) at this site!

Our failure to "nip in the bud" were obvious even though government doctors (not GMOA, who bum-sucks politicians) did a creditable job.

We were lucky that we were not a tourist destination for many except Chinese and Indians (that is also for commercial exploitation) after Church Bomb and Wahabis activities which Sirisena ans Ranil failed to address (includes Mahinda too, he did not suppress its activities emerging way back in 2008 fearing loss of Muslim vote).

Cash struck we relied on Chinese and allowed Visa Office for Chinese to operate without supervision.

Very stupid political action.

I have a saying, "Never trust a Chinaman" that includes SOHO in London.

The only difference between Indians (RAW and Gandhis) and Chinese is very simple.

Indians get caught lying but Chinese never get caught with the HELP of WHO with an Ethiopian heading it shamefully.

When India and Africa get affected there is no stop of it spreading like a wildfire (poor sanitation, lack of water, malnutrition, poverty and joblessness compounding).

We may have to go back to hand to mouth existence (with unbearable debts and nobody giving a free lunch- an euphemism of mine) and NM and Sirima Era of Pan Poling-Bread queues and Manioc and Batala.

History repeats itself and SLFP/SLPP (I call it Pathala Party) unlike the UNP cannot feed the masses, especially in the North!

It is like Un SuKi of Myanmar taming the Army.

Very soon we won't be able to tame the emerging army influence on politics.

Thankfully our Police Force kept them at bay! 

Above are SAD realities (only a few mentioned).

COVID-19: Ceylonese Response

Emerging Questions, Testing Times

Reproduction

Rajan Philips

It is now one month after the WHO declared Covid-19 a global pandemic. Some clarity is emerging through the viral cloud about what happened, what went wrong and what might have been done differently. It is legitimate to ask if Wuhan had to be isolated from the rest of China, why could not China have been isolated from the rest of the world. Had that twin isolation been undertaken, China would have got reconnected with the world in 67 days at most, the time it took China to end the isolation of Wuhan. In fact, China’s external isolation would have ended a lot sooner. Trade connections and supply chains would have survived an immediate isolation with minimum disruptions, and would not have been catastrophically broken as they are now. 

This is all now hindsight, but the questions to China and the WHO are not going to go away.

There is plenty of blame to go around the world for general government inertia as well as sinister political calculations. Early warnings were ignored in the US and pandemic emergency plans meticulously prepared in western countries after the SARS crisis were not even looked at this time. 
The exceptions are the few East Asian countries, perhaps Australia and New Zealand down under, and Iceland and Denmark up north. There are broader questions as well – from the direct connections between the growth of global agri-business and the release of pathogens from their harmless natural settings to hit and harm human hosts, and the diminishing global investment in the study of and preparedness for communicable diseases relative to lifestyle illnesses. But the questions and the debates will have to wait for another day until the current fight against the virus is brought under control.

There is no primeval fight or flight option. But fight and feed. Fight the virus, feed the people. That is the task of every government and it cannot get more basic for any government. And the task should not be made more difficult by the all too familiar lapses into never ending spats over race, region and religion. When nothing works, blame the unreliable Chinese or the ugly American. If neither works, blame the Muslims, especially in South Asia. The European Union that was created to end its recurrent internal wars is warring again over supplies and subsidies in the fight against the virus. And for the great NATO, it is business as usual. They will get paid for doing nothing as usual, or for desk-top testing of non-existent pandemic scenarios, unlike everyone else in the world.       

Oh, yes, “April is the cruelest month.” T.S. Eliot would never have imagined that the famous opening line of his melancholy poem, The Waste Land, would turn out to be a morbid prophesy not only for the country of his birth, but also for the country of his adoption. The United State of America, where Eliot was born, is now the epicentre of a global pandemic. And the United Kingdom, of which he became a citizen after renouncing his American citizenship, is faring proportionately the same, if not worse. Prime Minister Boris Johnson himself has become a prime patient of Covid-19. Mr. Johnson is reportedly recovering well, after being in intensive care unit but without needing ventilator support, and much to the relief of a Brexit-battered and virus-hit nation. In general, however, and as usually alarmingly in the US, marginalized people are faring the worst.

The number of Covid-19 cases and deaths worldwide keep rising relentlessly. There are different lights in different tunnels. Europe seems to be on the mend finally, but only through a mountain of the dead. In the US the virus is surging in one state after another, but the curve appears to be flattening in general. Africa is no longer immune as it appeared to be at the start, and the worst is yet to come both for the continent’s health and its economy. East Asia is relatively stable, including China the origin of the viral quake. South Asia is sitting somewhat precariously in the middle, with India looming as the huge known unknown. That is the current picture and also the context for ongoing decision making.

Decision Making

Decisions are now being made in three interlocking planes, the science about the virus, the public action to contain its transmission, and governmental efforts to cushion the economic fallouts. The practical side of the science about the virus is all about testing. It is the paucity of testing and the lack of sufficient knowledge about the virus that has made contact tracing and physical distancing – from simple home isolation, to centralized quarantines, to total lockdowns - the only way to break the chain of transmission and stop the viral spread.

It is the same paucity that has given rise to two, rather crude but the only available, universal metrics in the tracking of the virus and the fighting of its transmission: the number of days it takes to double the number of Covid-19 cases; and the number of tests per million population. The former helps in plotting the curve and the latter to assess the extent of the virus spread and to see if and how containment measures are working. For comparison, in the pandemic hotspots like China, Italy, Spain and the US, the number of days during which cases doubled, shrank from six to seven days at the start to three to four days during the surge.

Sufficient testing is needed to decide how and when the current isolation and distancing could be relaxed, and in what stages. Until then, there are economic fallouts to be taken care of. Unlike any of the past economic upheavals, the current shutdown is the worst supply side crisis ever, and writ large over the world like never before. While during the 2008 Great Recession, the western countries were hit hard and the peripheral economies were relatively spared, it is the global periphery that will be hit harder than the economic centres in the current showdown. Global initiatives have been either promised or called for by G20 leaders ($5-trillion), the UN ($9-trillion) and a large group of former world leaders ($5-billion) – that includes President Chandrika Kumaratunga. If any or all of them were to materialize, that would ensure a significant cashflow to peripheral countries. But how soon and how much are indeterminate, and the current beggar-thy-neighbour attitude to one another among the  western countries does not augur well for much global certainty.    

Testing delays have been universal, except again for the few East Asian countries. Even the US got tied up in regulatory knots and wasted precious time in the beginning before ramping up its testing program. The countries that are doing better in containing the virus are also doing larger number of tests than others. South Korea and Singapore are at 9,000 and 12,000 tests per million people, respectively. Australia is at 13,000 tests per million people, while Bahrain and Iceland are off the charts at 35,000 and 89,000 (multiple) tests per million. Timing is important. Germany and Italy are doing 15,000 tests per million, but they started late, especially Italy. France and England are under 5,000 tests per million, while the US and Canada are hitting close to 7,000 and 10,000 tests, respectively, but with significant regional variations.

Testing time for Sri Lanka

By all accounts, Sri Lanka has done phenomenally well in contact tracing and supervised quarantining. The record on testing, however, is nowhere near as good. Currently, the tests are reportedly limited to patients only, and about 3500 tests have been carried out so far according to recent news reports. That would place Sri Lanka at about 175 tests per million people, and in the same South Asian camp as Bangladesh at 36 tests per million (with 6,000 tests), India at 107 (145,000 tests), and Pakistan at 212 (45,000 tests). Sri Lanka has been conducting 150 to 300 tests daily, although it is said to have the capacity to go up to 1500 tests a day. At this rate, it will take just over two months to reach a reasonable target of 5000 tests per million (i.e. 100,000 tests). There have also been suggestions that the daily test rate can go up to 12,000 tests a day, but there has been no follow up regarding an aggressive testing program  

There is then the debate, including in Sri Lanka, about what tests to perform and who should be targeted for tests. The primary test type is the diagnostic laboratory PCR (Polymerase Chain Reaction) test that detects the virus and confirms infection in a person. Multiple tests are needed in some cases before infection is confirmed. In many jurisdictions, this test and confirmation are required for ‘treating’ patients, even though, as some epidemiologists and physicians have pointed out, there is no accredited therapy for Covid-19.

The WHO definition of a confirmed case as “a person with laboratory confirmation of COVID-19 infection”, gives PCR test a special imprimatur. Dr. Jayaruwan Bandara, Director of the Medical Research Institute, has called it “the gold standard test” for diagnosing Covid-19. Understandably so, and the same token entails many restrictive guidelines for carrying out the test. The lab work invariably takes time and it has taken too much time even in western countries to increase the laboratory throughput of test results.

In addition, the PCR test is not a mass surveillance test to assess the spread of infection in a community. Hence the call for a second test, the serology test, that detects the antibodies that are produced to fight the virus infection. This can be used for both diagnosis and for population surveillance that will show the number of people who have been infected, including those with minor symptoms and those who are asymptomatic. Detecting asymptomatic cases is the special advantage of the serology test, knowing that asymptomatic transmission of the coronavirus is what renders it intractable.

As against these merits of serological testing, there is conventional reluctance in (government) medical and health regulatory circles to implement a serological testing program at the early stages of an epidemic. The reluctance might be because the regulatory agencies are not prepared to apply the serology test for diagnostic purposes insofar as the test does not detect the virus or early infection. Serology tests are typically used after an epidemic to assess the levels of infection and immunity in the community to prepare for the next outbreak. This point has also been made by the Director General of Health, Dr. Anil Jasinghe, who has indicated that “PCR is the test that was used by China and South Korea, at the initial stage of Covid-19, and that tests, like blood antibody testing, were used later.” The Sri Lanka Medical Association (SLMA) has also called for expanding PCR testing instead of shifting to serology testing.

On the other hand, the GMOA, in my understanding from news reports, has been pressing for implementing a rapid (serology) test program, and to carry out tests among 45,000 or so ‘contact traces’, who are in quarantine and are yet to be tested. In between, Chair Professors of Medicine (and specialist Physicians) from six of the island’s medical faculties, in their letter to Lt. Gen. Shavendra Silva, Chairman of the Covid-19 National Task Force and Dr Anil Jasinghe, Director General of Health Services, recommending next steps, have called for increasing test capacity and to “seek advice from virologists regarding what tests are most appropriate for use in specific scenarios.”

Across the world, a Canadian epidemiologist, Prof. Dawn Bowdish of McMaster University, has said that serology tests “are absolutely the gold standard for understanding the spread of this infection.” So, if both the PCR and serology tests are gold standard tests according to medical experts, albeit for different purposes, why not use both – from a simple and practical policy standpoint, to serve both purposes in Sri Lanka, and since both are needed. That is, both to diagnose patients and to track the virus spread. New serology tests are already being used in a number of countries, each priced at $10 (Rs. 2000, less than the PCR test cost of Rs. 6000), and able to give results in 20 minutes.

One more viewpoint on the matter of testing might be of particular relevance in the Sri Lankan context, with a tradition of doctors providing exceptionally good diagnosis in spite of limited resources for laboratory testing. Prof. David Fisman, Infectious Disease Epidemiologist and Physician at the University of Toronto, has suggested that given the newness of and the lack of information on Covid-19, ‘clinical case definitions’ should be used to identify Covid-19 cases where formal testing facilities are not sufficiently available. According to Dr. Fisman, clinical definitions were used during the SARS outbreak in Canada, and at the height of the current crisis in China, CT-scans were used in diagnosing Covid-19. Dr. Fisman has also suggested that in a pandemic situation such as this, every patient admitted to a hospital should be tested for Covid-19, along with healthcare providers. Testing of inmates in prisons, and other high-density dwellings and institutions would also make sense.

At this early stage of an epidemic caused by an etiologically little-known virus, the sampling for testing is invariably not random. Optimal sampling strategies have been developed for other disease epidemics that are both time-dependent and independent, and target both the vector (virus) and the host (human) populations. For now, in the case of the coronavirus, the rather crude metric of ‘tests per million’ appears to be the only guidance everywhere. Random sampling has been reported in Iceland, but the randomness assumption there is also being contested. In the light of all this and to get to practical matters, what could be the next steps in Sri Lanka?

Next Steps and Potential Slips

There is no further need to belabour the case, which is to implement both the PCR and the serological tests as rapidly as possible and as in many numbers as possible. Sri Lanka could learn from Vietnam, which has a low testing rate, about 1,200 tests per million people (and a total of 115,000 tests), but has aggressively carried out contact tracing and targeted ring-testing among the traced contacts to break the chain of transmission. The Sri Lankan government should support medical and health professionals to devise testing programs specific to each district, based on the experience so far and district-specific infection information, and implement them aggressively. There are medical faculties practically in every province and their resources should be leveraged to maximum benefit through co-ordination with the MRI and the Director General of Health Services.

It would also be helpful if the government could set up a proper professional forum where all the medical voices and opinions could be channeled and consulted without their having to find independent media outlets to express themselves. There is some media muttering that some medical voices are closer to the political powers than others. But that is inevitable and in itself should not be much of a concern, provided the scientific independence of the MRI and the administrative independence of the Director General of Health Services are not compromised.

To strike a personal note, I have found the silence of Dr. Tissa Vitarana in all of this somewhat puzzling. As onetime Director of the MRI, he was a highly respected medical scientist and was universally liked as a person, as some UNP Doctors used to say, in spite of his affiliations to the LSSP. His age should not be a factor, because everybody who is somebody in the current Administration is old. Dr. Vitarana is the only medical scientist who is politically associated with the current Administration. He is the Governor for the North Central Province and is also on the SLPP National List for the parliamentary election. And he could be a source of experience and wisdom in linking medical-scientific thinking and political decision making.

A ramped-up testing program and informed consultations based on test results will be critical in determining the next steps in coming out of the current curfew situations in the country. The virus is not going to disappear any time soon any where in the world, until an effective therapy or a successful vaccine is found. So, there cannot be a total relaxation of the current restrictive measures. In fact, it would be prudent to expect and prepare for restrictions and relaxation to alternatingly continue for rather long periods of time. And there are good practices to follow – from Vietnam, South Korea, Singapore and Taiwan.

Singapore is currently implementing a series of “stepping up measures” to deal with a second spike in the local transmission of the virus. Singapore calls the measures a “circuit breaker”, not a lockdown or a curfew, and they are being implemented with due preparation and prior notice to avoid public confusion and transport stampedes.  The measures will initially last a period of one month, which is calculated to cover two cycles of viral incubation. Additionally, modern supermarkets and traditional ‘wet markets’ will remain open and people will be allowed shop in orderly manner while maintaining minimum physical separation. These are not difficult measures and similar measures can be easily implemented in Sri Lanka. In Colombo, and other main cities, it should not be difficult to keep markets open and designate separate days of the week for households from different areas (e.g. by streets or ward) to do their shopping.  

Overall, the government faces three challenges: containing the virus; cushioning the economic fallouts; and ensuring the survival of constitutional politics. On the first, the government deserves all the credit that has been extended to it. Hopefully, it will keep up the good work, informed by sufficient test data and appropriately adopting good practices from East Asian countries. It is too soon to pass verdict on the second challenge. Even without the virus the government was in a deep hole and the virus has made it infinitely worse. Its first responsibility is to support employees and businesses who are involuntarily locked out of work, and this goes far beyond fulfilling the already established subsidy practices.

To that end, the government should look for immediate funding opportunities anywhere and everywhere, bilateral or multilateral. It could even send Chandrika Kumaratunga and Ranil Wickremesinghe as urgent emissaries to scour the world and not to return without foreign exchange. They could be more useful to the country from the outside than from within. Of course, they cannot emplane immediately, nor is physical travel really necessary with the new virus making virtual connections the new reality. Desperate times call for desperate measures, and no one is going to lose by working together in this crisis. Hopefully, I am not jinxing the possibility of a positive outcome for the country by publicly suggesting it.

The government should also forcefully nix lamebrained ideas emanating from within its ranks. Two have surfaced so far – one on (ab)using the EPF savings as a stimulus source, and the other to bring back import substitution from the long-ago dead. Neither seems to have found any traction, and hopefully both are still born, or dead on arrival. This is not to say that there is no room for new ideas, only they should not be lamebrained.

Worldwide food scarcity has been talked about even before the arrival of the virus, and its arrival makes it all the more urgent. Sri Lanka can and must re-energize its food production, but without raising barriers. It is a fact of Sri Lankan economic history that local food production has thrived only when there was no barrier at the customs, or checkpoints at district boundaries. One can be a socialist and doesn’t have to feel shy about saying this. As for new ideas, it would be worth for some in the government and the industry to explore the possibility of retooling the island’s industrial knowhow and technology in medical glove making and the garment industry to cater to the rising global demand for hospital gowns and other Personal Protection Equipment (PPE) for frontline healthcare providers. 

The third challenge is also the government’s Achilles’ heel, and where it can slip. The success here will be marked not by the extent of the SLPP’s victory at the next parliamentary election, whenever it comes, but by the extent to which President Gotabaya Rajapaksa and his Administration abide by constitutional norms in exercising executive power. A curfew without declaring emergency, avoiding emergency rule to avoid recalling parliament, and bankrolling off the national coffers, no matter how empty, without parliamentary approvals – are all jointly and severally beyond the pale in every direction. The President has the power and the option not to do any of this. And those who advise him to the contrary are not serving the President or the country well.

The latest in this vein is the missive by Presidential Secretary, Dr. P. B. Jayasundara, to Mahinda Deshapriya, Chairman of the Election Commission. The latter was ill-advised to start a public correspondence with the President on deciding a new date to hold the now postponed parliamentary election. Dr. Jayasundara, rather than elevating the discussion, has chosen to lower it by indulging in pettifogging and seriously indefensible polemics. He has lowered the office of the President. In the midst of a generational battle against a novel pathogen, President Gotabaya Rajapaksa deserves better from his Secretary.   

My Experience with operating Ventilators

My Experience with operating Ventilators

My Experience with operating Ventilators started with neonates and ended in geriatrics.
I am thankful I am now in geriatric age and is not working in a hospital.
i quietly moved to my original interest pathology, where I have after the fact estimation of effects.
Thankfully my senior teacher, the Professor of Pathology warned me of the limitations.
He said I know only 40% currently and at best of your work and research you will bring it up to 60% and no more.
At best 40% will be a mystery and never resolved by scientific inquiry.
My research proved he was absolutely right and I could not find an explanation for 42% (2% is probably is the margin of error of my study).
my experince in paediatric neonatolgy is that I saved life briefly for them to a long life of agony with assortment of cerebral palsy and mental deficits.
It was easy for me to give up paediatric and paediatric oncology (leukaemias).

Leaving UK was instinct driven mandatory action.

Coming to geriatric ventilation, my or our plan was to wean off within five (5) days before the patient become ventilator dependent or develop ventilator related complications.
The five days was not arbitrary but a good safety valve in my experience.

I asked permission from the patient having given the basic information of the invasive procdure well in advance.
If the patient is unable to communicate I would ask the kith and kin.

My favorite patient in New Zealand with his permission put on a ventilator for three times (that was his wish).
In between the fist and third he broke both his hips which I helped to implant artificial prosthesis with 80% mobility (with 20% help, getting out and getting into the bed).
My other favorite patient with testicular cancer and large cannon ball secondaries in the lung refused ventilation by default.
His only request was for me to be at bedside when the time comes.
I was not on call but I made him a practical Buddhist in few minutes and showed him the exit and new life at the end of the tunnel.
On return from New Zealand I continued in private practice without ventilators (even for a brief periods) for five years before coming back to Dental Hospital for research without a supervisor (no emergency care or ventilators at all).
For the last three years no medical practice and no blogging for two years and the Coronavirus incarceration has made me to blog again.
I am currently trying (Kampuchia tea excluded) to identify 20 odd medicinal plants of use in day to day life.
Ginger, vinegar and lime are the fist three followed by Aralu, Bulu and Nelli  (Weniwel Gata excluded due good vaccination program including BCG).
So I have to formalize only 14 indredients (Gypsum, Sahinda Lunu and Pulmanikkam excluded with common salt).

Mind you salt and water is the best antiseptic (absolutely without sugar) to wash ones hands.
Sugar and salt are the basic ingredient of saprophytic life forms (they assemble the rest including amino acids from these two ingredients, just as by the fungus and bacteria in Kampuchia Colony).

I will stop blogging moment the curfew is listed.

Kombucha Tea

Reproduction

Kombucha Tea

Kombucha (also tea mushroom, tea fungus, or Manchurian mushroom when referring to the culture; botanical name Medusomyces gisevii is a fermented, slightly alcoholic, lightly effervescent, sweetened black or green tea drink commonly consumed for its supposed health benefits. Sometimes the beverage is called kombucha tea to distinguish it from the culture of bacteria and yeast. Juice, spices, fruit or other flavorings are often added to enhance the taste of the beverage.
Kombucha is thought to have originated in Manchuria, China where the drink is traditionally consumed, or in Russia and Eastern Europe.
Kombucha is now homebrewed globally, and also bottled and sold commercially by various companies.
Kombucha is produced by fermenting sugared tea using a symbiotic culture of bacteria and yeast (SCOBY) commonly called a "mother" or "mushroom". The microbial populations in a SCOBY vary; the yeast component generally includes Saccharomyces cerevisiae, along with other species; the bacterial component almost always includes Gluconacetobacter xylinus to oxidize yeast-produced alcohols to acetic acid (and other acids).
Although the SCOBY is commonly called "tea fungus" or "mushroom", it is actually "a symbiotic growth of acetic acid bacteria and osmophilic yeast species in a zoogleal mat [biofilm]".
The living bacteria are said to be probiotic, one of the reasons for the popularity of the drink.
Numerous implausible health benefits have been attributed to drinking kombucha.
These include claims for treating AIDS, aging, anorexia, arthritis, atherosclerosis, cancer, constipation, and diabetes, but there is no evidence to support any of these claims.
Moreover, the beverage has caused rare cases of serious adverse effects, including fatalities, possibly arising from contamination during home preparation.
Therefore, the potential harms from drinking kombucha may outweigh the benefits, so it is not recommended for therapeutic purposes.