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.

Common Sense and Common Law

Common Sense and Common Law

We as a nation (including tress passing on pedestrian crossings and Ambulance Drivers and Government Drivers taking politicians -and some killing the pedestrians-over speeding) DO NOT follow basic rules.

What we lack is common sense and common law, that include U.N.O, W.H.O. and emerging economic Kill Country, the mainland China (aborted abruptly and TIMELY by a small or tiny RNA polymerase virus).

1. Number one is eating all animals like civet bat and snakes.

That is violation of ALL Animal Rights to live in harmony with animal predators (not for human needs) to control the population balance.

Human can survive well on a vegetarian diet!

2. Then not stealing something that belongs to a second or third party.

The king of this is killing, the 10% dealer who supervises the distribution and divert the limited resources to the “Pathala Party” or SLPP goons.

3. Then the same Pathala Kings who rape underage Girls and Boys including some saffron clothed guys.

4. Then spreading false information (that include all religions) that one of the Chiefs trying to absolve god of all responsibilities and blaming only humans.

He forgets that there still a few guys / girls who better versed and kinder than several gods (of all religions) put together!

5. Then of course the “Majja Pama Dattana Veramani” or “Tikak Gathanam Hary” or Small Tot is OK mentality.

Fortunately this is the common denominator of Ceylonese including Chief Priests (“Dasa Mula Aristata” more powerful than Vodka) and the worlds highest per capita alcohol production (both legal and illegal) and consumption country overtaking America and Russia by many a mile.

If you look at the above it is the Pan Sil or Five Precepts' Violation, Right Left and Center.

Mind you some of my friends ask me “how to make alcohol at home” and I refer them to read Louis Pasteur and his monumental experiments on yeast, rabies and small pox.

I know a very simple method (mind you one cannot make “King Coconut Wine” in Kandy due to global warming) but won’t tell you, since I have stopped making them.

There is a substitute called “Mongolian Tea” which has three ingredients.

1.Tea

2.Sugar

3. And Mongolian Fungal Flora.

Now I do not drink tea that is 90% adulterated in Ceylon.

Sugar is expensive but I love chocolates not sugar.

The fungus flora I stop cultivating many moons ago since, if it is not kept under 100% darkness in between cultures, it results in contamination of germs of all kinds including amoebae.

 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.
 

Wash Your Hands—A Lot

Wash Your Hands—A Lot

We all know that washing our hands keeps germs at bay—but make sure to rinse with regular soap and water, 

Lipman says. The recent popularity of antibacterial soap has created harsher products loaded with toxins that can actually increase the risk of creating resistant bacteria. These soaps also tend to over dry and crack the skin, making the transmission of viruses that much easier. So stock up on nondrying soaps and keep them on hand throughout the season.
 My Addition
 These toxic chemicals percolate into water and kill fish (gills are affected) and also friendly microorganisms.
End result is an increase of mosquitoes and dengue and other mosquito born diseaes.
Any over-kill method has tremendous turn around effects on flora and fauna including our birds and their breeding patterns.

Snake Age of India at Buddha’s time

Snake Age of India at Buddha’s time

Told to me by a very knowledgeable guy.

It was called “Ahi Yuga” in a particular state, in Buddha’s time.

The snake charmers are called "Ahi Kuntakas".

They used to consume snakes as a delicacy.

A virus transmitted by these snakes killed almost all in every household and those affected were kept isolated in closed doors to die in agony.

Then Buddha had asked his followers to stop eating flesh of following ten animals (I am not sure of the original 10).

1. Snakes

2. Monkeys

3. Pigs

4. Dogs

5. Domestic cats

6. Tigers

9. Lions

10. Elephant meat

?

11. Bats

12. Toads

13. Turtles

14. Tortoises

(Mind the list would have been longer and fish was not included).

Now I can see why Chinese, Koreans and most of the Chinese stock deliberately stopped Buddhism spreading in their territories.

Now the WHO is ably helping China to come out clean on “Wild Animal Trade” globally.

WHO and CHINA'S Failure

Reproduction

WHO and CHINA'S Failure

The WHO has not pushed China on early missteps.
When cases of a mysterious viral pneumonia first appeared in Wuhan in December, Chinese health officials silenced whistleblowers and repeatedly played down the severity of the outbreak.
Even as late as mid-January, as the virus spread beyond China’s borders, Chinese officials described it as “preventable and controllable” and said there was no evidence it could be transmitted between humans on a broad scale.
The WHO endorsed the government’s claims, saying in mid-January, for example, that human-to-human transmission had not been proved.
Critics say the organization’s repeated deference to Beijing exacerbated the spread of the disease. A group of international experts was not allowed to visit Wuhan until mid-February.
“They could have been more forceful, especially in the initial stages in the crisis when there was a cover-up and there was inaction,” said Yanzhong Huang, a global health expert specializing in China at Seton Hall University.
Huang noted that during the SARS epidemic in 2002 and 2003, which killed more than 700 people worldwide, the WHO pushed the Chinese government to be more transparent by publicly criticizing it for trying to conceal the outbreak.
At one point during the SARS epidemic, officials at hospitals in Beijing forced SARS patients into ambulances and drove them around to avoid their being seen by a visiting delegation of WHO experts, according to reports at the time.
WHO officials were slow to declare a public health emergency, critics say.
Even as the virus spread to more than half a dozen countries and forced China to place parts of Hubei province under lockdown in late January, the WHO was reluctant to declare it a global health emergency.
WHO officials said at the time that a committee that discussed the epidemic was divided on the question of whether to call it an emergency but concluded that it was too early. One official added that they weighed the impact such a declaration might have on the people of China.
After the United States announced a ban on most foreign citizens who had recently visited China, the WHO again seemed to show deference to Chinese officials, saying that travel restrictions were unnecessary. The group officially called the spread of the coronavirus a pandemic March 11.
Some experts argue that the institution’s delay in making such declarations deprived other countries of valuable time to prepare hospitals for an influx of patients.
“It reinforced the reluctance to take early strong measures before the catastrophe had actually landed on other shores,” said François Godement, senior adviser for Asia at Institut Montaigne, a nonprofit group in Paris. “The WHO’s tardiness or reluctance to call out the problem in full helped those who wanted to delay difficult decisions."
The WHO defended its actions, saying Wednesday that it had “alerted member states to the significant risks and consequences of COVID-19 and provided them with a continuous flow of information” ever since Chinese officials first reported the outbreak Dec. 31.
Guterres of the United Nations said, “It is possible that the same facts have had different readings by different entities.” He added in his statement: “Once we have finally turned the page on this epidemic, there must be a time to look back fully to understand how such a disease emerged and spread its devastation so quickly across the globe and how all those involved reacted to the crisis.”
China’s influence at the WHO is growing.
China’s leader, Xi Jinping, has made it a priority to strengthen Beijing’s clout at international institutions, including the WHO, seeing the U.S.-dominated global order as an impediment to his country’s rise as a superpower.
China contributes only a small fraction of the WHO’s $6 billion budget, while the United States is one of its main benefactors. But in recent years, Beijing has worked in other ways to expand its influence at the organization.
The government has lobbied the WHO to promote traditional Chinese medicine, which Xi has worked to harness as a source of national pride and deployed as a soft-power tool in developing countries, despite skepticism from some scientists about its effectiveness.
Last year, the WHO offered an endorsement of traditional Chinese medicine, including it in its influential medical compendium. The move was roundly criticized by animal welfare activists, who argued that it could contribute to a surge in illegal trafficking of wildlife whose parts are used in Chinese remedies.
China has sought to promote traditional Chinese medicine in the treatment of symptoms of the coronavirus both at home and abroad. Last month, the WHO was criticized after it removed a warning against taking traditional herbal remedies to treat the coronavirus from its websites in mainland China.
China’s role at the WHO will probably continue to grow in the coming years, especially if Western governments retreat from the organization, as Trump has threatened.
“This is part of China’s efforts to more actively engage in international institutions,” said Huang, the global health expert. “It will not please every country or every actor, but it’s going to affect the agenda of the WHO.”
This article originally appeared in The New York Times.

Tuberculosis and BCG vaccination.

Tuberculosis and BCG vaccination

My advice as a pathologist is that the TB vaccination (BCG) should be given at birth.

Furthermore, Mantoux test should be done before adolescent are vaccinated.

There were only two in our class (I was one and the other was Donald, Jaffna Tamil, my best friend) who were Mantoux negative out of over 50).

Only two of us got the BCG vaccination.

In other word 95% were exposed to TB as a Child (they should not be vaccinated to avoid reactivation of OLD TB).

This is true in India and Africa.

Then there is also Atypical or Anonymous Tuberculosis (PHD thesis of one of my teachers was not validated by the crooked supervising committee.in Peradeniya, fearing one may not get a chance to go abroad for higher studies).

Local degrees were considered inferior.

 

So annoyed my teacher gave up local research and ended up in Australia as a GP.

He had five children and all of them are doing well in many fields abroad.

So I decided to do my research in this country well past 50 yeas (my thesis) and part of the good quality data, I never gave to the University but used as my base for three books published at Amazon.)

By the way, I used five times the university contribution from my own pocket.

The money allocated was meager.

Coming to TB vaccination (polybacterial and polyvalent) as a whole there are lot of antigenic particles that activate lymphocytes and later taken up by the macrophages for intracellular digestion.

What it signals is that the macrophage has a non spcific receptor on its surface to bind coated Coronavirus (not RNA particles).

One should identify this receptor in any new protocol.

Good, Bad and The Ugly

Good, Bad and The Ugly

The Coronavirus has good and the bad of us in one go.

Good think about it is, that we eat what we have not what we wished to have eaten.

For me all the collections of chocolates are over.

The Fruit and Nut ice cream I finished a month earlier.

Stopped alcohol totally due to the Tax Imposition by previous government.

Previous government lost due to this single tragedy.

This government will lose due to banning foreign alcohol and increase in illegal alcohol production and price.

Also they did not lower the price of alcohol and the price of Petrol and Diesel that plummeted due to Saudi action on Russians was a non event for us.

That low price is completely put under the carpet for now.

I have few friends who will definitely vote against who love alcohol as a way of life.

My advice for them to drink “Dasa-Mula-Aristaya” our high priests consume before a sermon and its alcohol content is over Vodka by many a mile.

I am currently preparing a list of 10 locally available (some may have to be imported like “Weniwel”) medicinal plants to be added to “Dasa-Mula-Aristaya” as our export quality local production with the help of “Siddha Lepa Veda Mahattaya” of old.

Bad things are the local “Paraya” dogs are hovering all over looking for food in desperation.

We do not have any food left to feed them like sprats and dry fish!

It was not my gut feeling, not to have another dog after our loving one's demise.

But I continued to feed the “Paraya Dogs” in plenty but never allowed them to follow me to home.

If I did NOW is the time for me to have a heart attack.

Now they call the “Politicians Paraya” after not having got a payment or have to pay the “Give Away Money” in installments over two years with six months grace period.

As for the birds including lovely parrots and Ceylon Oriole come daily to feed on mulberry (Ambul Ambili- found the Sinhala name while searching for medicinal plants) fruits and the “Honey Birds” feed on the three flowering plants.

Magpie and Bullbul started devouring and gorging on the guppy fish in style, I moved them to the big fish tank in panic state.

Now all the water lilies have large leaves giving them cover from the predators.

A Bullbul pair made a nest over the pond and I made it sure I spray enough water over them while watering the tall bamboo trees covering the edge.

They decided not to lay eggs.

As for the rooftop garden there are no restrictions and they can feed and drink and make even nests, if they so desire.

The black bees have a colony and they feed on the lily flower pollen.

It takes solid three hours for me to water the plants and fill the containers (drying up in hot sun).

On an economy note, I decided to feed the fish only twice a week since my last packet of fish food is going down fast.

They have to survive on diatoms and algae and the population control is on the card and birds doing it in style.

The bat who decided to make a home did not find a partner and never came back with Coronavirus as a treat for the New Year.