REGULAR INTAKE OF MEDICINE "ADHERANCE" IMPROVED HIV PATIENTS-THE LANCET STUDY


PROF .DRRAM,HIV /AIDS,HEPATITIS ,SEX DISEASES & WEAKNESS expert,New Delhi,India, profdrram@gmail.com,+917838059592,+919832025033,ON WHATSAPP

A new dtudy has been published in The Lancet - Infectious Diseases, the breakthrough deals with how patients take their medication and adhere to regimes, as too many face irregular regimes or discontinue medication.A new program or better patient assistance was designed by University of Aberdeen and Academic Medical Centre (Amsterdam) teams. University of Aberdeen Professor, Marjin de Bruin, stated ‘this is the first adherence intervention in HIV care that demonstrates clinical and cost effectiveness. The intervention can be applied in routine clinical care, and the effects have been reproduced in consecutive trials. Although HIV medications are very effective, they can have quite a few side effects and people with HIV don’t usually experience any symptoms of the disease, so for these and other reasons it is unsurprising that adherence among some patients is suboptimal. We designed a programme in such a way that it would fit in with routine care and only adds about 10 minutes to the consultation. Our intervention has proved to be very successful at improving drug-adherence and in turn reducing treatment failure. Importantly, these effects were most profound amongst patient groups from which we know struggle most with this treatment. As well as important for patients’ own health, having a very low viral load means that people are extremely unlikely to transmit the virus to other people. So not only is this a significant improvement to individual patients’ health, it is also important for public health because it may help to curb the pandemic by interrupting the transmission of the virus. That the intervention also saved money rather than required extra resources was unexpected, and strongly suggested that introducing this programme in routine HIV care is beneficial for patients and safety. It is very important to note that the medication non-adherence is very common with long and short-term treatments for many conditions, often contributing to poor patient outcomes and increased health care expenditure. We will therefore seek to adapt and test the benefits of this intervention in a range of other chronic condition.’

A battle is being fault every second day as AYUSH OR AYURVEDA/HOMEOPATHIC/UNANI SIDDA/ ACUPUNCTURIST/ ACCUPRESSOR/REKI /RMP /COMMUNITY PRACTITIONERS/ALTERNATIVE MEDICINES HEALERS can be treated as ALLOPATHIC DOCTORS OR MODERN MEDICINE DOCTORS and inspite of being training only in their systmem OF THERAPY ,CAN THEY USE MODERN MEDICINES /DRUGS TO CURE DISEASES in Practice ?Can be appointed at same level in Govt.Hospitals by Government /Pvt Hospitals & Nursing homes using modern surgical procedures or medicines for treatment or Can be converted in to Modern Medicines Doctors? Regarding this SUPREME COURT UNDERLINES THAT NO ALLOPATHIC DOCTOR CAN WRITE AYUSH MEDICINES SAME WAY NO AYUSH DOCTORS CAN WRITE MODERN MEDICINES AND CAN NOT PRACTICE AS MODERN MEDICINES DOCTORS as Modern medicine is very Life saving but fatal too as any mistake can cause serious damage or kill the patient so cant be practised by simple knowing few pharma medicines and as its study is difficult and need a course of six years for undergraduate, 10 yrs for PG and 12-15 yrs for being superspecialist with hard to crack entrance examinations at every label sothat DOCTORS PRODUCED HAVE GOOD KNOWLEDGE TO BE RECOGNISED NATIONALLY AND INTERNATIONALLY.HENCE A STRICT MCI MADE TO LOOK AFTER ITS ETHICS,CURICULLUM AND TRAINING BUT AS MBBS DOCTORS HAVE NAME AND FAME WITH MONEY SO MANY PVT MEDICAL COLLEGES CAME AND UNDER TAINTED MCI WITH DR KETAN DESAI OR FOLLOWERS AS GOVERNORS SOLD EVERY ETHICS RECOGNISED MANY PVT MEDICAL COLLEGES WITH FAKE PATIENTS,GHOST FACULTY TEACHERS AND POOR LABS/OTS AND EQUIPMENTS TAKING CRORES AS BRIBE AND A MARKET OF BLACK MONEY OF THOUSAND CRORES IS EXISTING SO THERE IS SHORTAGE OF DOCTORS MORE FOR SPECIALIST AND SUPERSPECIALISTS. To counter this SHORTAGE ,our policiticians have recommended that ALL AYUSH DOCTORS SHOULD BE TRAINED A LITTLE AND CONVERT THEM TO MODERN MEDICINES DOCTORS AS THERE IS CORRUPTION AND KICKBACKS IN OUR POLITICS SAME WAY THEY THINK DOCTORS CAN BE MADE but who will get treated by these no educated QUACKS as Politicians and rich affordable always move to specialists and super specailist for their problems only poor and backward will be allowed to die in their hand ,secondly no country in world will recognise them,no one from foreign country will come to India for treatment whose modern medicines,at present time,is at par or excellant than UK/USA/Germany/France /Australia's Treatment Modalities. But our politicians for winning votes want otherwise,they have posted Ayush doctors with same payment scale in all government hospitals ,started a new ministry disregarding the fact that MOST OF THEM TREAT PATIENTS IN THEIR CHAMBERS IN CITY/TOWN/ MOHALLAS/ VILLAGES AND EVEN IN METROS BY MODERN MEDICINES ONLY PUTTING TOUGH COMPETITIONS TO TRAINED MODERN MEDICINES DOCTORS.GOVERNMENT NEVER TAKES ACTION AGAINST SUCH "QUACKS" AS STATED BY SUPREME COURT. IT IS CLEAR THAT TO BE MODERN DOCTORS MANY USE EASY AYURVEDA / HOMEOPATHIC / UNANI SYSTEM TO BE A DOCTOR WHERE FEES ARE CHARGED ONLY AND MANY STUDENTS ARE PASSED WITHOUT PROPER TRAINING BY PAYING BRIBES TO THESE AYUSH COLLEGES AND AFTER PASSING THEY ONLY USE MODERN MEDICINES AND WORK AS JUNIOR DOCTORS IN MANY SMALL AND BIG HOSPITALS/ NURSING HOMES OF MANY CITIES/TOWN ALMOST ALL OVER INDIA WHICH HAS BEEN TERMED ILLEGAL BY SUPREME COURT.IN INDIA ANY BODY CAN PRESCRIBE MEDICINES,WITHOUT TRAINING MANY "BABAS"/SADHU PRACTICE MEDICINES AND ARE HIGHLY RECOGNISED IN THE SOCIETY AND OUR LAW ENFORCEMENT AGENCY NEVER TAKES ANY ACTION,IN COURT JUSTICE IS SO MUCH DELAYED THAT NO ACTION HAPPENS IN 10-20 YRS SO TO BE A DOCTOR IS A FASHION IN INDIA IF ONE CAN'T READ MEDICINES THEN TAKE A TRAINING IN REKI, SABLOK, ACCUPUNCTURE,MAGNET THERAPY,ACCUPRESSURE, PHYSIOTHERAPY, OPTOMETRY,LAB ASSISTANT OR AS RMP NURSE AND PUT "DOCTOR "INITIAL BEFORE NAME AND "DOCTOR SIGN" ON YOUR CHAMBER/HOUSE/ MARKET/VEHICLE AND PRACTICE ,NO BODY WILL CHECK YOU AND IF CAUGHT, PAY MONEY TO HEALTH OFFICIALS/ POLICE/POLITICIANS OR COURT AND GET FREE SO TO PRACTICE MEDICINE IN INDIA IS VERY EASY AND IS A GOOD PROFESSION TO EARN .EVEN SENIOR DOCTORS WHO GET REFERRAL FROM SUCH "QUACK" DOCTORS,TRY TO PROTECT THEM FROM INSIDE BUT OUTSIDE THEY ARE AGAINST THEM IN THEIR ASSOCIATIONS LIKE "IMA". A NEW BATTLE FOUGHT IN KERALA HIGH COURT WHERE SURGERY AND OTHER PROCEDURES AS DELIVERY OF CHILD BY USING MODERN MEDICINES CAN BE TAUGHT TO THEM OR NOT AND LATER CAN THEY PRACTICE IT USING MODERN MEDICINES.During the hearing, allopathic practitioners argued, that such training and observations hardly benefitted people while being in clear violation of the spirit of the MCI Guidelines. Ayurvedic practitioners on the other hand argued such training and observations were a part of their curriculum and was being imparted to students for the last 20 years.Dr Rejith Anand, general secretary of Ayurveda Medical Association of India said that knowledge could not be monopolised by anyone, which emphasised the right of Ayurveda students to train in modern medicine and the future of Ayurveda students and even existence of Ayurveda colleges hangs in balance, unless the government takes a concrete decision.If the training is not imparted as per syllabus, the Central Council of Indigenous Medicine (CCIM) and even the state council is unlikely to give registration to students and affiliation to colleges.” The argument was met with a strong rebuttal from the allopathy doctors, who stated that no ‘observership’ of any kind could be allowed in modern medicine hospitals, and if such a thing happens, allopathic practitioners would oppose it. Dr A V Jayakrishnan, IMA State president highlighted that this went clearly against MCI guidelines which state that modern medicine students can only be trained in modern medicine institutions. Speaking to IE, he also questioned Ayurveda doctors’ claim of observing the procedure for an exposure in basic aspects of modern medicine, saying,‘’Our system is different from theirs. Then what is it they want to observe? Surgery, labour and autopsy are not exhibitions. Moreover, what use it will be for an Ayurveda doctor who does not practise modern medicine?’’ PLEASE WRITE YOUR VIEWS WHETHER MODERN MEDICINES DOCTORS SHOULD ALLOW THIS"QUACKERY" ? THE PRESENT TOUGH COMPETITIONS OF MODERN MEDICINES DOCTORS IN PRACTICE TO FACE SO CALLED "QUACKS / OR OTHER PATHY DOCTORS USING MODERN MEDICINES FOR TREATMENT" BE ALLOWED BY OUR POLITICIANS LAW ENFORCEMENT AND DELIVERING SYSTEM? OR CHANGING THEM LEGALLY INTO MODERN MEDICINES DOCTORS BRINGING NEW LAW IS JUSTIFIED OR NOT?

WHY ART CALLED HAART WHAT IS COUNITY VIRAL LOAD
PROF.DRRAM ,HIV/AIDS,SEX Diseases, Hepatitis .& Deaddiction
profdrram@gmail.com,+917838059592,+919832025033,,INDIA
HIV/ AIDS,HEPATITIS,MODERN MEDICINES AT CHEAP RATE.
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ART is the acronym commonly used today to describe HIV antiretroviral therapy. Previous to this, clinicians and scientist would use the term cART (combination antiretroviral therapy), and previous to that the popular term HAART was used to describe "highly active antiretroviral therapy."
Whatever the acronym used, the term implies the use of three or more antiretroviral drugs, either taken individually or in fixed dose combinations. The aim of therapy is to ensure the suppression of HIV to so-called "undetectable" levels—meaning that the virus is not fully eradicated, but is simply beneath detection levels of current testing assays.
As opposed to single-drug or dual-drug therapy, the combination of three or more active drugs is known to effectively suppress the variety of resistant HIV that can exist within a viral population. Essentially, if one drug is unable to suppress a certain viral mutation, the others will likely be able to do so.
High levels of adherence are needed in order to maintain therapeutic drug levels in the blood. If these levels fall beneath the therapeutic threshold, resistant strains are provided an opportunity to thrive. The larger these resistant populations, the less effective the drugs will be in suppressing HIV replication—eventually leading to viral rebound and treatment failure.
Classes of ART
There are currently five classes of antiretroviral drug, each of which inhibit a specific stage in the HIV life cycle:
Entry or Fusion inhibitors (which include CCR5 receptor antagonists)
Nucleoside and nucleotide reverse transcriptase inhibitors (NRTI/NtRTI)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Integrase inhibitors
Protease inhibitors
Other classes of antiretrovirals are being investigated, while newer-generation drugs aim to improve tolerability, reduce adverse effects and simplify dosing for those on therapy.
To this end, an increasing number of fixed dose combination (FDC) drugs are now available, combining two or more drug into a single pill or tablet. Some, including Atripla ((tenofovir + emtricitabine + efavirenz), Triumeq (abacavir + lamivudine + dolutegravir) and Stribild (tenofovir + emtricitabine + elvitegravir + cobicistat) offer all-on-one formulations for simplified, daily dosing.
Future of ART
With advances in HIV drug developments, ART is now being employed as a means to reverse infection rates in high prevalence HIV populations.The strategy, known as Treatment as Prevention (TasP), has been shown to reduce the risk of transmitting HIV by suppressing viral activity to undetectable levels. In doing so, the risk of transmission is reduced by as much as 96%.By ensuring widespread drug distribution, ART can lower the so-called "community viral load" (the median viral load within a community) to levels where the likelihood of transmission is significantly, even profoundly, reduced

INDIAN MOS HEALTH ANUPRIYA PATEL SAYS "ILLEGAL SURROGACY IS A 2 BILLION DOLLAR INDUSTRY "



The government said commercial surrogacy has become a USD 2 billion illegal industry and a means to exploit vulnerable women even as it vowed not to let women in India become “baby factories”.

Minister of State for Health Anupriya Patel said commercial surrogacy has also become a means of exploiting children also, when they get abandoned. “We want to communicate that surrogacy should be the last option and we in no way are going to promote the idea of commercial surrogacy,” Patel told NDTV.


The minister also spoke on Surrogacy (Regulation) Bill 2016, which was recently approved by the Union Cabinet, and has drawn criticism from several quarters. She said the government is “conscious and sensitive” and various issues which has not been touched so far may be addressed in the course of discussions in the parliament. The bill is yet to be tabled in Parliament and there will be many more rounds of deliberation, Patel said.

“It’s a long process. I believe that the outcomes are going to be in the larger interest of the nation,” she said. She said 80 per cent of the total child births taking place through surrogacy in India are for foreign nationals. “Women in India are not baby factories. If you consider the total number of births of children which are taking place through surrogate mothers, 80 per cent of such births have been for foreign nationals. “Why are they doing this? Are Indian women only made for this purpose? They are trying to escape the tough laws of surrogacy in their own homeland and therefore they are coming to India because poor, vulnerable tribal women are easily available. They give them petty money,” she said. The bill proposes a complete ban on commercial surrogacy and allows only legally-wedded Indian couples to opt for it. It also seeks to bar unmarried couples, single parents, live-in partners and homosexuals from opting for surrogacy.

I THINK WHAT SHE SAYS IS ALMOST CORRECT ILLEGAL SURROGACY TREAT OUR POOR MOTHERS BADLY AND ONLY AS COMMIDITY TO BE PURCHASED BY MONEY

APPROACH TO ANAEMIA IN GENERAL PRACTICE
DR.S.ABBAS ALI
MD DNB MNAMS
Fellowship in cardiology
PGDCC (ultrasonography)
PGDCC(Echocardiogram)
FCGP,MCCP (Cardiology)
Lecturer, department of medicine
KD MEDICAL COLLEGE, MATHURA

Anaemia is usually defined clinically as a reduction of the haemoglobin concentration to less than 13g/dl (males) or less than 12g/dl (females). Haemoglobin constitutes about 1% of total body weight. It is a common problem in general practice.
Degree of Anaemia: Anaemia is often classified as mild degree (9-11 gm %), moderate
(7-9 gms %), severe (4-7 gm %) and very severe (<4gm %). It is also classified according to Haematocrit (PCV) %.
While evaluating of the patient with anemia and making of specific diagnosis requires a clinical assessment and laboratory investigations. The two must be put together for a comprehensive diagnosis.
Clinical assessment requires careful history and physical examination.
A careful evaluation of medical history often gives vital clues to the cause of anemia. The acuity of anemia, association with other symptoms & history of any chronic illness are important. Some important points
History Comments
Age Iron def. rare before 6 months
Neonatal anemia with reticulocytosis suggests blood loss or Hemolysis.
B-thal. sickle cell anemia appear by 4-8 mths. of age

Genetic & family history X-linked: G-6-PD def
Autosomal dominant: Spherocytosis
Autosomal recessive: Sickle cell anemia, Fanconi
Family member with h/o early cholecystectomy/ biliary calculus
Race & Ethnicity

Nutrition Cows milk & iron deficiency
Strict vegetarian: B12 deficiency
Goat’s milk: Folate def.
Pica, Plumbism & iron def.

Drugs G-6-PD def
Immune mediated hemolysis (Penicillin)
Bone marrow suppression
Phenytoin & folate def.

Diarrhea Malabsorption of iron, B12 &E
Inflammatory bowel disease
Milk protein allergy- chronic blood loss
Intestinal resection & B12 def

Infection Giardia- iron def
Intestinal bacterialovergrowth- blind loop & B12
Epstein barr, CMV & Parvo virus- Bone marrow suppression
Malaria, Kalazar, Chronic infection


Nutritional history related to drugs or alcohol intake and family history of anemia should always be assessed. Certain geographic backgrounds and ethnic origins are associated with an increased likelihood of an inherited disorder of the hemoglobin molecule or intermediary metabolism. Glucose-6-phosphate dehydrogenase (G6PD) deficiency and certain hemoglobinopathies are seen more commonly in those of Middle Eastern or African origin, including African Americans who have a high frequency of G6PD deficiency. Other information that may be useful includes exposure to certain toxic agents or drugs and symptoms related to other disorders commonly associated with anemia.
Physical Examination
 General appearance of child & assessment of growth parameters helps decide the acuity or chronicity of anemia & other associated illnesses.
 Look for signs of trauma
 Presence of petecie, bruising & ecchymosis
 Lymphadenopathy, Hepato-spleenomegaly & abdominal mass. Splenomegaly and lymphadenopathy suggest an underlying lymphoproliferative disease,
 Prominent cheek bones, frontal bossing indicates hemolytic anemia
 Associated congenital malformations- Fanconi anemia.
 Tell tale signs of any chronic illness e.g. hypertension, short stature, arthritis, cluubing, cyanosis etc.
 petechiae suggest platelet dysfunction
 blood in the stool
 In the anemic patient, physical examination may demonstrate a forceful heartbeat, strong peripheral pulses, and a systolic "flow" murmur. The skin and mucous membranes may be pale if the hemoglobin is <80–100 g/L (8–10 g/dL). This part of the physical examination should focus on areas where vessels are close to the surface such as the mucous membranes, nail beds, and palmar creases. If the palmar creases are lighter in color than the surrounding skin when the hand is hyperextended, the hemoglobin level is usually <80 g/L
Laboratory Evaluation: Initial Laboratoryy workup of anemia requires

1. Complete blood count (CBC) and it is the single most important investigation in anaemia. It
should include Hb, Hct, WBC, platelet count and RBC indices viz. RBC count, MCV, MCH, and RDW. The components of the CBC also help in the classification of anemia. Microcytosis is reflected by a lower than normal MCV (<80), whereas high values (>100) reflect macrocytosis. The MCH and MCHC reflect defects in hemoglobin synthesis (hypochromia). Automated cell counters describe the red cell volume distribution width (RDW).
2. Peripheral blood smear examination: A careful evaluation of the peripheral blood smear is important, and clinical laboratories often provide a description of both the red and white cells, a white cell differential count, and the platelet count. In patients with severe anemia and abnormalities in red blood cell morphology and/or low reticulocyte counts, a bone marrow aspirate or biopsy can assist in the diagnosis. The peripheral blood smear also provides important information about defects in red cell production. As a complement to the red cell indices, the blood smear also reveals variations in cell size (anisocytosis) and shape (poikilocytosis).
3. Reticulocyte count: An accurate reticulocyte count is key to the initial classification of anemia. Normally, reticulocytes are red cells that have been recently released from the bone marrow. Normally, the reticulocyte count ranges from 1 to 2% and reflects the daily replacement of 0.8–1.0% of the circulating red cell population.

The above triad comprises the primary investigations in anaemia and can be performed
on a single EDTA blood sample.
Secondary investigations are guided by the results of the above tests in a given clinical context, and may include
1. Tests of Iron Supply and Storage: they include serum ferritin, total iron binding capacity, serum iron, serum transferring percentage. This tests reflect the availability of iron for hemoglobin synthesis. The percent transferrin saturation is derived by dividing the serum iron level (x 100) by the TIBC. The normal serum iron ranges from 9 to 27 mol/L (50–150 g/dL), while the normal TIBC is 54–64 mol/L (300–360 g/dL); the normal transferrin saturation ranges from 25 to 50%. A diurnal variation in the serum iron leads to a variation in the percent transferrin saturation. The serum ferritin is used to evaluate total body iron stores. Adult males have serum ferritin levels that average ~100 g/L, corresponding to iron stores of ~1 g. Adult females have lower serum ferritin levels averaging 30 g/L, reflecting lower iron stores (~300 mg). A serum ferritin level of 10–15 g/L represents depletion of body iron stores. However, ferritin is also an acute-phase reactant and, in the presence of acute or chronic inflammation, may rise several-fold above baseline levels. As a rule, a serum ferritin more than 200 g/L means there is at least some iron in tissue stores.
2. vitamin B12, and RBC folate levels
3. Hb electrophoresis and quantitation (Hb A2, Hb F etc)
4. Blood biochemistry for hepatic and renal functions
5. Bone-marrow aspiration
6. Trephine biopsy from bone marrow
7. Imaging studies may include X-ray chest/ skull/ other bones as warranted, ultrasound abdomen, radio-isotope studies
8. Other specialized tests include Coombs test, osmotic fragility, Ham s test, erythropoietin level, immunocytochemistry, cytogenetics etc
CLINICAL APPROACH TO A PATIENT WITH ANAEMIA
Anaemia is not a disease by itself but only a manifestation of disease. Hence, it is imperative to look for the underlying disease responsible for anaemia.
KEY ISSUES to decide in a patient with anaemia are:
1. Is it a TRUE anaemia?
2. Is the anaemia HEREDIATARY or ACQUIRED?
3. Is there any ABNORMAL BLEEDING?
4. Is there exposure to DRUGS, CHEMICALS, or TOXINS?
5. Is there a co-existing SYSTEMIC DISEASE
6. What is the nature of DIET and ETHNICITY.
CLASSIFICATION OF ANAEMIA broadly anaemia is classified in to
Hereditary : the defect often lies within the RBC. It means its Hb or- its enzyme or- its membrane. Reticulocyte count is high in hereditary anemias.
Acquired: here The defect is often extra-corpuscular
Classification Based on RETICULOCYTE INDEX Normal 0.2 – 2.0%
Reticulocyte count Very Low indicates a decreased RBC production in bone-marrow.
RETICULOCYTE COUNT Very High indicates an excessiveproduction of RBCs in bone-marrow anaemia results from either excessive destruction or excessiveloss of RBCs
RETICULOCYTE Normal (0.2- 2.0%) indicates no positive diagnostic
Classification of anaemia based on MCV (RBC Size) : MCV or mean corpuscular volume is an important parameter to classify anemia.
Microcytic (MCV <80 fl or femtolitres): it is due to inadequate Hb synthesis
Causes
1. Iron deficiency anaemia – commonest
2. Thalasmia
3. Lead toxicity
4. Anaemia of chronic disease
5. Sideroblastic anaemia
Macrocytic (MCV >100 fl)
Causes
MEGALOBLASTIC: Altered DNA synthesisleading to large & fluffy nucleus in the early RBCs
1. Usually from vitamin B12, folate deficiency, or some enzymatic involvement. Segmented nutrophils commonly associated with B12 or folate deficiency anaemia
2. Diet and drugs are the commonest culprit.
3. Increased demand may occur in haemolysis and during pregnancy & lactation
NON-MEGALOBLASTIC: DNA in red cells is normal or OK.
Causes:
1. Liver diseases
2. Alcoholism
3. Aplastic anemia
4. Hypothyroidism
Normocytic (MCV 80-100 fl) Most anaemias start as normocytic. In most diseases, it remains normocytic only
Causes
1. Anaemia of blood loss
2. Anaemia of chronic disease ( sometimes low MCV)
3. Bone marrow failure
4. Renal failure
Differential diagnosis of microcytic anaemia
IRON DIFICIENCY ANAEMIA – DIAGN0SIS THROUGH LAB INVESTIGATIONS
Hb% -- ---low
Serum ferritin ------ low
Total iron binding capacity -----very high
Serum iron ------low
MCV -----low
THALASMIA: It is due to defect in globin chain.
Hb%------normal
Serum ferritin ------normal
Total iron binding capacity------- normal
Serum iron --------normal
MCV ------low
Sideroblastic anaemia
Serum iron : increased
Serum ferritin: increased
Total iron binding capacity: normal
MCV----low
Anaemia of chronic disease:
Serum iron : low
Serum ferritin : increased
Total iron binding capacity : decreased
MCV-----low

Management
The treatment of anemia depends on the cause. Deficiency anemia can be effectively treated by therapeutic doses of the deficient mineral or vitamins. In anaemias, a right treatment may bring patient back to life whereas an inappropriate or delayed treatment may take life away