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How to Be Safe During (and After) Emergency Room Visits

For older people, a visit to the er can lead to more health problems and additional hospitalizations.

Walking into the emergency treatment room, I noticed two things: First, there were several family members circling defensively around a small figure on the bed. And second, they looked hostile.

Then I recognized the patient, a tiny older woman I had admitted to the hospital several weeks earlier for a badly broken wrist she'd sustained after she fell on her icy porch.

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I had fondly thought of her as “Ma,” as her family referred to her. Her liveliness and her kindly manner reminded me of my own mother, who, until a fall in her 90s, had also been sharp, active and living a full and independent life in her own home.

Emergency Room Tips:

• Understand that you may have to fight to get your loved one admitted to the hospital.
• Watch for physical and emotional changes: Frailty, worsening memory, fatigue and lack of appetite are common among patients who have recently visited the ER.
• Keep pushing for more care. Schedule a follow-up visit for shortly after the patient is discharged from the ER.
• Find the right specialists. Some hospitals now offer “ acute care for elders ” units with specialists on hand.

Ma smiled, recognizing me and remembering my name. Her greeting defrosted the family a little, but their doubts about her well-being soon became obvious:

"Ma was fine before the fall and admission, and now she's back."

Unspoken, but loud and clear, was: “Did someone do something wrong?”

The wrist was healing, but her chart said “Fever, Weak,” and she looked the part. I quickly diagnosed her with a significant urinary tract infection and dehydration. She would need to be admitted to the hospital again.

And regrettably, I needed to have a serious conversation with her family about post-hospital syndrome and the genuine possibility that Ma might never be the same.

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Explaining post-hospital syndrome

After 36 years of emergency practice, this scenario had become all too familiar to me: A self-sufficient older patient visits the ER, often for a minor issue or injury. But what at first seems like a small setback begins a rapid functional decline and a loss of self-sufficiency that results in that patient returning to the hospital again and again. Often, those hospitalizations unleash a torrent of health woes that severely impact the patient's long-term well-being and that can even lead to death.

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Successful aging requires us to optimize every bodily system in order to preserve an ever-more-fragile status quo. The ability of your body to compensate for even a minor health problem often becomes more limited with age. Think of a pyramid of oranges in a supermarket: It's stable, but if you remove just one of them, the whole structure collapses. It can be like that with an older person's health as well. Something like a fall or an illness happens and, all of a sudden, a once healthy person becomes frail.

One in 5 older patients who visit the ER will be back in the hospital within 30 days.

Approximately 1 out of every 5 ER visits by people 65 and older result in readmission, even when the initial visit is for something minor, like Ma's broken wrist. One in 3 of those patients will return to the ER within 30 days; 1 in 10 will die within 90 days of their first visit. In a study, 34 percent of Medicare patients who were hospitalized experienced functional decline resulting in readmission.

This is the phenomenon known as post-hospital syndrome. Researchers attribute it to the stress of hospitalization itself rather than to the nature of the original illness or its treatment; in fact, only 17 to 30 percent of return hospital visits are for the same condition as the initial admission. Instead, patients wind up returning to the hospital for any number of reasons — from opportunistic infections and unrelated injuries to entirely unexpected diseases.

Each subsequent return to the hospital increases the likelihood of permanent functional loss and makes it more likely that the patient will need to be discharged into a long-term care facility.

Getting a handle on ER trauma

No older adult's discharge paperwork ever states the reality of “a 15 to 35 percent short-term chance of functional decline, return to the hospital, or failing to regain one's prehospitalization state.” But if you need to visit the ER, or if you need to bring a loved one, it's important to understand that even a brief hospital visit may have long-term implications. That doesn't mean “don't go to the ER.” It means to “go prepared."

1. Find the right hospital

Sometimes you don't have a choice which hospital you go to, but sometimes you do. ERs with lower return rates tend to have a greater volume of patients, assigned social workers and higher hospital-admission rates (meaning more of the people who go to the ER are admitted rather than treated and released). To find the best option, your physician should almost always be the first source of information. Doctors and their families get sick, too. Where would they go?

Multiple organizations compile statistics and create ratings on various hospital quality indicators, including:

• Medicare ( medicare.gov/hospitalcompare )
• The Joint Commission ( qualitycheck.org )
• The Leapfrog Group ( leapfroggroup.org )

2. Find specialists  who know how to treat aging patients

Many hospitals have specialized “acute care for elders” inpatient units, and there is a growing number of certified geriatric emergency departments across the country; to find one near you, visit acep.org/geda . The Institute for Healthcare Improvement recognizes 450 “age-friendly health systems” on its website.

3. Don't just think over and out

It may feel like a win if your loved one is discharged from the ER on the same day, but often it's not — especially if this is a return trip. Instead of declaring the case closed, make a follow-up doctor visit shortly after the ER episode. If things don't check out well, push hard for a hospital admission or for an aggressive, rapidly initiated outpatient care plan.

This is an important step in shielding your loved one from further complications. One study found that half of Medicare patients needing rehospitalization within 30 days had not seen a physician in the interim. But you may have to push: Medicare targets and fines hospitals for readmissions within 30 days, which means providers are often resistant to readmitting patients. Question your doctor thoroughly before letting your loved one return home.

4. Anticipate a long-term impact

Someone who fell once is likely to fall again . Aids as simple as a cane or walker, along with home-based training for balance, mobility and muscle strength, can reduce future falls and the associated decline. And the home should be assessed for hazards, from challenging stairs and slippery rugs to icy front porches.

But don't leave it at that; a watchful eye can make a big difference in detecting signs of creeping frailty. Keep an eye out for decreased mobility or an increased need for assistance with the activities of daily living: getting out of bed, using a toilet, bathing, dressing, grooming and eating. If you're not there, ask care providers or friends to keep an eye out, too. And check with insurers to see what services or gear they will cover.

5. Watch for physical and emotional changes

In addition to frailty, other findings associated with hospital returns are depression , worsening memory, fatigue, dizziness, decreased appetite, incontinence, trouble communicating or thinking, or increasing numbers of prescribed or over-the-counter medications. Any of these clues can indicate an acute, reversible illness such as pneumonia or urinary infection. Recognizing and then treating them early can help avoid a return trip to the hospital.

As for Ma, the last I heard, she was again well and living independently, thanks to a mobilized and vigilant family working with her doctors to avert post-hospital syndrome. A concerned, informed and proactive patient and support system are the best defense against the real possibility of functional decline in older adults following illness or injury.

Kenneth Frumkin, M.D., is a retired emergency room physician in Horsham, Pennsylvania.

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Inside Russia's largest emergency room, as COVID-19 deaths soar

Just over 41% of adults in russia have been vaccinated against covid-19.

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For more than 200 years, Russia's largest emergency department has treated some of Moscow's most critically ill.

Its patients have included victims of the Napoleonic wars and deadly terrorist attacks in the 90s and 2000s. Now five floors of the Sklifosovsky Institute for Emergency Medicine have been turned into a red zone, where some 100 COVID-19 patients are cordoned off from the rest of the hospital.

Some are on oxygen. Others are on ventilators. But all of them are unvaccinated, says Dr. Yevgeny Ryabov, an administrator in the hospital's COVID department.

"This is some kind of indifference and, to some degree, ignorance," he told CBC News as he did morning rounds on Monday with a large team of doctors and nurses.

CBC was invited into the hospital's red zone this week to see how staff are trying to treat an unprecedented surge in infected patients — a deluge which one official described as a weight caving in on the health-care system.

While the entire country has rolled out various COVID-19 restrictions, including a national non-working week and a partial lockdown in Moscow, it hasn't been enough to motivate half of Russia's adult population to get vaccinated, even as deaths have reached record levels .

Russia's national coronavirus task force has reported more than 1,100 COVID-19 deaths each day for the past week, but some in the health sector suggest it is a dramatic underestimate of the total loss and the scale of the ongoing crisis. 

Inside the red zone

Before doctors and nurses are allowed to enter the red zone at the Sklifosovsky Institute, they have to put on several protective layers, including a gown, hood, goggles, a respirator and two layers of gloves. 

The rounds on Monday started at 8 a.m. — earlier than normal because staff wanted to attend a memorial for a retired colleague who recently died of COVID-19.

In the past 18 months, this hospital lost 10 of its current and retired staff to the virus.

WATCH | A look inside a Russian hospital struggling with COVID-19 cases:

Inside a Russian hospital struggling with COVID-19 cases

"This is the most difficult, when you have to bury the people that you know very well," said Dr. Sergei Petrikov, the director of the Sklifosovsky Institute for Emergency Medicine.

He led a large medical team through each room, where they reviewed medical images and charts for patients in various stages of medical distress.

While some patients were sitting upright, hooked up to supplemental oxygen, others were lying on their stomachs in a prone position in an attempt to try to help their lungs take in more air. 

Several patients were on ventilators, and a few were hooked up to extracorporeal membrane oxygenation (ECMO) machines, which pump and oxygenate a person's blood outside of the body. It is known as a last resort when it comes to life support. 

The unvaccinated 

On each door, a sign listed the names and ages of the people in each room. 

While CBC saw some patients in their 20s and 30s, most in the ICU were older. Doctors said many had complex conditions, including suffering from heart disease and stroke.

• With COVID-19 deaths climbing and hospitals strained, Russia rolls out restrictions

Lydia Garilova, 74, said that she never bothered to get vaccinated because she spent most of her time at home alone. But she got sick on Oct. 11, and has been hospitalized since Oct. 19. 

"It's difficult. If I would've known before, I would have gotten vaccinated," said Garilova. "I did not think this would affect me … but unfortunately it did not just pass me by."

Petrikov said he has heard plenty of reasons why some COVID patients didn't get the shot. 

"One of them said he was living in a forest … and nobody was near him. Now he is on mechanical ventilation," he said. 

"One man said that he had a special blood group and people with this blood group never get a COVID infection. Now he is on mechanical ventilation."

• Moscow mayor asks unvaccinated seniors to stay home over next 4 months as part of new restrictions

While Russia's Sputnik V was the first COVID-19 vaccine in the world to be approved for widespread use back in August 2020 and studies, including one published in The Lancet have pointed to its effectiveness, less than half of the country's 144 million people have been vaccinated to date. 

The vaccine is only approved for use in people over the age of 18 and, according to the website Gogov , which collects and publishes vaccination data from across the country, just 41 per cent of adults in Russia have received two doses. 

Vaccine hesitancy 

Despite the pleas from officials, along with incentives for seniors to get vaccinated — including a payment of 10,000 rubles ($175) — the country's vaccination rate is only increasing slightly.

Dr. Vasily Vlassov, a professor of health-care administration and economics at Moscow's HSE University, believes part of the vaccine hesitancy stems from the fact that the risk of COVID-19 was downplayed at the beginning of the pandemic.

A report done for Harvard's  Nieman Foundation found that early on, state-controlled media in Russia covered conspiracy theories related to the virus. And even when the country entered a strict lockdown, much of the coverage showed how well Russia was handling the emergency, as new hospitals were being built.

In April 2020, during a video conference with Russian President Vladimir Putin, a health official boasted that Russia had one of the lowest mortality rates in the world, and the country sent ventilators and other equipment to Italy and the U.S., where hospitals were overwhelmed.

Most of the pandemic coverage in Russia hasn't been as devastating as other countries, Vlassov said.

When India experienced a deadly spike of infections earlier this year, he said the images of grieving families and funeral pyres were everywhere — but there hasn't been footage showing the scale of death in Russia during its current devastating fourth wave. 

Another big factor driving the low vaccination rate is distrust in the government and its domestically made vaccine, he said. "Unfortunately, trust in Russia is at a very low level; it is catastrophically low."

• Russia has plenty of COVID-19 vaccine doses. What's missing is trust

During Soviet times, there wasn't much hesitancy, as the national immunization program was mandatory and Russia was proud of its scientific research and vaccine development. 

But global health experts  say part of the rise of today's anti-vaccination sentiment can be traced to a column published in a popular daily newspaper in 1988 that suggested "dirty" vaccines were causing weakened immune systems. 

Those arguments continued to circulate in Russia and still resonate with a portion of its population.

While Putin was vaccinated with Sputnik V, he didn't receive his shot until March 2021 — months after the vaccine was first available. And unlike many other world leaders, he was jabbed off-camera, behind closed doors.

Distrusting doctors 

Unlike in North America, where there is mostly widespread consensus in the medical community around the safety and effectiveness of COVID vaccines, a survey conducted in April by Russia's Levada Centre found just 70 per cent of doctors surveyed trusted Sputnik.

About a quarter of them said they weren't ready to get vaccinated. The survey also found there was less support for foreign-made vaccines.

• Seeking travel freedom, Russians flock to Serbia for Western-made COVID-19 vaccines

But Vlassov was confident enough in the Pfizer-BioNTech vaccine that he flew out of Russia to receive it; in recent weeks, there have been several reports about Russians flying to Croatia and Serbia to get vaccinated. 

Vlassov said he believes that if Western vaccines were available in Russia, more people would be rolling up their sleeves.

Lack of transparency

Independent demographer Alexey Raksha said the Russian government might be able to convince more people to "take this virus more seriously" and get vaccinated if it were more transparent about the country's pandemic death toll. 

Raksha used to work for the state statistics agency, Rosstat, until he said he was forced to resign in July 2020 — in part because of publicly questioning Russia's official COVID-19 data in publications, including the New York Times.

He argues the data released daily by the national coronavirus task force is "distorted" and obscures the true toll of the pandemic.

According to official government statistics, just over 31,000 people died of COVID-19 in October, but Raksha calculates that the number is likely closer to 100,000 based on something known as "excess" deaths — a measure of all fatalities above an average baseline, not just those where COVID-19 was labelled the cause. 

Right now, he said, Russia's excess deaths are far higher than what's typically recorded. He says he receives his data from some of Russia's 85 regions, as well as from sources within government ministries.

A recent analysis done by Reuters shows there have been at least 630,000 excess deaths during Russia's coronavirus pandemic, up until September, while a separate analysis by the Financial Times  pegs the number at more than 750,000. 

Meanwhile Rosstat has found 462,000 Russians have died from coronavirus and related causes since the start of the pandemic, while the task force, which reports deaths daily,  states just 203,000 Russians have died of COVID-19.

• Pandemic early warning system has issued only a handful of alerts since start of 2020

In Oryol, some 350 kilometres southwest of Moscow, health-care workers have also raised concerns that Russia's official statistics aren't matching what they are seeing on the ground. Paramedic Dmitry Seregin told Reuters that in just one day, 26 patients who died after having a COVID-19 infection weren't part of the city's daily statistics.

"I have a reason to assume that officials distorted the numbers and registered them during several days," he said.

State of restrictions

And even as COVID deaths continue to climb — 1,189 were announced Wednesday — the mayor of Moscow has said that the city's partial lockdown will not be extended past Nov. 7. 

The restrictions, which have been in place since Oct. 28, have closed restaurants and all non-essential stores.

Russia is currently in the middle of the government-ordered non-working week, though one other region, Novgorod, situated between Moscow and St. Petersburg, has announced the non-working days will be extended until Nov. 15.

Back at the Sklifosovsky Institute, Dr. Petrikov admits there are days when the hospital has to turn patients away and send them to other hospitals.

He said he believes vaccination is the only way out of the crisis and is disappointed more people aren't getting their shots. But he said it changes very little for his medical staff.

"It doesn't matter if they are vaccinated or not vaccinated," he said. "We do our work."

ABOUT THE AUTHOR

Foreign Correspondent

Briar Stewart is CBC's Russia correspondent, based in London. During her nearly two decades with CBC, she has reported across Canada and internationally. She can be reached at [email protected] or on X @briarstewart.

With files from Corinne Seminoff and Reuters

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Putin visits the wounded at a military hospital in Moscow, in a first since the Ukraine invasion.

The Russian leader also announces new social welfare measures and military benefits in an apparent effort to show Russians he is aware times are tough.

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By Anton Troianovski

• May 25, 2022

President Vladimir V. Putin visited wounded soldiers on Wednesday and announced a raft of new social welfare measures and military benefits — an apparent effort to show Russians that he was aware times were tough as the war in Ukraine entered its fourth month.

The Kremlin released brief clips of Mr. Putin, dressed in a white gown and flanked by Defense Minister Sergei K. Shoigu, greeting patients at a military hospital in Moscow. It was the president’s first time visiting the wounded since the start of the war, but his words were sparse: “He’ll be proud of his dad,” Mr. Putin told a patient with a 9-month-old son.

Later, Russian state television showed Mr. Putin meeting senior government officials at the Kremlin. He directed them to increase payments to service members deployed in Ukraine and to double the child care allowance for women in the military.

He said that while the military doctors he met on Wednesday had assured him that “they have all they need,” the government should “promptly, quickly and effectively respond to any needs” in the medical care of wounded soldiers.

“They are all heroes,” Mr. Putin said of Russian soldiers in Ukraine. “Each of them is exposing his life to mortal danger, doing so consciously, and they should be treated as such, as heroes.”

The Russian Defense Ministry last released casualty figures on March 25, when it said that 1,351 Russian service members had been killed in Ukraine.

Mr. Putin also promised wider social welfare measures, even as he repeated his insistence that the Russian economy was not suffering as much as some had predicted at the beginning of the war. Pensions for non-working seniors, along with the minimum wage, will be raised 10 percent in June, he said.

Anton Troianovski is the Moscow bureau chief for The New York Times. He was previously Moscow bureau chief of The Washington Post and spent nine years with The Wall Street Journal in Berlin and New York. More about Anton Troianovski

Modi bear-hugs Putin in Moscow, marking deep ties between Russia and India

Despite Washington’s efforts to woo Prime Minister Narendra Modi and isolate President Vladimir Putin, the visit shows continuing close relations between their countries.

NEW DELHI — Indian Prime Minister Narendra Modi has been hosted by President Biden at a state dinner and lavished with praise by White House officials, who describe ties with India as “one of the most consequential relationships” for the United States.

But this week, Modi reminded the world that he has another close relationship — with “my dear friend Vladimir Putin.”

As Modi makes his first visit to Russia since Russia’s 2022 invasion of Ukraine, the images emerging from Moscow of Modi wrapping the Russian president in a hug send a clear signal that the South Asian giant will maintain deep ties with Russia despite the Biden administration’s efforts to woo its prime minister. It also shows that Putin is not as isolated as the White House has hoped.

The trip to Moscow, which overlapped with three days of NATO meetings in Washington, was met with consternation in Washington and Kyiv. Asked about the Modi-Putin meeting, State Department spokesman Matthew Miller told reporters at a press briefing: “We have made quite clear directly with India our concerns about their relationship with Russia.”

On X, Ukrainian President Volodymyr Zelensky posted photos of a children’s hospital in Kyiv that was struck by a Russian missile on Monday and criticized the meeting. “It is a huge disappointment and a devastating blow to peace efforts to see the leader of the world’s largest democracy hug the world’s most bloody criminal in Moscow on such a day,” he wrote.

The meeting represented a coming together of two leaders who need each other but are otherwise drifting closer to dueling camps led respectively by the United States and China. For Modi, Russia remains a crucial source of weaponry and energy and space technology that India sees as indispensable in becoming a great power. Analysts also say India does not want Russia to grow overly dependent upon India’s rival neighbor, China.

Putin’s war effort, meanwhile, has been funded in significant part by Indian purchases of Russian oil products, which have increased almost 20-fold since 2021. Russia, likewise, hopes India will keep some distance from the United States, and Putin spokesman Dmitry Peskov mocked the West this week for feeling “jealous” about Russia-India ties.

The Moscow meeting appeared to deepen what the two countries call a “special and privileged strategic relationship.” As Modi wrapped up his visit on Tuesday evening, Indian and Russian officials announced their ambition to expand annual trade volumes to $100 billion by 2030 and sign long-term agreements on oil and gas supplies while diversifying trade beyond the energy sector.

The two countries signed agreements to collaborate on polar research and, in a speech to the Indian diaspora in Moscow, Modi also announced the opening of new consulates in Kazan and Yekaterinburg to enhance ties between the two peoples.

“India and Russia are walking shoulder-and-shoulder and infusing new energy into global prosperity,” Modi said in his speech. “Any mention of Russia reminds every Indian of an ally that has been with us through good times and bad, as a trusted friend of India.”

Almost immediately after Modi arrived Monday evening, the leaders showcased their friendship at the Russian leader’s residence in Novo-Ogaryovo, near Moscow, for tea on an outdoor terrace.

“It is a great honor to visit a friend’s home,” Modi said, according to clips released by Russian state media, after he warmly embraced Putin with his trademark hug. Putin congratulated Modi on his recent reelection victory and drove him around his dacha’s manicured grounds in a golf cart, the official footage showed.

On Tuesday, Putin led Modi on a tour of an exhibition by Russia’s State Atomic Energy Corporation. Rosatom officials said this week that it is in talks to build six new nuclear power reactors in India — a fast-growing economy with soaring energy needs.

Modi’s trip to Moscow, coming less than a month after he was sworn in for a third term, broke with the Indian tradition of prime ministers visiting South Asian neighbors first after an election. But it demonstrated Modi’s global aspirations and gave him a chance to show Putin that India has not lost its autonomy even though it is receiving new investments, technologies and weaponry from the Biden administration, Indian analysts say.

“The decision to go early in the term is a signal that India remains invested in the Russia relationship — that is part and parcel of India’s foreign policy, cutting across party lines,” said Pankaj Saran, a former Indian ambassador to Russia and deputy national security adviser who continues to advise the Indian government.

The Indian establishment, Saran added, still considers ties with Washington its highest priority. India could seek to assuage U.S. concerns by arguing that an India that is friendly with Russia could prove useful as a potential interlocutor between Moscow and the West, he said.

At a formal meeting with Putin at the Kremlin on Tuesday afternoon, Modi called for “dialogue” to end the fighting in Ukraine and indirectly raised the hospital attack in Kyiv a day prior that Zelensky accused Russia of carrying out. “Anybody who believes in humanity is aggrieved at the loss of life in war or in terror attacks,” Modi told Putin. “Even so, it breaks our hearts to see innocent children get killed.”

Putin replied: “I am grateful to you for the attention you are paying to the most pressing issues, including trying to find some ways to resolve the Ukrainian crisis, and of course, primarily by peaceful means.”

Indian Foreign Secretary Vinay Kwatra told reporters Russia would work to discharge all Indians currently serving in the Russian military, after Modi apparently requested the step.

The issue became politically contentious in India this year after reports emerged that Indians seeking job opportunities as “security helpers” or porters were recruited to Russia and deployed to fight on the front, possibly against their will. Indian officials say at least four Indians have been killed in combat so far.

Even though the India-Russia relationship was cemented during the Cold War, the energy and defense ties between Russia and India — the world’s largest weapons buyer and the No. 3 importer of oil — have continued to thrive. Indian imports of Russian crude rose from $2.5 billion in 2021, before the invasion of Ukraine, to $46.5 billion in 2023, according to Indian Commerce Ministry data. Last year, only China purchased more Russian crude.

Indian officials say the transactions have been priced below the $60-per-barrel cap imposed by the Group of Seven countries, and the United States has refrained from criticizing India’s purchases. But they represent such a large windfall for Russia that Indian officials have begun to voice concerns about India’s mounting trade deficit with Russia.

And while U.S. officials have publicly and privately urged India to wean itself off Russian weapons, the Russian state-owned arms giant Rostec announced last week that it would manufacture armor-piercing tank rounds inside India to supply India’s army.

Indian officials hope that Putin will maintain a degree of independence from China in exchange for receiving India’s support, at a time when Russia is increasingly seen as a junior partner to Beijing. India and China have been locked in a tense border dispute since 2020.

Even as Modi, the leader of the world’s largest democracy, embraced Putin, the Russian leader’s brutal use of his country’s judicial system for political purposes was on full display. A Russian court on Tuesday ordered the arrest of Yulia Navalnaya, the widow of political opposition leader Alexei Navalny, who died in an Arctic prison earlier this year. Navalnaya, who is living outside Russia, was accused of participation in an extremist community.

She has accused Putin of killing her husband, who previously had survived an assassination attempt by Russian security agents using a banned chemical weapon. Many world leaders condemned Navalny’s death, and some, such as Biden, said Putin was responsible.

On X, formerly Twitter, Navalnaya mocked the judicial process in which, since taking over her husband’s work abroad, she has faced multiple allegations.

“Oh, there’s no normal procedure? A foreign agent, then a criminal case, then an arrest?!” she posted. “When you write about this, please don’t forget to write the main thing: Vladimir Putin is a murderer and a war criminal. His place is in prison, and not somewhere in The Hague, in a cozy cell with a TV, but in Russia — in the same colony and the same 2 by 3 meter cell in which he killed Alexei.”

For Putin, Modi’s visit, which wrapped up Tuesday, provides a further chance to show he is not totally isolated over his war in Ukraine.

“For Putin, it’s very important. It is international recognition,” a Russian official said, speaking on the condition of anonymity because he was not authorized to discuss the matter. Touting Russia’s relationship with India also allows Putin to boost Russia’s position in relation to China, he said.

Just last month, Putin visited North Korea in a trip that was “not received very well in Beijing,” said the Russian official, who is close to senior Russian diplomats.

“When we became completely dependent on China, we suddenly had the visit to North Korea and now this balance with India,” the Russian official said. “With these types of triangles, [Putin] is able to balance the situation to show that he is not completely subservient.”

Belton reported from London and Ilyushina from Berlin. Anant Gupta in New Delhi contributed to this report

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Trump appearance at nyc kosher deli canceled at last minute after owner dies.

Former President Donald Trump’s scheduled campaign trail appearance at a popular Brooklyn kosher deli was canceled Thursday after the owner died of a heart attack. He was 76.

Trump had been expected to stop by Gottlieb’s — a mom-and-pop restaurant known as a staple of Hasidic Williamsburg — before heading to Washington, DC, to speak at a “Combatting Antisemitism” event.

But the deli’s beloved owner Shalom Yoseph Gottelib — a dedicated dad and hardworking businessman, who often gave food to the needy — was hospitalized with pneumonia earlier this week and died after suffering cardiac problems Thursday, according to friends and religious leaders.

“Everybody’s in shock. He was a good person, and he was an icon because of the iconic restaurant he ran for a very long time,” said Rabbi Abe Friedman, a friend of Gottlieb. “Going from welcoming Trump to a funeral is quite shocking.”

The soft-spoken deli owner — whose Hungarian-born father, Shlomo Zelka, founded the deli in 1962 after surviving the Holocaust — was known for working “every day” and generously helping poor folks, said Rabbi Moshe Indig, a Jewish community leader.

“Let’s say someone came and told him their mother was sick, had to go to the hospital. He’d say, ‘How many portions do you need? Take it,’” Indig said. “Every Friday before closing he’d take all the leftovers and pack them up and send them to families.”

“He was a real old-time gentleman,” Indig added. “This is a great loss for the community.”

The restaurateur served up everything from matzo balls to classic knishes while adhering to strict Jewish dietary laws such as keeping meat and dairy products separate.

The eatery is one of the few “Glatt kosher” delis — which require the lungs of slaughtered animals to be free of defects — left in the U.S., according to atlasobscura.com.

When the deli first opened, orthodox Jews would flock there from far and wide, Indig said.

“People used to come from all over, driving for hours to get here to get the gefilte fish, the matzo balls, the kishka, the knish — all the original, traditional foods,” he said.

In the days leading up to his death, Gottlieb was well enough to attend a granddaughter’s wedding last week before his health took a turn for the worse.

“He was a very good person, very charitable, always with a smile, always with a good word,” said Borough Park Jewish community leader Rabbi Bernard Frelich.

He practiced Judaism devoutly, was generally apolitical and “surprised” when Trump’s team picked his shop to visit, Indig said.

“He was never involved in any politics, but somebody – I don’t know why, I don’t know who – picked this location for [Trump’s] visit,” he said. “It was good PR, but they had nothing to do with politics.”

Gottelib’s son Menashe has run the restaurant, located on Roebling Street and Division Avenue, for the past few years.

Gottelib’s funeral will be held at 172 Ross St. in Brooklyn at 2 p.m.

On Wednesday, Trump, 78, stopped by the Bitcoin bar PubKey in Manhattan before holding a campaign rally at Nassau Coliseum on Long Island.

The Republican nominee has opted to rally in New York — despite having little chance of winning in the deep blue state — in part because support on Long Island will be crucial in determining who controls the House next year.

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