Wednesday, October 21, 1998

Some problems of the elderly
By S.K. Jindal
"ADDING years to life" is the broad principle on which one works in medicine.

Breastfeeding on world agenda
By Moussa Awounda
STOCKHOLM: Action to promote breastfeeding instead of baby milk substitutes, a major cause celebre a decade ago, seems to have faded in recent years.

Harvesting of donated eyes : right perspective
By Amod Gupta
AS a matter of policy, we at the PGI encourage local eye bank facilities to at least harvest the eyes to avoid unnecessary delays in the procurement of eyes and the last rites.

Surgeon stores severed fingers on body
By Martin Wainwright
SURGEONS at Britain’s biggest teaching hospital have pioneered a ground-breaking technique of storing amputated fingers on a patient’s body for almost a year before sewing them back into place.

Start with a good and wholesome breakfast
EATING breakfast benefits memory. This was the conclusion of researchers who compared three studies involving breakfast, memory function and blood glucose levels.

Folate and heart risk
ADDING as little as 100 micrograms of folate a day to your diet can produce significant health benefits.

Some problems of the elderly

By S.K. Jindal

"ADDING years to life" is the broad principle on which one works in medicine. Adding years, however, is not simply the prolongation of life — it is also synonymous with aging. It not only alters the professional opportunities and social relationships, but also affects the body functions. Every body system ages with years and hence the question of "adding life to years" gains greater significance.

There are several kinds of physiological changes which take place in the elderly. The stamina gets diminished, endurance becomes poor and defences inadequate.

All the body systems age and their functions become diminish with time. The brain function, for example is dulled and reflex actions are slowed. There is inadequate coordination of activities. Blood vessels are hardened and the normal range of blood pressure is increased.

The chest wall becomes rigid and the lung capacity is decreased. There is sluggishness of intestinal function and motility. Bones start losing calcium, their surfaces become irregular and the joint movements get restricted.

All these changes are not essentially seen in all people. The types and the degrees of changes may vary among individuals. But the overall function is decreased and the body gets more prone to developing medical and related disorders.

More important than the physical changes are the psychological alterations and social interactions which greatly influence the occurrence and management of medical problems. There is a kind of despondency. A feeling of uselessness creeps in. Some patients may even express the futility of continuing further. Those in whom depression is the predominant feature do not cooperate with the treatment team or respond rather poorly.

Some others are, perhaps, too demanding and completely oblivious of the natural cycle of life. All this, however, is a part of the game and nobody can complain much about the sick and the suffering. You cannot hope to convince and teach a wise senior citizen who often understands more of life than you do. We only suggest and, at best, advise.

There are several factors other than age itself which are important in determining the problems in the elderly. There are some differences in diseases and their symptoms among men and women. The presence of chronic diseases such as atherosclerosis, hypertension, diabetes mellitus, coronary heart disease, chronic bronchitis and emphysema predispose individuals to one or the other problem and its complications. Similarly, the cumulative effects of life-time exposures to environmental, industrial and occupational hazards have a great beaading on the causation of disease. It is also at this age when personal habits related to food, life-style and addictions demonstrate a telling effect.

The health advice related to a balanced diet, regular exercises, avoiding smoking and alcohol, etc., become important overnight.

Perhaps, it is already late to prevent the onslaught of adverse health factors. But, unfortunately, the problems do occur among the more conscious and disciplined individuals as well, although much less often in statistical terms. More importantly, they are better tolerated, less severe and relatively easily managed in them.

Of various symptoms experienced by the elderly, some are caused by distinct disease-syndromes while others are nonspecific and partly unexplained. A general feeling of weakness and tiredness, loss of interest, sleep-disturbances and general aches or pains may partly reflect depression and partly nutritional deficiencies. They may also point to the presence of a physical illness related to one or more body systems.

Breathlessness, fatigue and inability to do work may occur due to impaired cardiac and/or respiratory functions, anaemia, and metabolic or other systemic disturbances. Bone and joint changes may cause pain and difficulties related to movements.

Of the more clearly defined diseases, infections, cancers and other tumours, heart attacks, strokes, emphysema and degenerative diseases such as spondylitis are common. Similarly the more localised problems such as frozen joints, diminished vision and loss of hearing are as debilitating and incapacitating as other and more serious systemic illnesses.

One of the major issues concerning the management of medical problems at this age is the difficulty in making a diagnosis. The disease-presentation is mostly atypical and is complicated by the presence of multiple abnormalities. The risks of diagnostic tests, many of which are likely to be invasive, pose further limitations. The treatment, therefore, is often palliative.

The management poses problems because of increased drug toxicity, poor tolerance and compromised functions of other systems. Terminal care, involving endotracheal intubation, resuscitation and assisted ventilatory management, raises important ethical and social issues.

Frequently, such measures end in prolonging the misery than offering relief. But this is not to say that radical treatments are not useful or employed. But one needs to strike a balance between the risks and benefits of a particular option. Although this principle holds true for all the decisions made for different medical problems, it is much more so in the aged. A conservative approach is, perhaps, more useful than aggressive and heroic measures.

But I must admit that the approach is greatly influenced by the disease, the availability and resources related to disease-management and, above all, the patient and his/her family. I am reminded of an old quote by a senior citizen who had jokingly but wisely said: "I shall always like to be treated by the person who treated my parents or, perhaps, my grandparents, if he is alive and around.

Dr S.K. Jindal, MD, FAMS, FCCP, FNCCP, is Additional Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh.

Breastfeeding on world agenda

An international award to a foundation for campaigning against baby milk substitutes has brought breastfeeding back into the limelight. Since intensive attention was put on the subject in the 1980s, the subject has had all too little care. The problem remains.

By Moussa Awounda

STOCKHOLM: Action to promote breastfeeding instead of baby milk substitutes, a major cause celebre a decade ago, seems to have faded in recent years. Yet the problem has not gone away.

The multinational companies selling baby milk powder are marketing their products with unrelenting vigour, and even though many boycotts of the 1980s are still in place they are out of the public eye.

Nestle, the biggest manufacturer with 40 per cent of the market, even forced UNICEF (the UN Children’s Fund) to take down posters warning of risks associated with the powder when both had exhibition stands at the annual conference of Britain’s ruling Labour Party. The party organisers said they were "offending our sponsors".

UNICEF research suggests that reversing the decline in breastfeeding could save the lives of 1.5 million infants every year. It shows that babies fed on milk substitutes are up to 2.5 times more likely to die of diarrhoea — a key infant killer — than those who are breastfed.

After all, milk powder needs added water. If the water is unsafe, as is often the case in developing countries, then the powdered milk is by definition dangerous. And breast milk contains antibodies against some infections that, obviously, powder cannot supply.

Which is why the staff of the Geneva Infant Feeding Association (GIFA) in Switzerland, a member of the International Baby Food Action Network, could not believe their ears when they heard that IBFAN had won an international award.

Nancy-Jo Peck, of GIFA, who is also health adviser in the Europe region office for IBFAN, said: "This recognition confirms that we have made some headway after all these years fighting on behalf of babies and mothers. We hope it will help put breastfeeding issues on the world agenda again."

IBFAN brings together 150 pro-breastfeeding groups from 90 countries to campaign jointly. It was one of four organisations named by the Right Livelihood Award Foundation in Stockholm to share SEK 1.8 million.

The other winners were the US-based Caner Prevention Coalition; the Centre for Peace, Non-violence and Human Rights in Croatia; and the Grupo de Accion por el Biobio in Chile.

Jakob von Uexkull, the German-Swedish philanthropist who founded RLA, quoted the jury’s citation which praised Right Livelihood for "its committed and effective campaigning over nearly 20 years for the rights of mothers to choose to breastfeed their babies, in the full knowledge of the health benefits of breastmilk, and free from the commercial pressure and misinformation with which companies promote breastmilk substitutes".

Uexkull called on governments to make law in accordance with the World Health Organisation’s International Code on the Marketing of Breastmilk Substitutes.

He said companies continued to break and bend the code, refusing to "put the health and lives of babies before profits".

The code was one of the early successes of the campaign to promote breastmilk. It arose from a meeting between the WHO and UNICEF in 1979, at which Dutch-born Annelies Allain and Briton Andrew Chetley were present.

That year the two founded IBFAN as a network of organisations, since charities like War on Want, Chetley’s then employer, could not take on such an overtly "political" campaign.

The breastfeeding movement was already in existence at that time. It was born during the post-1960s intellectual climate, its initial supporters inspired by the growing consciousness of global exploitation by multinationals.

Some saw it as a gender issue, emphasising women’s rights to choose how to bring up their children.

Between then and IBFAN’s founding, the movement began to grow. By 1977 boycotts of Nestle and other food companies including Cow and Gate, Wyeth, Albert Ross and Mead Johnsson, pushed the issue of unethical and pressure marketing of baby food to world attention.

In Switzerland, a War on Want pamphlet entitled The Baby Killer was translated as "Nestle Kills Babies". The company sued, both for the title and for alleged libels within the pamphlet.

But after two years all charges except those relating to the title had been dropped. The judge fined the two activists responsible just $ 150.

In 1978, the US Senate held hearings under Senator Ted Kennedy into baby milk marketing. A Nestle executive called to testify agreed with Kennedy that reconstituting baby powder using polluted water caused waterborne infections. But the company had "no corporate responsibility" arising from that fact, he said.

Over the succeeding years the spotlight seemed to shift — partly, perhaps, through the more broad-based agenda championed during the UN Decade for Women, 1985-95.

The single-issue breastfeeding movemnet, some said, had become just part of the mainstream.

In Britain, Baby Milk Action — a constituent part of IBFAN — briefly lifted its sanctions against Nestle in 1984. Although it later resumed the boycott, once it was realised that Nestle had reneged on its assurances, the lull obviously affected momentum and public following.

In many African countries, the power of the baby food lobby, it advertising, and the growing number of women joining the workforce have all conspired to minimise the breastfeeding cause.

In the Philippines, Nestle has allegedly been hiring nurses to act as health workers, whose recommendations to new mothers always include the use of baby formula.

Against this unsympathetic backdrop, breastfeeding activists welcome the Right Livelihood Award. It is also a measure of the sensitivity sections of society attach to the harm food companies can do, especially as world markets globalise and liberalise.

To Baby Milk Action in Britain, this recognition re-emphasises the need for a global role, since Nestle and the other companies hardly market their products in Britain and other parts of Western Europe.

"The award gives us added impetus to focus more on areas of policy and legislation," said Patti Rundall, from Baby Milk Action. "With our experiences we are able to help our sister organisations abroad in these areas". — Gemini

The writer is a Kenyan journalist living and working in Sweden. Child growth and nutrition are her major concerns.

Harvesting of donated eyes : right perspective

By Amod Gupta

AS a matter of policy, we at the PGI encourage local eye bank facilities to at least harvest the eyes to avoid unnecessary delays in the procurement of eyes and the last rites. Logistically, it is nearly impossible for the PGI doctors to be rushed to every city of North India for such purposes. We have always encouraged NGOs and eye care professionals to start such initiatives locally.

To facilitate the harvesting of the eyes, we were instrumental in forming a registered Eye Bank Society under the presidentship of the Adviser to the Administrator, Chandigarh Administration, and the Health Secretary, Chandigarh, as the Senior Vice-President, with the Deputy Commissioner, Chandigarh , and the Director, Health Services, Chandigarh Administration, as its ex-offico members besides several socially active citizens as its members.

The society was formed with the primary objective of facilitating eye donation in the city and the surrounding areas. We have established an "Eye Donor Memory Lane" to perpetuate the memory of those who gifted their eyes in the Eye Department, PGI, which was formally inaugurated more than a year ago.

With the assistance provided by the Eye Bank Society, the Eye Department at the PGI has been able to increase its corneal grafting by more than 300 per cent. The Eye Bank Society has also approved the procurement of a van to cut short the interval of the harvesting in donated organs.

The Eye Department has been doing pioneering work in all spheres of its activity and the ill-thought-out comments by some uncreative people have come to us as a great discouragement in pursuing the goal of excellence.

We have always gone beyond the call of our duty and have been providing excellent tertiary care to the patients of this region.

We believe that some commercial organisations are exploiting this situation for obvious reasons.

It is pertinent to mention here that the harvesting of an organ under the Organ Donation Act, 1994, by any unauthorised and unqualified individual is illegal and is a criminal act.

At the PGI, only the doctors of the Eye Department have been authorised to harvest the donated eyes from the city and the surrounding areas in a radius of 15 km. There were nearly 145 such donors in the past five years. When our team of doctors went to the homes of the deceased to harvest the eyes, their families received letters of gratitude from us. We trust that the entire matter will be seen in the right perspective.

Dr. Gupta is the Professor and Head of the Eye Department at the PGI, Chandigarh

Surgeon stores severed fingers on body

By Martin Wainwright

SURGEONS at Britain’s biggest teaching hospital have pioneered a ground-breaking technique of storing amputated fingers on a patient’s body for almost a year before sewing them back into place.

A woman mangled by a croissant-packing machine has spent eight months with three severed fingers from her right hand attached to her left forearm, before a 12-hour operation this week in which they were delicately replaced on her recreated hand.

The fingers, amputated after the accident in Leeds, in the north of England, left the rest of the teenager’s hand terribly mutilated, were kept alive by plastic surgeon Simon Kay, who grafted them on to the unaffected arm where they were "fed" by its main artery. A fourth "finger" was attached to the new hand by using one of the 19-year-old woman’s toes.

Mr Kay, who lost part of a finger himself in a childhood accident, said that the very complicated and technical surgery, carried out under magnification, would result in a usable new hand for the woman, who wants to be identified only as Louis.

Mr Kay, aged 46, has been a pathfinder in recreating fingers from toes at St James’s University Hospital, Leeds, and is the first British surgeon to attempt the new "storage" technique. Only three other cases have been carried out worldwide, including an American operation where an amputated hand was kept alive in the patient’s armpit.

The successful delay allowed Louise’s mauled hand to be treated until the original shattered limb was capable of receiving the digits. Intensive physiotherapy was carried out on the patient’s wrist and on the fingers in their temporary home, to make sure that they retained the power to bend and grasp.

Mr Kay said last week that the fingernails on Louise’s "banked" fingers had required cutting regularly during the eight months and the digits had grown normally although at a slightly slower rate than if the nerves had also been connected.

Nerves from one of Louise’s ankles were also transplanted into the new hand — two per finger — and plastic tendons were added to the fingers and toe. Mr Kay and his team then reconnected nerves, muscle and blood vessels between the four digits and the palm.

Lousie was recovering from the operation, after keeping the stored fingers hidden under a bandage since the accident last December. Her hand was trapped in the wrapping machine at Country Style Foods, Leeds, when she tried to free a blockage but was caught by sealing jaws heated to 200 C. "There was a time when I thought: why don’t I leave the hand as it is, because I’ve already got a lot of scars to get used to?" she said. "But now, even if I can just pick up a piece of paper, it will be wonderful."

The teenager has endured repeated surgery in the restoring of her palm and knuckles, including skin grafts from her hip and thigh. Her fiancé, Mick, aged 34, was trained by physiotherapists to exercise both hand and fingers regularly at home.

"I was shocked when I came round from surgery last year and a bit bewildered," said Louise.

"I was conscious of what I looked like and that it would change my life. But I have got used to the idea now, and have tried to use the hand without fingers as normal."

The final stages of the operation saw the fingers detached from their temporary home, chilled and then taken with a section of artery to Louise’s palm for sewing back on.

— By arrangement with the Guardian, London.

Start with a good and wholesome breakfast

EATING breakfast benefits memory. This was the conclusion of researchers who compared three studies involving breakfast, memory function and blood glucose levels.

Dr David Benton and Pearl Parker from the University of Wales in the U.K., found that a higher blood glucose level after eating breakfast is one of the key reasons for the improvement in mental performance.

It particularly affects the speed of recalling new information, but does not influence other aspects such as intelligence test results or mental tasks related to conditioning or developed skills.

Unlike other parts of the body, the brain uses glucose exclusively to meet it’s energy needs, as it has a relatively greater need for energy (glucose).

The authors comment that "the traditional assumption that the brain is well supplied with glucose is now being questioned as a result of a series of reports, indicating that raising blood glucose concentrations improves cognitive functioning."

In this study, eating breakfast was found to improve performance on three tests of memory. In some tasks, the decline in performance associated with not eating breakfast was reversed by a glucose-containing drink.

The tasks that were improved required the retention of new information — for example, recall of stories and word lists. This aspect of memory has been called "declarative memory" (information that can be consciously recalled and declared verbally). The other type is "procedural memory", which includes conditioning, habituation and skills such as riding a bicycle — this was unaffected by breakfast consumption.

The authors believe a question for future study is whether the nutritional composition of breakfast also has an influence on memory.

These results support the belief that a healthy breakfast gets you off to a good start for the day. Not only does it provide valuable amounts of important nutrients for good health, but it may also enhance mental abilities at work and school, at least in the morning.

Source: Benton D., Parker P. Breakfast, blood glucose and cognition. Am. J. Clin. Nutr. 1998.

Folate and heart risk

ADDING as little as 100 micrograms of folate a day to your diet can produce significant health benefits.

In Ireland a study of 30 healthy men, aged between 34 and 65 years, showed that blood homocysteine levels — a risk factor for heart disease — were reduced with taking additional folate.

The levels of folate taken were relatively low, and achievable by the use of folate-fortified foods.

For 26 weeks the men were given either 100, 200 or 400 micrograms of folate per day, in addition to their daily diet which supplied an average of 280 micrograms per day.

Overall, the homocysteine was significantly reduced at all dosages. The results were also analysed according to the men’s initial homocysteine levels, which found that the significant effect occurred in those with higher homocysteine levels. This indicated that men with lower homocysteine levels (the lowest one-third of values) were already well-nourished in relation to folate.

An interesting finding was that the results were as good with 200 micrograms as 400 micrograms a day.

This study shows that adding 100-200 micrograms to the usual dietary intake can reduce homocysteine levels, even when they are within the normal range. Breakfast cereals are fortified up to 15 micrograms (25% RDI) per serve. This is likely to be effective in people with higher homocysteine levels. Other research has indicated the importance of fibre in preventing heart disease. Therefore folate-fortified, fibre containing cereals would be a good breakfast choice.

Source: Ward M, McNutty H, McPartilin J et al. Plasma homocysteine, a risk factor for cardiovascular disease, is lowered by physiological doses of folic acid.

O.J. Med., 1997(Kellogg’s Nutrition Advisory Service)