Wednesday, October 28, 1998

Visiting a patient: 18 commandments
By S. M. Bose
A visit to the hospital to see an ailing relative or a friend is a ritual religiously performed by our people without giving any thought to its desirability. These visitors do not seem to have any clue to the problems their visits can create for the patient or for them. A few helpful recommendations ...

Ayurvedic ‘thefts’ cost India dear
By Sanjay Suri
LONDON: India is losing an estimated $ 10 billion a year in the international market from pilferage of Ayurvedic products and services, practitioners of the ancient Indian system of herbal medicine say.

Iron deficiency in obese persons
THE consequences of chronic iron deprivation are well known, leading to the development of iron deficiency anaemia, but the effects of acute iron deprivation on iron metabolism are less well characterised. The effects of acute iron deprivation have not been studied in obese subjects consuming a very-low-energy all protein-diet.

Eat right & take a multivitamin
By Damaris Christensen
Even a well-balanced diet does not contain enough folate to lower homocysteine levels and prevent heart attacks ...

Advanced cancer
Supportive care of patients
By J. D. Wig

THE physician caring for the patient with advanced cancer must concede at some point that the chances of recovery are negligible and that the specific anti-tumour therapy has little to offer.

The focus must remain clear in considering supportive care, maximising the comfort. This requires rapid and persistent attention to symptoms such as pain, depression, non-adaptation to the situation (anger, anxiety, shock — fear of death) and nutrition (loss of weight and appetite). The treatment of these symptoms is important and with proper attention the patients can experience significant relief and maximise their opportunity for acceptable levels of the quality of life.

Pain relief: Clinicians have a moral duty to relieve pain and suffering and patients should receive adequate pain management. As the pain experienced is multi-factorial, the treatment often includes a multi-disciplinary approach (drugs and surgical, anaesthetic or other measures). The management plan needs to remain flexible and responsive to patient’s changing needs. The oral route of medication is preferred. If it is not possible, other routes are considered like injection therapy or the spinal infusion of drugs.

Pain reflects the anatomical location of the primary tumour as well as areas of the spread. Pain can occur as a result of the tumour infiltrating the tissues, creating amass effect and stretching a capsule, or by necrosis and ulceration.

Pain can also occur as a result of the treatment (surgery or radiation). Decompressive surgery may not be feasible because of the size of the tumour. In situations where it is possible, decompression may help relieve the pain (intestinal obstruction, blockage in the spinal column). Thus each complaint needs to be clearly elucidated.

Pain killers (analgesics) continue to be the main stay of the treatment. One should begin with the least toxic drugs, increase the dose to its maximal effectiveness/least toxicity and use increasingly powerful drugs. Patients need to be placed on round-the-clock maintenance doses of drugs rather than using them “as needed” dosing. “Rescue doses” should be offered for intermittent, unexpected painful events.

Narcotic analgesics (opiods-morphine) are the central component of pain management in moderate to severe circumstances.

The overwhelming majority of patients can be made comfortable by the titrated administration of these drugs and still maintain an adequate clarity of the sensorium and respiratory drive. Constipation is a real problem as a result of this therapy and needs treatment (laxatives).

Parenteral administration allows for the rapid onset of action and combined with patient-controlled analgesia pumps (PCA) provide the greatest pain relief in the shortest period. The use of continuous infusion with PCA also allows stabilisation of the dose with appreciably less drug. Spinal infusion can diminish the total narcotic dose to one tenth of the oral equivalent. However, side-effects such as respiratory depression and urinary retention are possible and need close monitoring.

Nerve blocks (surgically or under radiological guidance) have been used.

Depressive symptoms: One must assess the patient’s coping response to stress and pain, change in the mood that may occur because of pain and expectations about pain management and relief. The presence of depressed mood, agitation, hopelessness, diminution of interest and tearfulness must be taken seriously and a psychiatrist’s help should be sought. The use of psychotherapy and psychotropic drugs can significantly diminish symptoms and improve the quality of life. The use of psychostimulants may allow for improved mood and may counter the sedation from drugs used for pain relief.

Shortness of breath (dyspnoea): This can occur in the absence of lung or pleural involvement or underlying heart or respiratory disease. This symptom is a good marker for the debility of terminal cancer. General muscle weakness may be responsible for dyspnoea. Shortness of breath because of fluid collection in the pleural cavity or the abdomen (ascites) needs appropriate treatment in the given situation.

Loss of appetite (anorexia): It is a common problem in these patients and is due to a number of causes — abnormalities of taste sensation and psychological factors etc. Patients begin to lose weight and develop complications of nutritional deficiency, muscle wasting and susceptibility to lung complications. Feeding tubes may have to be placed for giving nutritional support.

The control of pain, improvement in nutrition, and psychological support to patients and their families are the most important things that we, as clinicians, are able to give to our patients with advanced cancer. Attention to pain and psychological distress can often allow for the successful treatment of symptoms. The focus must remain clear. One should concentrate on maximising the comfort, and physical and emotional well-being.

Dr Wig, M.S., F.R.C.S, is Additional Professor of Surgery at the PGI, Chandigarh.

Visiting a patient: 18 commandments
By S. M. Bose

A visit to the hospital to see an ailing relative or a friend is a ritual religiously performed by our people without giving any thought to its desirability. In contrast to western culture and tradition, we feel that we would be wrong if we do not pay repeated visits to see a known ailing patients. Most of the patients and their relatives also feel bad and harbour a grudge against a person who fails to make a “courtesy call” on the hospitalised individual. These visitors do not seem to have any clue to the problems their visits can create for the patient or for them. The commonest one is giving or receiving infection.

The following recommendations may be found helpful:

1. It is wise to ask the doctor or the nurse on duty if you can visit the patient or not.

2. Do not visit the patient if you have any infection — an upper respiratory tract infection, infected wounds etc. The patient is likely to catch the infection from the visitor and the visitor too is likely to get hospital infection. The offending organism may be drug-resistant.

3. Do not disturb a sleeping patient. He may have been given a sleeping pill or an injection to help him sleep and rest.

4. If a large number of persons come to visit a patient during the visiting hours, they should take turns so as to avoid crowding the room or the ward.

5. Do not visit the patient if the “No visitors” sign has been displayed. You can leave your message with the nurse.

6. Do not sit on the patient’s bed and do not keep anything on it.

7. Do not take small children to the hospital. They can easily catch an infection. They are also likely to disturb the peaceful atmosphere of the hospital.

8. Do not carry any edible thing (fruits included) to the patient unless you have been asked to do so.

9. Ask the doctor or the nurse before offering any drink or food to the patient. His condition may not allow him to consume anything.

10. Leave the place when the doctor comes to examine the patient. The doctor may not like to ask questions or examine the patient in your presence.

11. Do not visit a seriously ill patient, or anyone shortly after an operation. The patient requires rest. You may send flowers or get-well cards through the nurse.

12. Medical history is a confidential document (between the doctor and the patient). Do not show unnecessary interest in the details of the ailment.

13. Do not give unsolicited advice. Do not make suggestions and comments on the disease or on the attending doctor. The doctor knows more than you do. If you have any suggestion or a complaint, you may see the doctor or the hospital administrator.

14. Do not scan the case files and the x-rays. These are confidential documents and you are not supposed to go through them.

15. It is a common sight to find people eating, or drinking tea, while visiting the patient. Do not do so when you are by the bedside of a patient. You may go to the hospital canteen if you are hungry or thirsty.

16. Smoking is prohibited on the hospital premises.

17. Do not spit or throw away anything casually in the hospital. Use the dustbin. Cleanliness should be maintained in all the areas of the hospital by all of us.

18. Do not examine the patient or his wound, etc, even if you happen to be a doctor. This is unethical.

Professor Bose, the recipient of countless degrees, honours and awards, is a renowned teacher and surgeon at the PGI, Chandigarh.

Ayurvedic ‘thefts’ cost India dear
By Sanjay Suri

LONDON: India is losing an estimated $ 10 billion a year in the international market from pilferage of Ayurvedic products and services, practitioners of the ancient Indian system of herbal medicine say.

“What is happening is large-scale theft of our intellectual property rights, “G. Warrier from the Ayurvedic Company of Great Britain told India Abroad News Service.

“Take the simple case of isabgol,” Warrier said. “This is being sold by a British company under the name Fybogel,” he said.”Its sales in Britain are worth about 80 million (dollars) a year,” he said.

Isabgol — or Fybogel as the British know it — has come as a godsend to millions of Britons suffering from the irritable bowel syndrome. But nobody knows, and the few who do, do not acknowledge, that this is an Indian product. “They are buying raw material cheap from India and selling it at a huge profit,” Warrier said.

But far worse than such theft is “the theft of systems of knowledge. In India someone learns to practise Ayurveda after five or six years of training. Here quacks are setting up shop after two weeks of some sort of introduction to Ayurveda. It’s like taking someone to the barber’s for neurosurgery.”

The worldwide market for herbal medicine and for natural treatment is worth about $20 billion, says Warrier, who brings out several publications on the study and spread of Ayurveda. “The origin of a lot of herbal medicine being sold today lies in Ayurveda.”

There are some genuine western herbal medicines and several Chinese herbal remedies, Warrier says, but many of herbal drugs sold around the world today rely heavily on Ayurveda.

Indian vaids, or Ayurvedic practitioners, in London say that western governments do not listen to their pleas against such pilferage and the Indian government is doing nothing about this either.

“Only now the Indian government has slowly begun to wake up to this problem,” a vaid practising in South London told IANS. “But even then there is little they are doing or even prepared to do.”

Another vaid, R. Murthy, said the neglect of the issue by the Indian government is “appalling.” India is surrendering its fortune, he said.

One company started by an American began to call itself Aveda, Warrier pointed out. “There was some truth here because what they were practising was definitely not from the Vedas,” he said. But the company was bought recently for $400 million. Veda or Aveda, there is big money to be made from Indian products and systems — but it’s westerners and not Indians making the money. “It’s a huge, huge theft,” says Warrier.

“The most widespread pilferage seems to be taking place in the USA and Germany,” Warrier said. In Britain, Ayurvedic treatment is a business worth about $750 million, he said.

Foreign governments are encouraging pilferage “by banning the import of the products from Indian companies, and by allowing western practitioners to take those products and market them under their own brand name,” he said.

If only fizzy wine from a certain part of France can be called Champagne, or only whisky from Scotland can be called Scotch, only Ayurvedic products from India should be allowed to be called Ayurvedic, Warrier reasons.

Given the reliance on Indian products and systems, India by right should have at least a $10 billion earning from use of its products and systems abroad, Warrier said. By the year 2010 this market will double to $40 billion. “We must act to get our rightful share of that before it is too late,” he said.

The author works for India Abroad News Service.

Thought for food
Iron deficiency in obese persons

THE consequences of chronic iron deprivation are well known, leading to the development of iron deficiency anaemia, but the effects of acute iron deprivation on iron metabolism are less well characterised. The effects of acute iron deprivation have not been studied in obese subjects consuming a very-low-energy all protein-diet (VLED).

Therefore, an investigation of indexes of iron metabolism as well as other trace elements in a large group of obese subjects consuming a VLED was conducted.

The study examined whether the observed changes could be prevented by adequate iron supplementation. The study included a total of 43 obese patients, 29 women and 14 men, aged 15-66 years with a BMI of 38.79 ± 8.25. No patient had anaemia, renal impairment, hepatic dysfunction, or infection or suffered from a hematologic disease, cancer or inflammatory disorder.

A first group of 25 subjects did not receive iron supplements and constituted the core of this report. Another group of 18 subjects who received iron supplementation were subsequently studied.

Patients were initially fed a mixed diet containing 40% of energy as carbohydrates, 40% as fat, and 20% as protein. This diet was later modified with the daily energy intake reduced over the weeks.

Profound changes in iron metabolism occurred during a two-week VLED in the obese subjects which included a sharp decrease in serum iron already apparent after one week, which was 50% of baseline values, as well as a slight, non-significant reduction in TIBC after three weeks. These changes were similar to those observed in normal individuals undergoing prolonged fasting, although the magnitude of the changes was smaller for TIBC and larger for serum iron.

It was concluded that a two-week VLED-induced functional iron deficiency is too short in duration to significantly affect erythropoietic activity. High-dose oral iron supplementation can only partially compensate for this phenomenon.

Although total energy, protein and fat content also co-varied with iron across groups, comparisons of the groups with identical iron intake (lowest and highest VLED groups) showed that total energy and macronutrient content had far less influence on thyroid hormone changes than did the iron content of the diet. Obesity in itself is associated with many alterations in the immune system, but acute energy deprivation in obese subjects causes more pronounced changes in immune function.

In conclusion, provision of an additional small amount of dietary iron (9 mg/d) above the RDA will help promote the return of iron-status indexes and T3 toward baseline values at a faster rate in patients consuming VLEDs. This return of circulating thyroid hormone concentrations towards baseline values promotes greater retention of a negative energy balance during VLEDs and should promote greater rates of weight loss.

The alterations in indicators of iron status are not associated with an increased likelihood of anaemia, although they are apparently related to thyroid hormone responses to energy deprivation.

Note: The figures indicate that anaemia is not one of the outcomes of VLEDs, despite the drop in transferrin saturation to low values for a period of time. Alterations in red blood cell indices are not mediated by absolute iron deficiency, inflammation or protein malnutrition, but could be related to alterations in the iron storage and release behaviour of the reticuloendothelial cell during energy deprivation alone.

However, in all weight reducing diets, it would be advisable to have a nutrient-dense meal. Fortified breakfast cereals can begin the day well, i.e. high in carbohydrates, low fat and nutrient-dense.

Source: Beguin Y., Grek V., Weber G., Sautois B., Paquot N., Pereira M., Scheen A., Lefebure P. and Fillet G; Am. J. Clin. Nutr., 1997;66:75:9 and Kellogg’s Nutrition Advisory Service.

Eat right & take a multivitamin
By Damaris Christensen

HIGH levels of folate in the diet have been associated with lower blood levels of homocysteine, and people with high levels of homocysteine seem to be more likely to develop heart disease, explained lead researcher Dr Manuel R. Malinow in Portland. Malinow and his colleagues gave 75 men and women, ages 45 to 85, who had heart disease, breakfast cereals fortified with one of three levels of folate and then measured the effects of the different diets on the amount of homocysteine in the patients’ blood.

Homocysteine levels did not decrease significantly among patients given cereal containing 127 micrograms of folate daily, about the amount expected to be gained through food fortification.

The evidence linking heart attacks with homocysteine levels and folate intake is very strong.

This study shows that even a well-balanced diet does not contain enough folate to lower homocysteine levels and prevent heart attacks.

“We as doctors need to change from saying “eat right or take a multivitamin” to saying “eat right and take a multivitamin”, he said.

Folate from fortified grain products is more readily absorbed by the body than naturally occurring folate in foods, so fortification is very important,” he said.

The author is an American diet expert.