The Tribune, Chandigarh, India

Ageless agility
By Dr G.D. Thapar
God willing, you will live to ripe old age. You will then like to be a wise old man, respected in the community to whom younger people will come for advice and guidance. Mental agility, keen intellect and the ability to solve problems are what you will then need. They are important attributes of successful ageing. The important question is: Is it possible to ensure such a thing and, if so, how?

The realm of the mind
Key to schizophrenia treatment
By Patricia Reaney
Scientists said in London on Monday that they might have found the key to better treatment for schizophrenia and drug addiction.

Drinks: hard facts
By Dr R.J. Dash
Alkuhl was used as an "essence" in medicine and religious ceremonies in the Arabic world of the 9th century. Our own "somarasa", in the Vedic era referred to as a refreshing drink used by "kings, royal persons and Brahmins", is well known. From such medicinal and recreational use, alcohol became a drug of abuse in the 17th century.

The taming of AIDS
By Dr Naveet Wig
All AIDS patients are offered therapy. In general, any patient with less than 500 CD4+ T cells/mm3 or greater than 10,000 (bDNA) or 20,000 (RT-PCR) copies of HIV RNA/ml of plasma should be offered therapy. The decision to begin therapy is complex and must be made in the setting of careful patient-counselling and education. Affordability, willingness, adherence, pill-burden, side-effects and drug interaction are the main problems during ART. .

Honour goes to heart
The state of Punjab and the Tagore Heart Care and Research Centre, Jalandhar, have the distinction of receiving a coveted international award. Dr Harinder Singh Bedi, Chairman of the Department of Cardiac Surgery at the Tagore Centre, has been nominated as Deputy Governor of the A.B. Institute Research Association in North Carolina (USA), and also as Deputy Director-General of the I.B. Centre, Cambridge, England.

Ageless agility
By Dr G.D. Thapar

God willing, you will live to ripe old age. You will then like to be a wise old man, respected in the community to whom younger people will come for advice and guidance. Mental agility, keen intellect and the ability to solve problems are what you will then need. They are important attributes of successful ageing. The important question is: Is it possible to ensure such a thing and, if so, how?

The protective effect of education and mental activity: As long ago as second century B.C, philosophers thought that active mental life might forestall or delay the enfeeblement of old age. Cicero suggested that old people would preserve their intellect if they would preserve their interests.

The truth of such statements has now been confirmed.

A low level of education has been found to be associated with the high prevalence of dementia. Several studies have indicated that education and the continued use of the brain protect one against mental degeneration, the prevalence of which may be as high as 8 per cent among the illiterate but less than ½ per cent among the educated. Education and mental activity are believed to protect one from neurodegeneration. Let us see how they do it.

The ageing brain: It is true that, in common with other body systems, the cells (neurons) of the brain diminish in number as age advances, but this does not make any perceptible difference to the mental capacity of the person, his thought process and alertness. Intellectual deterioration is not inevitable with ageing. There are a large number of old people who are mentally agile and intellectually sharp.

Neurons have extensions called dendrites which branch out and form connections with dendrites from other neurons forming an intercommunicating network so that when a neuron dies, its work and functions are taken over by other neurons.

Neuronal networking continues to occur throughout life. Continued mental activity protects one against neurodegeneration by the activation of brain cells which, in turn, stimulates protective mechanisms such as DNA repair. Secondly, mental activity improves the networking in the brain cells through the growth of dendrites. It is this increased mental reserve in the form of the networking of neurons that prevents dementia and preserves intellect in old age.

By contrast, head injuries, for example those caused during boxing, may deplete these reserves early and bring forth a pathetic picture of dementia.

The only difference between a young and an old person is that the capacity to learn new things and techniques diminishes with age. This is more than compensated by the increased capacity to utilise the knowledge and techniques already acquired and perfected over one's life-time. It is, therefore, important to learn as much as possible during younger years so that you have a large number of skills at your disposal for utilisation during old age.

Activities that help keep the intellect intact: Just as physical activity builds up muscles and keeps the body in good shape, intellectual activity is essential for the maintenance of intellectual and mental health. All intellectual activity is useful in building up mental reserves, which will stand you in good stead when you reach old age. As you indulge in games like tennis and badminton for the good of your body, you should indulge in serious mental exercises for the good of your brain. Such intellectual activities as chess, crossword puzzles, brain-teasers or twisters, etc, stimulate your brain.

In addition, keep up your interests in your hobbies, family, community and the world at large. All these activities will not only provide fun and relaxation but also help you to continue feeling young longer and ward off many effects of old age when it comes.

The author is a former Director (Medical), chief of the medical unit at the Willingdon (now Ram Manohar Lohia) Hospital, New Delhi, and a consultant in medicine and cardiology at INAS Hospital, University of Tripoli. He is now based in Ambala.

The realm of the mind
Key to schizophrenia treatment
By Patricia Reaney

Scientists said in London on Monday that they might have found the key to better treatment for schizophrenia and drug addiction.

They think the clue to controlling the illnesses is the interaction of proteins on the surface of brain cells that act like night club bouncers deciding how much dopamine and other brain chemicals to let into the cell.

Dopamine is linked to pleasure and addiction. Other brain chemicals called GABA are associated with learning, memory and emotion. Too much or too little dopamine and GABA chemicals produce many of the symptoms of schizophrenia and addiction.

"This is the first demonstration that these proteins actually talk to each other," Dr Hyman Niznik, of the university of Toronto, said in a telephonic interview.

Niznik and his colleagues have discovered how the protein systems interact and join together.

"This may provide us with a new therapeutic window on how to restore normal cellular function in diseases like schizophrenia with the right medication that can either block this interaction or make it happen," Niznik explained.

There are many different types of receptors in the brain. Some, like D I and D5, respond to the same drugs but others are very specific.

In a report in the science journal Nature, Niznik describes how dopamine D 5 receptors can directly alter the function of GABA receptors by binding to them. Scientists had previously thought that other proteins called G-proteins, were also needed.

"We've shown how these two receptor proteins bind to each other in order to modify each other's function," said Niznik.

"It's like cutting out the middle guy— you don't need the G-protein to let these receptors talk to each other. We believe this to be a very general phenomenon."

Niznik and his colleagues think people suffering from schizophrenia, which occurs in 1.5 per cent of the world's population, have " a coupling problem" between brain receptor proteins.

The findings open up another avenue for treating schizophrenia, different from the approach of antipsychotic drugs which target other brain receptors.

Schizophrenia is the most common form of severe mental illness. Its causes are still unknown but scientists know it affects chemicals in the brain and believe there is a biological link which can predispose a person to the disease.

Sufferers experience hallucinations, hear voices and suffer from depression and bizarre and often violent behaviour. The illness usually begins in the late teens or early 20s. — Reuters

Drinks: hard facts
By Dr R.J. Dash

Alkuhl was used as an "essence" in medicine and religious ceremonies in the Arabic world of the 9th century. Our own "somarasa", in the Vedic era referred to as a refreshing drink used by "kings, royal persons and Brahmins", is well known. From such medicinal and recreational use, alcohol became a drug of abuse in the 17th century.

Today, 50 to 70 per cent of all men and less than 1-50 per cent of all women drink alcoholic beverages. About 1-12 per cent of them are heavy drinkers.

While ethyl alcohol (ethanol) is friendly to man, methyl alcohol is deadly. Sudden death following alcohol abuse, is often traced to methyl alcohol-contamination. Survivors, if any, become totally blind.

Inebriation from an alcoholic beverage is directly related to the alcohol content: 250 ml of beer being equivalent to 20 ml of whisky, rum or brandy, 25ml of gin, 100 ml of champagne, red or white wine or, 60 ml of sherry. The alcohol content in these volume-equivalent beverages is 10 kg and all are equally dangerous. It is unwise to consider beer as a safe drink and only whisky and rum as "alcohol".

Alcohol is absorbed rapidly in empty stomach but it is slowly oxidised in the liver. The rate of alcohol degradation is 150 mg/kg body weight/h. A 60-kg man will take one hour to degrade 9gm of alcohol. Men degrade alcohol faster than women. Habitual users degrade alcohol much faster than occasional drinkers. One can differentiate between a habitual drinker and a casual one from the speed of alcohol consumption in a social gathering.

A normal liver oxidises alcohol by alcohol dehydrogenese to acetal-dehyde and, thereafter, by aldehyde dehydrogenese to acetate for further metabolism as a substrate for glucose. But a liver exposed to repeated alcohol onslaughts develops a ten-time faster alcohol oxidising system to produce acetal-dehyde. In the long run, alcohol produces more glucose and fat in the body, leading to a fatty liver as well as increased fat deposition in the heart and the muscles.

One gm of alcohol generates 7 kcal of energy compared to one gm of carbohydrate, protein and fat, yielding four and eight kcal, respectively. Since alcohol provides only calories but no vitamin or mineral, it has no food value.

It is called the source of empty calories.

In addition to the calorie value, the carbohydrate content adds up to the calorie content. For example, though 250 ml of beer is similar to 20 ml of whisky in its alcohol content, the former provides 120 calories while the latter yields only 70 calories.

The medicinal value of alcohol is recognised in improving one's appetite, stimulating food consumption, peripheral vasodilatation (flushing) and mood elevation probably due to the blunting of psycho-social inhibitions.

Alcohol-inebriation is habit forming. It leads to addiction. The progressive increase in the alcohol oxidation ability leads to a higher and higher increase in the volume of alcohol consumption. Thus, a benign looking social habit turns into alcohol addiction. Alcoholism in the family is, perhaps, the strongest predictor of alcohol abuse in an individual. Children of alcoholic parents are four times more likely to become alcoholic than the children of non-alcoholic parents. A genetic basis for alcoholism has also been projected though very little is known about the specific genetic mechanisms involved.

Studies have been largely inconclusive as to why one indulges in drinking alcohol. Psychoanalysts believe this to be due to a certain fixation in personality development. Alcohol promotes mood and provides an escape from the harsh realities of life. To some, it provides a self-destructive drive derived from intense anger, and the feeling of frustration or inferiority.

Others attribute alcoholism to a learning process similar to speaking, reading and writing by a growing child. The reduction in anxiety after consuming alcohol and discomfort on its withdrawal makes one's body and mind dependent on alcohol. Further, an increase in endogenous opioids, the pain-relieving chemicals from the brain, by alcohol, induces euphoria and relief from stress. Such physio-biochemical messages get imprinted in the thought process favouring the continuance of alcohol use and abuse.

People, indulging in drinking alcoholic beverages, are broadly grouped into those (1) who drink too much of alcohol (alcohol abuse) and (2) who have developed alcohol dependence. The alcohol-abusers continue drinking despite the knowledge that several social, occupational, psychological or physical problems are caused and worsened by alcohol or drinking it is hazardous when driving an automobile. For alcohol dependency, the individual demonstrates at least a couple of the following: preoccupation with the procurement of particular brands of alcohol, the consumption of large volumes of alcohol over long periods of time or progressively increasing the consumption of the volume of alcohol, the proneness to developing alcohol withdrawal symptoms and drinking alcohol to avoid them, the continuation of alcohol abuse despite suffering from health problems related to continuous alcohol use, the giving up of important social, occupational or recreational activities in favour of alcohol session (s), the expression of persistent desire and making efforts to control alcohol consumption, etc.

Continuous efforts are being made by de-addiction centres to help both alcohol-abusers and alcohol-dependants. Success, however, depends to a large extent on the support of one's family and friends.

Dr R.J. Dash heads the Department of Endocrinology at the PGI, Chandigarh. He is the seniormost professor in his speciality in the country.

The taming of AIDS
By Dr Naveet Wig

All AIDS patients are offered therapy. In general, any patient with less than 500 CD4+ T cells/mm3 or greater than 10,000 (bDNA) or 20,000 (RT-PCR) copies of HIV RNA/ml of plasma should be offered therapy. The decision to begin therapy is complex and must be made in the setting of careful patient-counselling and education. Affordability, willingness, adherence, pill-burden, side-effects and drug interaction are the main problems during ART. When initiating therapy in the patient who has not received ART earlier, one should begin with a regimen that is expected to reduce viral replication to undetectable levels, i.e highly active antiretroviral therapy (HAART). This includes a combination of two nucleoside analogues (NRTIs) and one potent protease inhibitor (PI), i.e triple drug therapy.

Triple drug therapy in India costs Rs 25000 per month. Further, this therapy is to be continued life-long. Hence, practically, such therapy is beyond the reach of all AIDS patients unless the cost of these drugs is reduced. Earlier studies in the West have shown the benefit of dual drug therapy. Hence it is recommended that patients who wish to take ART in India and can't afford triple drug therapy may be offered a dual NRTI combination the cost of which may be around Rs 4000 per month. Such option improves the quality of life and decreases the incidence of opportunistic infections.

Guidelines for optimal antiretroviral therapy and for the initiation of therapy in pregnant HIV-infected women should be the same as those delineated for non-pregnant adults. The rise associated with pregnancy should be explained to the mother. The decision to use any antiretoviral drug during pregnancy should be made by the woman following discussions with her health-care provider regarding the known and unknown benefits and risks to her and her foetus.

The risk of transmission of HIV from mother to child is 15-50 per cent. The factors associated with increased mother-to-child transmission include a low CD4 T cell count in the mother, high viral load in the mother, prolonged delivery time, early rupture of membranes, placental infection and the mode of delivery. There is a debate going on regarding vaginal delivery versus caesarean section. Caesarean section has its own associated morbidity.

To prevent vertical transmission, zidovudine should be included in all regimens. A randomised, double-blind, paediatric ACTG 076 clinical trial proved that ZDV reduces the risk of perinatal HIV transmission. The drug was administered according to the following regimen: orally (100 mg five times a day), antenatally after 14 weeks gestation and continued throughout pregnancy, intravenously during the intrapartum period (2 mg/kg loading dose over one hour, then a continuous infusion of 1 mg/kg/h until delivery), and to the new-born (2mg/kg orally every 6 hours), begun six to 12 hours after birth for the first six weeks of life. This chemoprophylactic regimen reduced the risk of perinatal transmission by 66 per cent.

Thai trial of "short course" zidovudine in the dose of 300 mg twice a day during the last four weeks of pregnancy and 300 mg every three hours during labour reduced vertical transmission by 51 per cent in women who were not breast-feeding. This regimen is estimated to cost roughly Rs 2500. This is the minimum which should be offered to all HIV positive pregnant women. However, ideal would be triple drug therapy if the patient can afford it or dual drug therapy.

There are options available once the mother is found to be HIV positive during labour to prevent vertical transmission. Zidovudine at the dose of 300 mg every three hours should be given to the mother along with zidovudine to the new-born (2 mg/kg orally every six hours) begun six to 12 hours after birth for the first six weeks of life. The other drug that has been found effective is nevirapine. Two tablets of 200-mg nevirapine, which cost Rs 400 can be given to the mother along with the first dose to the new-born within 72 hours.

HIV can be transmitted from a mother to her baby through breast milk. This isn't a problem in developed nations, where HIV-infected women can use the formula for their infants. But alternatives to breast-feeding aren't easily available in developing countries and breast-feeding protects infants from other potential infections.

Counselling and educational, and psychosocial support are important issues. They play a major role. Good counselling helps the individual and his family to cope with the circumstances arising as a result of the HIV status. Tips for good counselling include making the patient comfortable, listening carefully to his problems, creating his confidence in the doctors and assuring confidentiality and being empathetic towards him. Other tips include providing the relevant information to the individual and his family for which they have come, helping the person and the family to reach a decision, time-to-time reassurance and the importance of regular health follow-ups, most importantly assuring 24-hour medical facilities.

All HCWs should be aware of post-exposure prophylaxis (PEP). PEP should be available for 24 hours in all hospitals in the country. All health care workers who get needle-prick injuries or are exposed to HIV-infected material should receive adequate PEP. It depends on the exposure risk (high risk or low risk) and on the stage of the HIV patient (low or high viral load). A recommended regimen is either the basic regimen consisting of two NRTIs or the expanded regimen consisting of 2 NRTIs, and 1 PI. PEP is given for four weeks and HCWs HIV testing is done at baseline, six week, three months and at six months.

The optimum medical management of the HIV-infected individual is the prime responsibility of all physicians. Management guidelines are quite simple. However, the biggest obstacle in ideal management is the lack of money.

Preferably, patients should be offered triple drug therapy. Since the cost is the main factor, dual drug NRTI therapy may be offered to patients who are willing to take it but can't afford triple drug therapy. Short course zidovudine has proved effective in reducing perinatal transmission and this therapy should be offered to all HIV-infected women who wish to continue their pregnancy. So, all-out efforts should be made to prevent perinatal transmission which could help in bringing down the number of HIV cases. Prophylaxis for opportunistic infections should be provided to all patients. All doctors and health care workers should be aware of universal precautions and PEP. Extra care should be provided to these patients so that the "discrimination" by doctors against HIV patients can be disproved.

(Concluded)

Dr Wig is a faculty member at the AIIMS, New Delhi.