Cooperation for cure
The patient’s partnership in disease management is essential
By Dr S.K. Jindal
There is no better example of mutual trust and belief in a relationship than that between a doctor and a patient. This is a relationship of a wide spectrum which resembles that between the parents and the children on the one hand, and between the seller and the consumer on the other hand. It extends from compassion, responsibility and empathy to consumerism, business and (sometimes) confrontation.

Asthma prevention: some tips
By Dr Shakuntala Lavasa
The prevalence of asthma has increased all over the world. It is estimated that approximately 40% of the population has the genetic make-up to develop asthma. As many as 5% of the infants show the evidence of asthma soon after birth, 19% have symptoms by one year of age and 20% by the age of five years. One out of 20 children, as per hospital records, is asthmatic today whereas two years back it was one out of 40. 

November 14 is World Diabetes Day
Diabetes is costly; prevent it!
By Dr R.J. Dash
India enjoys supremacy in the number of patients with diabetes. Today we have an estimated 30 million people with diabetes and another 25 to 30 million with impaired glucose tolerance (IGT), the forerunner to diabetes. This is the highest number that any country in the world has to take care of and it is projected to treble in the next quarter-century.

Osteoporosis: causes and treatment
By Dr Rajeev Goel
Osteoporosis is characterised by low-bone mass as well as the deterioration of bone tissue at the microarchitectural level. This causes the fragility of the bones which consequently increases the fracture risk.

Cure for arthritis discovered
British scientists have announced what they say is the first evidence of a cure for rheumatoid arthritis, the Sunday Telegraph reported. A research team at University College in London says that it has discovered what causes the body’s defences to mistakenly attack healthy joints and tissues.

• Pregnant women need more iodine

Cooperation for cure
The patient’s partnership in disease management is essential
By Dr S.K. Jindal

There is no better example of mutual trust and belief in a relationship than that between a doctor and a patient. This is a relationship of a wide spectrum which resembles that between the parents and the children on the one hand, and between the seller and the consumer on the other hand. It extends from compassion, responsibility and empathy to consumerism, business and (sometimes) confrontation. Moreover, the relationship is neither permanent nor obligatory. It is a partnership which succeeds admirably when both the partners are mutually responsive and responsible. One cannot just rely on the doctor alone to get the positive results. Similarly, the doctor must not assume the role of "Mr Know-All" and "Mr Do-All" whenever managing a sick individual.

The issue that a patient needs to participate and cooperate in almost any plan of medical management is undebatable. A prescription is meaningless unless it is effectively utilised by the patient. It is common knowledge that most people do not follow the treatment instructions in toto. This is perhaps inherent in human nature. Yet we often tend to blame the prescription or the physician for any unfavourable outcome of an illness. Endless examples of such experiences can be given.

The issue of treatment compliance is best understood in the case of de-addiction programmes. Compliance can hardly be expected on the mere advice to quit alcohol, a habit-forming drug, or tobacco consumption. Everyone may want a magic medicine to get rid of a habit causing distress. But success can be achieved only with a prolonged and arduous programme involving the whole family.

Certainly, people do understand that a psychiatric disorder or a drug dependence problem is difficult to treat especially because the patient himself- or herself is not fully competent and involved. Let us take simpler examples of an acute infection and a relatively chronic illness such as pulmonary tuberculosis. As per several assessment studies, more than 80 per cent of the people will falter on either the dose or the duration of the prescribed drugs. It was the realisation of this very fact that led the World Health Organisation and also the Government of India to adopt the strategy of the Directly Observed Therapy, Short Course (DOTS) for tuberculosis where each treatment dose is required to be put in the mouth of the patient in front of a drug-provider.

Patient cooperation is important not only in taking the medicine, but also in following other instructions. Any number of bottles of cough mixtures and expectorants or strips of antibiotics will do not good to a patient of bronchitis or asthma who continues to smoke, irrespective of medical advice. Similarly, anti-diabetic and anti-hypertensive drugs will not serve the purpose unless dietary precautions are taken. Most patients with musculo-skeletal and joint problems cannot fully benefit without the recommended exercises and weight reduction. Unfortunately, many of the ancillary recommendations are difficult to follow, but these do play a crucial role in treatment plans. Quite often, the non-drug factors may determine the success or failure of a treatment.

Another important area where the patient's active participation is required is his or her appreciation and understanding of the disease, the anticipation of future complications, the progress of illness and the limitations of the treatment. While most diseases are treated in one or the other way, only a few are cured. Many of the illnesses require life-long treatment and remain controlled while others continue to progress, irrespective of the treatment. It is the last group of diseases which is difficult to understand. Treatment in these cases is aimed either at palliation or at somehow reducing the pace of progression. There is a constant dilemma — whether to treat or not to treat such patients, especially because treatments are associated with several other problems. There is no easy way to come out of this dilemma.

We always like to involve the patient and/or the family in treatment decisions. This, however, is not necessarily a successful strategy all the time. This is even more so in the case of relatively unfamiliar illnesses. People may know the ifs and buts of asthma, tuberculosis, diabetes, hypertension or cancer. But how many can really appreciate problems such as emphysema, cardiomyopathy, fibrosing alveolitis or motor neurone disease which may relentlessly progress to death, sooner or later?

The patient's ability to understand depends upon innumerable factors such as age, sex, education, occupation, religion, race and so on. Further, the explanation given by doctors are interpreted differently by different people. Generally, people would tend to translate all advice into their own beliefs and conveniences. There is almost always a lack of clear understanding.

The patient's interpretation of medical advice is quite personal for not only the serious and progressive disorders but also for other common problems such as anxiety, depression, allergies or infertility. There is never a direct correlation between what is advised and what is understood.

Lastly, the limitations and the problems of treatment are required to be accepted. Quite often, the treatment's effects are unexpected. There is no treatment which is one hundred per cent effective and safe. Even a highly effective drug in most patients may not show its useful effects in a few. Similarly, a very safe drug may well prove to be risky in some. It is a known fact that some patients may show allergic or hyper-sensitivity reactions to an otherwise innocuous drug. The same is true about complications following a surgical procedure. The issue of unexpected effects and reactions is always a sore point with patients.

On the other hand, many treatments are administered with the full knowledge of their side-effects and toxicity. Several kinds of surgical operations are done and medicines (such as corticosteroids and cytotoxic drugs) are given in spite of their known problems. Such a decision is obviously made in being the best (or better) of the available options. The problems ensue when the opted solution starts causing problems. Factually, no patient can appreciate the unforeseen problems of a treatment in spite of being told in the beginning. Yet, explanations require to be given.

To summarise, the patient continues to remain as an important and responsible partner in managing his/her disease. Unfortunately, the disease belongs to him/her alone. The patient needs all the attention and empathy of his doctor. But neither the doctor nor anyone else can own the disease. Although the treatment is given by the doctor, it belongs to both. The doctor is more like a counsellor or a facilitator than like God. He/she needs to keep in mind always the very ancient saying: I treat, He cures.

Dr Jindal is the Professor and Head of the Department of Pulmonary Medicine at the PGI, Chandigarh.

Asthma prevention: some tips
By Dr Shakuntala Lavasa

The prevalence of asthma has increased all over the world. It is estimated that approximately 40% of the population has the genetic make-up to develop asthma. As many as 5% of the infants show the evidence of asthma soon after birth, 19% have symptoms by one year of age and 20% by the age of five years. One out of 20 children, as per hospital records, is asthmatic today whereas two years back it was one out of 40. The actual incidence in the community must be much more than that in the hospital records. Until a decade ago, there was low prevalence of asthma but in the past few years it is increasing alarmingly. In a study, asthma accounted for 30% of the total respiratory tract diseases in children. New effective methods for treatment are being discovered with the hope of cure but preventing asthma is more important. Asthma prevention falls into two categories.

Primary — Preventing the initial development of asthma in susceptible people.

Secondary — Preventing exacerbation in patients who have developed asthma.

Most of asthma originates in childhood and is associated with allergy. When an infant is exposed to an allergen, there is the production of THI cells and TH2 cells with the dominance of the first, leading to tolerance in the normal infant. However, in infants with a genetic predisposition to asthma, TH2 cells dominate, and tolerance to allergens cannot be established. Primary prevention aims at reducing the factors that may prevent the establishment of THI (tolerance-producing) cells in the perinatal period and infancy. These are:—

Avoidance of maternal smoking.

Prolonged breast-feeding.

Delaying the introduction of salt, pulses eggs and allergen food in infants with the family history of allergies.

Reducing the environmental allergen load. (Don't use talcum powder, fragrant soaps, perfumes and other unnecessary articles for the baby).

Avoid fixed carpets. If it is unavoidable, clean it by a vacuum cleaner.

Reduce soft furnishing. Don't use soft toys.

Encourage ventilation and sun.

Frequently, place the bedding in sun.

Avoid smoking, room freshners agarbattis anti-mosquito coils and other fumes.

Use light-weight curtains. Wash them every fortnight.

Prefer window shades made of cotton to Venetian the blinds.

Avoid keeping pets in the bedroom at night. Bathe the pet every week with a shampoo.

Close the windows at night since night air carries much pollen.

Put mattresses and pillows in plastic casing; wash the bedding every week with hot water.

Repair plumbing leaks to check mould growth.

Check the refrigerator and throw the unused food away biweekly at least.

Seal dry grain, flour, rice and other stored food. Keep the storage area dry and clean.

Use damp cloth to dust.

Avoid parking under a tree.

Use the recirculating mode on airconditioners or heaters while travelling.

Avoid car perfume and smoking in the vehicle.

Wash your hands after gardening or handling animals to avoid rubbing allergens into the eyes or the nasal mucosa.

Perform exercises like walking at normal speed and deep breathing.

Wash sports equipment to prevent mould growth.

The early morning and late night air carries more pollens. Plan outdoor activities at other times.

It has been well established that food can affect asthma. Fatty acids particularly can have an adverse effect. Omega 3 fatty acids like fish oil, butter and monounsaturated oils are important in inflammation control.

Omega 6 fatty acids such as those in sunflower oil, margarine and polyunsaturated oils are proinflammatory and should be avoided. It is also prudent not to avoid food on presumptions alone as all nutrients are needed for growth.

In future, it will be possible to identify infants at risk based upon the genetic profile. The immune response may be modulated so that an infant develops a good THI response and becomes tolerant to the environment.

Dr Lavasa is a renowned paediatrician and allergy expert based at 226, Sector 9, Panchkula, (562239).

November 14 is World Diabetes Day
Diabetes is costly; prevent it!
By Dr R.J. Dash

India enjoys supremacy in the number of patients with diabetes. Today we have an estimated 30 million people with diabetes and another 25 to 30 million with impaired glucose tolerance (IGT), the forerunner to diabetes. This is the highest number that any country in the world has to take care of and it is projected to treble in the next quarter-century.

As the number of years with diabetes increases, the risks of blindness, kidney failure, neuropathies (including impotency) fatal heart attacks and stroke increase. Besides, there is a significant loss of hours of work — and reduced longevity. Keeping diabetes under control (fasting blood sugar at 110mg or low and post-meal blood sugar at 140mg or low) significantly reduces these complications and increases years of healthy life.

More than half of the people with IGT or diabetes are not aware that they have this disease. Tiredness, weight loss, frequent passage of large volumes of urine, thirst, an increase in appetite, repeated infections and delayed wound-healing are classical symptoms of diabetes. These, however, are noted in only one third of the patients. The onus of diagnosis, therefore, depends on the persons at risk.

Parental history of diabetes, obesity, hypertension, heart ailments, persons with large (4kg or more) or small (1.5kg) birth weight, diagnosed to have abnormal glucose profile during pregnancy, heart attacks or any stressful event are likely to meet diabetes. Such persons as lose weight despite eating good food, gain weight rapidly or abuse alcoholic beverages should get their blood glucose checked for the exclusion of diabetes.

The early diagnosis of diabetes helps in identifying the cause and risk modifiers. Life-style changes involving physical inactivity, high-fat, high-salt and calorie rich fast foods, sweatened or alcoholic beverages are most important causes of developing and worsening diabetes (in association with diabetes). Timely intervention in one's lifestyle controls diabetes, helps in arresting the progression of IGT to diabetes and even primarily prevents the onset of IGT and diabetes in a sizeable population at risk.

The direct cost of diabetes-care involving drugs, laboratory tests and doctors' advice is a conservative Rs 5000/year/patient — i.e. Rs 1500 crore for 30 million patients in a year. Hospital costs for the care of complications vary between a few thousand to over several 100 thousand per patient. The number of such patients with chronic complications of diabetes is increasing as many have longer years of poorly controlled diabetes.

The awareness of diabetes and its timely detection help us and our families. Lowering the number of patients with diabetes helps conserve our health budget, improve national economy and increase manpower resource.

Dr Dash is the Professor and Head of the Department of Endocrinology at the PGI.

Osteoporosis: causes and treatment
By Dr Rajeev Goel

Osteoporosis is characterised by low-bone mass as well as the deterioration of bone tissue at the microarchitectural level. This causes the fragility of the bones which consequently increases the fracture risk.

Osteoporosis not only impairs the quality of life for many older people but also becomes a matter of life and death in a few cases. In the West, osteoporosis has been labelled as the "silent epidemic" because the people suffering from it are unaware of their disease until they have painful disabling effect or potentially fatal fractures like the collapse of the bones in their back (vertebral fractures). Besides this, the commonly seen fractures are of the wrists, the hips and the femur.

We reach our peak bone mass in our twenties or thirties which starts to decline by 0.5% subsequently. This rate increases in the case of women by the drop in oestrogen production around menopause. In men, the rate of bone loss is slower and consistent. Moreover, there is no sudden loss of density in men as seen in certain postmenopausal women. That is why women are prone to higher risk.

Osteoporosis is diagnosed as clinically significant when the bones are more porous than they should be at a given age and there is an increased risk of fractures occurring even from minimal trauma. Osteoporosis has been classified as primary, secondary and idiopathic. Primary osteoporosis accounts for 60 to 80% of the cases and generally post-menopausal women fall in this category.

Secondary osteoporosis accounts for 20 to 40% and is generally associated with abnormalities of the endocrine system, anorexia nervosa, premature menopause (before the age of 45), hypogonadism in men, multiple myeloma, malabsorption of calcium and vitamin D, lactose intolerance (causes a low calcium intake), long-term alcohol intake and immobility. Besides this, the long-term use of drugs like steroids, anti-epileptics, insulin, etc, may also cause secondary osteoporosis.

The idiopathic form of osteoporosis is quite uncommon but often occurs in men and women below 50 years of age.

There are certain other factors which increase one's risk of developing osteoporosis like chronic liver disease, thyroid disease, rheumatoid arthritis, Cushing's Disease, oestrogen deficiency and even the family history. Researchers now believe there is a genetic factor predisposing some people to a reduced bone density. An Australian group of researchers claims to have discovered an "osteoporosis gene", the vitamin D receptor on chromosome 12.

The early stages of osteoporosis are difficult to diagnose. Fractures, especially those of the wrist, the femur and the vertebrae may indicate osteoporosis. Osteoporosis is diagnosed through patient presentation, clinical findings and by doing a bone mineral density (BMD) scan to assess bone density. The dual energy x-ray absorpitometry uses a low-dose radiation scan to find out osteopaenia (decreased calcification) or density of bones or osteoporosis quickly and without much discomfort.

From this the T or Z score is evaluated. The T score is calculated from a comparison with the young adult average and is indicative of absolute fracture risk for an individual. The Z score is the comparison of the same age average and indicates an individual relative risk for his age. Investigations like x-ray to establish fractures and biochemical tests of urine and blood to establish bone renewal are also carried out.

The treatment of osteoporosis can be in the form of Hormone Replacement Therapy (HRT). The non-hormonal treatment includes the use of bisphosphonates — a group of drugs that inhibits the resorption of bones and vitamin D to absorb calcium. The patient is relieved of pain through physiotherapy, hydrotherapy, acupuncture, heat or cold packs and appropriate analgesics.

Educating and creating awareness among the masses are essential. It has long been known that calcium-rich diet, sufficient intake of vitamin D and exercising are crucial to building strong bones which in turn decrease the risk of osteoporosis. Smoking can impair calcium absorption and cause early menopause, thereby increasing the risk of osteoporosis. Therefore, conveying this message to the younger generation should be one of our health education priorities.

Osteoporosis can be both debilitating and isolating. The resultant pain can restrict one's mobility. Moreover, the altered body image can also cause embarrassment to the person concerned.

The need for the prevention of the disease is clear. Exercise and active life are needed to improve the bone density. The objective in health promotion should be to reduce or prevent bone loss, provide dietary and healthy lifestyle education, prevent fractures and increase mobility, the awareness of the disease, support and advice to improve the patient's quality of life. All these together will go a long-way in preventing the pain and loss of independence that a fracture can bring in such patients.

Dr Goel is on the faculty of DMC, Ludhiana.