Can we live 100 years and beyond?-II
Where is Elixir of Life ?
By Dr G.D. Thapar
We are living in a zoo of our own making. This is where disease, decay, early burn-out, early old age and death lie. Free yourself from these shackles as much as you can.

Two steps forward in nuclear medicine
By Major-General (Dr) Jaswant Singh AVSM
during my three weeks' stay at the Army Hospital (R and R), Delhi Cantonment, recently for an unconnected disease, I had extended discussions with Lt Col J.K. Bhagat, Head of the Department of Nuclear Medicine. The following is a short account. It may be of use for patients as well as the enlightened citizenry.

T.B. and smoking
The devilish duet
By Dr Surinder K. Jindal

Tobacco-smoking, known to cause diseases from chronic cough to lung cancer, can now be credited with one more addition to its kitty. There is increasing scientific evidence in medical literature to suggest close association between tobacco-smoking and tuberculosis of the lungs. We have often talked about the infamous friendship between the tubercle bacillus and the human immuno deficiency virus (HIV) responsible for the grave combination of tuberculosis and HIV infection.

What is now being recognised is a similar association between the other two enemies of the health. This association may not appear to be as alarming as that with HIV infection, but the magnitude is certainly much larger and greater. It has been aptly termed as the dual epidemic of smoking and tuberculosis.

Sir Richard Peto, who achieved fame through his landmark studies on British doctors and others to define the close relationship of smoking with diseases such as lung cancer and chronic obstructive lung disease, has strongly suggested a three to five fold increase in mortality in tuberculosis attributed to smoking.

A large cohort study on the causes of deaths in tobacco users in Mumbai reports a two times higher risk of death due to tuberculosis. The risk increased with the increase in the amount and duration of smoking. In a small study at the PGI, we have found that smoking was present in 35 per cent of patients of tuberculosis of lungs compared to 11 per cent in patients suffering from non-tubercular respiratory diseases.

The human immunodeficiency virus is known to kill the T-lymphocytes which protect the body from various onslaughts by micro-organisms such as the tubercle bacillus. It cripples the immunological defences of all biological systems. Smoking is not as potent a killer of T-lymphocytes as HIV, but it affects the respiratory defences at several other non-immunological levels as well. Consequently, the proneness to tuberculosis and some other injections is increased.

Smoking causes numerous structural and pathophysiological alterations in the airways and the lung parenchyma. There is destruction of the normal protective lining of the respiratory tract. All these changes cumulatively result in the decreased capability of the lungs to expel and kill the invading particles and organisms from the atmosphere. The droplets containing tubercle bacilli, when inhaled, are, therefore, able to reach the lung and settle in a friendly environment. Tuberculosis results when the multiplication of the bacilli goes on unabated owing to the compromised defences.

Smoking may affect and influence tuberculosis at several different disease-levels such as infection and occurrence, complications and treatment response, relapse rates and mortality. Unfortunately, the effects of smoking at each level are known to be adverse as per the information available till date. The overall problem, therefore, is compounded manifold.

"Infection" in medical parlance is known as the introduction of organisms in the body while the term "disease" implies the presence of symptoms and signs caused by organisms. More than half of the Indians are infected by the tubercle bacilli. In normal circumstances, only one in 10 of the infected individuals develops the active disease.

It is quite likely that the rates of infection as well as disease are higher in smokers than in non-smokers. This is yet to be finally ascertained. But there is enough indirect evidence to suggest this linkage in studies from Spain, South Africa and the USA. Smokers for 20 years or more had 2.6 times the risk of non-smokers of having tuberculosis.

The second level of association is on the clinical manifestation of tuberculosis. Both smoking and tuberculosis cause lung destruction. A patient with both of the problems is likely to have severer disease and suffer from increased rates of complications. Patients are more symptomatic and breathless. The combined effects of tuberculosis and smoking-associated chronic bronchitis and emphysema are rather devastating and progressive. Early death is the obviously expected outcome.

Smoking is also known to influence the response to treatment. In our series, a greater number of smoker-tuberculosis patients were sputum-positive for tubercle bacilli than non-smoker patients. Delayed and inadequate treatment-response can be attributed to multiple factors such as the impairment of drug-induced killing mechanisms and increased drug-inactivation. Some effects may also be potentiated by smoking, resulting in increased drug-toxicity. Whether it also increases the emergence of drug-resistance is difficult to assess at present.

Finally, smoking may be responsible for the increased occurrence of relapses of tuberculosis after successful treatment. Tuberculosis is known to recur whenever the host conditions of the patient get worse. Smoking is clearly an important factor hostile to the healthy environment in the lungs. There is nothing better which the tubercle bacilli may require to re-emerge.

Undoubtedly, a lot more research is required before we get a clearer ;picture of this friendship between the two powerful enemies of respiratory health. Unfortunately, the worst interaction between these two killers is found among the poor, the homeless, the illiterate, the downtrodden and the disadvantaged — much more so in developing countries like ours. It is wiser to save money by quitting smoking and spending on treatment than to spend on smoking and die of tuberculosis.

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

Can we live 100 years and beyond?-II
Where is Elixir of Life ?
By Dr G.D. Thapar

last week, I described how we age and what brings old age earlier. To recapitulate; the genes, the environment and our lifestyle work together to influence longevity and our health in old age. Too much food, high in calories, brings old age faster. We can increase our lifespan by almost 40 per cent by eating food low in calories, i.e, less than 1500 calories per day. Antioxidants like vitamins A, C and E, found abundantly in fresh vegetables, fruits and nuts, reduce the damage done by oxygen-free radicals and thus prevent degenerative diseases and retard the process of ageing.

(Note: The prominently computer-typed byline — "By Dr G.D. Thapar” — was, because of a last-minute technical fault, erased from the first part of this article last week.)

Advances in the field of medicine, surgery and preventive health have already doubled the life expectancy all over the world. Imagine if all the new knowledge were put into proper use by individuals to prevent disease and degeneration, and suitable modifications made in people's lifestyle, food, work, etc. in the light of the new knowledge and insight, how many more fruitful years could be added to our lifespan and how much more healthy they would be! We would not then have to wait for the "Elixir of Life" to come.

The secret of health lies within us; disease comes from without. Nature has endowed us with an efficient system of fighting disease and damage repair. If we do no more than allow mother nature to look after us, we will be healthier and live longer. Add to this the use of modern medicine and surgery, and lo, we shall across the coveted 100-year mark!

The cage and the zoo

An animal is best in its natural habitat with its natural food. The moment you put him in a zoo, he loses his health and stamina in spite of the best conditions provided to him. Come out of the cage in which you have imprisoned yourself and discover for yourself what nature can do for you.

The zoo alluded to above is made of man-made materials and practices — overcrowded houses in large, overcrowded, overpopulated and polluted cities, overeating of rich fatty food obtained through chemical fertilisers and preserved with chemical preservatives, unhealthy and permissive sexual practices, stress at home and at work, smoking, drinking, etc. We are, in fact, living in a zoo of our own making. This is where disease, decay, early burn-out, early old age and death lie. Free yourself from these shackles as much as you can, and cultivate positive health by means which nature has provided. Given below are certain hints.

Cultivate positive health

The means to cultivate positive health are as under:

* Healthy living conditions in a simple, clean, uncrowded and unpolluted environment.

* A simple varied diet which is mainly lacto-vegetarian with plenty of fresh and green and leafy vegetables, fruits and nuts (but sparse consumption of animal foods).

* The sparse use of sugar, salt and fats; particularly animal fats, the lesser the better.

* A physically active lifestyle; the sparse use of automobiles; the use of one's legs or cycle for all distances less than 5 km.

* Regular moderate exercise of moderate intensity.

* Intellectually active life.

* Active interest in life, the family, the community and the world at large.

* Positive thinking of love, courage and optimism.

* Decisiveness.

* The attitude of happiness, helpfulness and thankfulness to people around you.

* Work for economic freedom.

* Authority with responsibility at work and a say in decision-making prevent work-related tension.

* Fidelity in marriage.

* Faith in the Supreme Creator, yourself and the inherent goodness of man.

* The timely treatment of disease; the avoidance of unnecessary tinkering with health or preoccupation with it.

* The use of preventive measures and vaccines, as indicated. These measures include non-use of chemicals, narcotic drugs, tobacco and alcohol.

There is nothing better than the cultivation of positive health, which is not merely the absence of disease; it includes vigour and stamina which keep diseases at bay, and ensure for us a healthy and long life. The real issue is not the number of years of our lifespan, important though it is. Of far greater importance than the number of years is the quality of life. It would be pointless to extend any further a life of disease and infirmity. In other words, it is one's healthspan rather than lifespan that is the more important thing. Aim at living a healthy life with zest and happiness and push middle age vigour far into old age. It is then certainly worthwhile to make it to 100 years and beyond.

(Concluded)

The author, who retains the copyright of the two-part article, is a former chief of the Medical Unit of the Willingdon Hospital, New Delhi, and a consultant in medicine and cardiology at the INAS Hospital, Tripoli.

Two steps forward in nuclear medicine
By Major-General (Dr) Jaswant Singh AVSM

during my three weeks' stay at the Army Hospital (R and R), Delhi Cantonment, recently for an unconnected disease, I had extended discussions with Lt Col J.K. Bhagat, Head of the Department of Nuclear Medicine. The following is a short account. It may be of use for patients as well as the enlightened citizenry.

Madam Curie separated radium from uranium in 1925; this paved the way for the utilisation of radioactive material for the treatment of cancer. With the advent of nuclear reactors and cyclotrons, a variety of artificial radio-isotopes were produced. As results of decades of research and efforts to bring the benefits of nuclear energy to the common man, radio isotope application started for the diagnosis and treatment of various diseases. A new branch of nuclear medicine was born.

The procedure in nuclear medicine utilises radio-pharmaceuticals (RP) for the diagnosis, follow-up and treatment of many diseases. The Alfa and Beta nuclear emissions are used for therapy because of their ionising properties which kill cells within a very short range. They cannot be detected externally. Therefore, they are not useful for imaging. The Gama rays, on the other hand, can be detected externally and so these can be used for imaging. Contrary to the existing fear in the mind of every one, the doses administered for this purpose have no adverse biological effect on a human being, but these techniques should not be used on pregnant women.

Nuclear medicine techniques are used for (i) diagnosis (ii) therapy (iii) research in medicine (iv) and the estimation of hormones and drugs in blood. Diagnostic studies can be imaging or non-imaging; both are non-invasive.

Radio-nucleotide imaging is useful, unique and sensitive in obtaining functional information of various organs in addition to anatomical information. A suitable organ-specific RP is administered by IV injection or orally. That is retained in the target organ. The distribution of this radio-activity is studied by a Gama camera and the images are produced by computers and displayed on x-ray films.

Thyroid scintigraphy is used in goitre, nodule, and hypo and hyper thyroidism. For this purpose, Tc-99 m and I-131 are used. Radio-iodine therapy for thyrotoxicosis is a well-established procedure, now especially for patients who are above 35 years or live in villages, cannot afford medical therapy for the minimum required period and are unfit or unwilling to go in for surgery.

Skeletal scintigraphy is done by 15-20 millicurie Tc 99 MDP iv injection and scanning is done after three hours. This investigation is utilised in the detection of benign or malignant tumours of the bone, bone metastasis, i.e, tumour spread, the response to therapy, the early detection of osteomyelitis, i.e, bone infection.

Renal scintigraphy: Many RPs are used for renal scintigraphy like Tc-99 M DTPA; various clinical problems which can be precisely diagnosed are: the assessment of individual and regional kidney functions, functions of obstructed kidneys, the blood-flow to kidneys, the progress and recovery of actual renal failure, the assessment of vascular disorders and hypertension, and finally, the functional assessment of the transplanted kidney.

Cardiac imaging: Myocardial perfusion scintigraphy (SPECT) is performed by Tc-99 M MIBI. Thallium is a metal of group 3. The initial thallium distribution depends on the regional blood flow of myocardium; normally 85% of thallium is removed from the coronary circulation in a single pass. The redistribution of thallium from the myocardium over a period of time determines the viability of the myocardial tissue. It helps ;in the functional assessment of anatomical abnormalities. Post-surgical (CABG) evaluation, the assessment of the effects of intra-coronary thrombolysis and the functional significance of collaterals is possible by this novel method. Gated blood pool scintigraphy (MUGA) is also performed to diagnose resting ventricular muscle dysfunction and the evaluation of heart murmurs.

Brain scintigraphy: Brain SPECT for cerebral blood flow is performed by IV injection of Tc-99 M. This is helpful in the diagnosis of the early ischaemic stroke, the prognosis of the stroke or Alzheimer's Disease and the diagnosis of Parkinson's Disease.

The unique features of radionuclide imaging can be illustrated as follows: (a) The assessment of the functional significance of anatomical lesions in coronary angiography, if studied by Stress Thallium Scintigraphy, will detect the culprit lesions. Predictions of favourable responses to renal angiography for renal artery narrowing can be done by positive captropril renogram.

(b) Many times, functional changes occur much earlier than structural changes. It is seen that when a CT scan and an MRI are normal in Alzheimer's Disease, the blood flow and the activity of acetyl choline receptors decrease in the brain.

(c) The grading of malignancies and the detection of early recurrence are possible by using F-18 DG, which is more reliable than CT scans or MRIs for these objectives.

It is seen that nuclear medicine is playing a very important role in the diagnosis, progress and treatment of such important diseases like myocardial infarction, kidney artery narrowing, Alzheimer's Disease, brain tumours, Parkinson's Disease, thyroid diseases and poor kidney function. Its non-invasive nature is an added advantage.

We have a well-run Nuclear Medicine Department in the Army Hospital (R&R) Delhi, where serving or retired personnel and their dependants are given authorised treatment. You have only to be referred to the department and ensure appointment. The rest is on the house.

The General has been a consultant surgeon to the Armed Forces for several years. He retired as the Director of Medical Services, Western Command. He is a practising surgeon based at Chandigarh.