Using antibiotics without rationale
The inappropriate use or indeed overuse of the myriad of antimicrobial agents which became available in the late 1980s and early 1990s has contributed significantly to the emergence of resistant microbes. These now pose a district threat in many areas of the world. 

Weight reduction: a practical view
Everyday one reads in the newspapers regarding different fasting methods to reduce weight. Flat stomach in two weeks or one pound loss of weight everyday, etc. All these advertisements have one thing in common: they exploit the impatience of those obese people who want to shed off their extra weight very fast and without making any serious effort.

INFO CAPSULE

Using antibiotics without rationale
Dr A.S. Bawa

The inappropriate use or indeed overuse of the myriad of antimicrobial agents which became available in the late 1980s and early 1990s has contributed significantly to the emergence of resistant microbes. These now pose a district threat in many areas of the world. Apart from a number of common bacteria (e.g. staphylococci, pneumococci and enterococci), some viruses (e.g. human immunodeficiency virus), fungi (e.g. Candida species) and parasites (e.g. malarial parasite) are now becoming increasingly resistant to many of the common antimicrobial agents which previously proved so efficient in their control.

Natural resistance: Some bacteria have always been naturally resistant to certain antibiotics. This so-called intrinsic or inherent resistance is chromosomally mediated and results from a variety of factors, including the absence of the drug’s target site and failure to penetrate the outer membrane barrier found in Gram-negative bacteria. Such resistance is usually well known and predictable, and causes a few therapeutic problems.

Acquired resistance: More important to the clinician than the well-documented intrinsic resistance is the ability of bacteria to acquire resistance after having previously been susceptible to the therapeutic agent in question. This acquired resistance may occur by spontaneous mutation or by the transfer of DNA from a resistant clone to a previously susceptible recipient. While acquired resistance in may be slow to emerge (e.g. penicillin resistance pneumococci), it more often develops rapidly, as evidence by the resistance of Staphylococcus aureus to benzylpencillin, which occurred in the 1940s and 1950s. The emergence of resistance in previously susceptible microbes is clearly one of the major concerns facing the medical profession.

Infection results when the equilibrium between the invading microbe (which is usually part of the normal flora) and the host defence mechanism is pushed in favour of the microbe. At a minimum, the mere deceleration of microbial growth and multiplication may allow the host defences to eradicate or at least control the causal microbes.

Hypersenstivity, skin rashes, changes in normal gut flora leading to diarrhoea and colitis, hepatitis, neural defects, kidney damage, bone marrow suppression and fever can all occur with antibiotics.

1. Off the shelf availability of these drugs. 2. Plethora of new antibiotics available in the market with aggressive marketing by pharmaceutical companies. 3. Physicians and surgeons sometimes prescribe drugs indiscriminately for personal gains. 4. Prescription of these drugs by doctors from alternate systems of medicine, who have no supporting scientific basis for use. 5. Self-medication. 6. Use of these drugs by allopathic physicians and surgeons for prolonged periods and sometimes unsupported by available scientific literature. 7. Limited public awareness regarding the side-effects of these drugs.

Recommendations

Common cold (coryza): Rhinoviruses are the chief cause (> 80 strains) producing self-limiting nasal discharge. The incubation period is one-four days. Treatment is symptomatic with no role of antibiotics.

Following any trivial trauma haematomas may form over scalp, thighs or scrotum, and require treatment in the form of cold compresses and oral anti-inflammatory agents only. If they persist, then aspiration followed by compression bandage is needed. Antibiotics have no role.

Cuts and wounds: Clean wounds inflicted by a sharp instrument or knives, cuts from glass, etc, need only cleaning and primary suture, and will heal without any antibiotic cover.

Nail/puncture wound: Foreign material is likely to be carried deeply into the underlying tissue. Treatment is wound irrigation, antibiotics and tatanus prophylaxis by a surgeon.

Animal bites: These have a high incidence of infection, presumably by mouth organisms. These need specialised surgical care by a surgeon and an appropriate antibiotic.

Burns: Immediate cooling of the part for about 20 minutes running cold water from tap is good enough. Local application with various ointments is beneficial. Oral antibiotics are not recommended till there is evidence of cellulites as observed by the treating surgeon.

Cystitis and lower urinary tract infection: Patients with dysuria, frequency and suprapubic pain. It is a common ailment in females. This condition needs either a single dose antibiotic or therapy for three days. No antibiotics thereafter.

Surgical prophylaxis: In clean surgeries like implants (orthopaedic, vascular or cardic), laparoscopic cholecystectomy, TURP, hernia repair, hysterectomy, caesarian section &CNS operations, prophylaxis with a appropriate broad spectrum antibiotic parenterally at the time of induction of anaesthesia and repeated once or twice depending on half life of the drug and duration of surgery. Thereafter antibiotics have no role.

1. Strict adherence to the established guidelines is important, especially in prophylaxis.

2. In therapy, the choice of the antimicrobial agent must take into account the patient’s physical and immune status, the type and location of pathology, and whether or not the microbe is intracellular or in some other way protected from antimicrobial activity (e.g. within biofilms or abscesses). It is important that the selected antimicrobial agent reaches effective and sustained concentrations at the site where the microbe is growing.

3. The most common error is to give antibiotics with no clear idea of the organism involved, and then to stop them before the infection is controlled. This may promote the spread of antibiotic resistance.

4. It is imperative for the medical community to use antibiotics judiciously for recommended indication supported by available scientific literature.

5. The emergence of microbes that are resistant to antimicrobial agents is inevitable, albeit at varying rates. Careful consideration must therefore be given to the selection and use of antimicrobials, both for the prevention and treatment of a disease.

6. In general, antibiotics should be avoided till the lab has cultured the organism, or a patient is very ill/and is in need of immediate treatment as in septic shock. In which case, culture blood, urine, sputum and any other relevant samples before treating.

The writer is Head, Department of Surgery, Govt Medical College Hospital, Sector 32, Chandigarh. Phones (Office) 665253/ 665545.

Weight reduction: a practical view
Dr Ravinder Chadha

Everyday one reads in the newspapers regarding different fasting methods to reduce weight. Flat stomach in two weeks or one pound loss of weight everyday, etc. All these advertisements have one thing in common: they exploit the impatience of those obese people who want to shed off their extra weight very fast and without making any serious effort.

Sport is one important activity that leads to successful weight reduction. In principle, our body has the choice of absorbing energy from three different sources: sugar or carbohydrates, facts and proteins. Proteins are basically used in the wear and tear of the body. Therefore, diets of carbohydrates and fats are major source of energy supply. When any physical activity is started, only carbohydrates are utilised for energy as they don’t require oxygen for metabolism, i.e. anaerobic. When the activity is continued, then with the help of oxygen fats are metabolised to produce energy, i.e. aerobic activity.

There is an improvement in metabolism when a person is doing aerobic exercises, but fat reduction starts in the body when one has to work at a "target heart rate" for about 20 to 30 minutes onwards. To calculate the "target heart rate" you subtract your age from 220, i.e. the maximum heart rate at birth. The "target heart rate" is 60 to 80 per cent of the maximum heart rate. For a person of 50 years the target heart rate will be as under:

220 (maximum heart rate) minus 50 (age) = 170 beats per minute

170x60 = 102 beats per minute

170x80 = 136 beats per minute

Divide the upper and lower target numbers by six. This rate will be for 10 seconds during exercise. Therefore, while doing exercise you can count your pulse up to 10 seconds on your wrist or neck, which should be between your upper and lower target rate.

It is specifically the condition uniformity in endurance training which is not fulfilled by almost any ball game such as cricket, volleyball, football and basketball, nor by squash, tennis or badminton. A major feature of this type of sport is a constantly changing pulse rate. One moment a player is standing quietly (for example, during the serve) and the next moment he is running for the ball. These constant variations in the heartbeat mean that the body is mainly converting carbohydrates for energy when oxygen is in short supply.

The logical conclusion we draw from these details about the metabolic processes favours uniform, long-term and not over-intensive endurance training. It is recommended in principal for weight and especially fat reduction that pick out any type of sport (for example, swimming, cycling, walking or jogging) which suits you best and which meets your current requirements. For beginners in particularly poor physical shape. initial aerobic training using 50 per cent of the maximum heart rate is recommended for the first few weeks or months before you can start burning off fat. At the end of the twelfth week of training increase your pulse rate to 60 or 70 per cent of the maximum heart rate. Repeat the condition test every four weeks and transfer to the next plan when you achieve average results.

Men are genetically predisposed to develop the so-called apple shape, that is to say that excess fat is stored mainly in the general area of the stomach. On the other hand, women develop the so-called pear shape, that is, excess fat is found on the belly, hips, buttocks and upper thighs. When we shed fat, we do so in reverse order to the order it was stored in. The areas which gained weight most recently will be the first to slim down. The areas you first little rolls of fat developed will be the last to lose them. But what can we say about the fear of building too much muscle? It is women who often have a certain fear of using the heavier weights in power training because they do not want to look muscular. A less effective method is the widely accepted practice of training using lighter weights in highly repetitive sequences.

The simplest way of not gaining more muscle, if you have reached your "personal limit", is not to increase your training targets any further.

Eat more and/or more frequently

The very people who tend to put on weight easily are often those who do not eat much. With two meals a day the average metabolic rate may therefore be much lower than with five meals a day at two or three-hour intervals. It should also not be forgotten that metabolism works slower at night than during the day. Therefore, one should take small and frequent meals which will prevent indigestion, hypoglycaemia, i.e. low energy level in the body which invariably leads to vertigo/ ghabrahat.

Guidelines/tips for an obese person for reducing weight are as follows:

(1) One should "eat to live" and not "live to eat". (2) No amount of mere wishing has ever shed even a gram of weight. (3) Believe in yourself. Set a "goal". (4) Create a realistic health approach. A specific strategy should be chalked out. (5) Identify small measures/ steps first. (6) Begin gradually and don’t expect to get shape overnight. Your fitness should start to improve within three months with constant efforts. (7) Create meaningful accountability. Write the diet in your dairy along with calories everyday. (8) Dietic habits of a family rather than the hereditary factor is responsible for obesity. (9) Taking three meals shows a great tendency to get overweight than taking five small meals, as it is the total intake of calories rather than the frequency of meals that determine the weight change. (10) Crash diet/ very low calorie diet can be deadly as it can lead to weakness. Those who succeed in reducing regain and exceed their original weight within a short period. (11) Obese individuals tends to eat more if excess food is served on the table. Not bringing enough food on the table is the best method of avoiding the temptation to over-eat. Therefore, serving out a limited portion from the kitchen can prevent overeating. (12) Leave the dining table when satisfied but not stuffed. (13) Instead of refined food, eat grilled/tandoori preparation. (14) Massage only helps in toning up the skin, decreases muscular fatigue, but in no way helps to reduce the weight. Massage only helps the masseur to reduce his/her own weight. (15) Steam bath leads to sweating, and one to two kg weight can be lost but drinking water to prevent dehydration regains the lost weight. Therefore, it has no place in the treatment of obesity.

The writer was earlier associated with the Indian cricket team as a doctor/physiotherapist.

MUMBAI: As a dangerous cocktail of stress, genetic predisposition, demographic trends and modern lifestyle makes the population, particularly in cities, more susceptible to cardiovascular diseases, entrepreneurs are rushing to make a "killing" by setting up new heart institutes in the city.

While all the "five star" hospitals in Maharashtra have a cardiology department, new specialty hospitals for treating heart diseases are coming up in the city with the aim of "catering" to the needs of the affluent class.

According to Dr H.O. Goyal, consulting physician in preventive management of lung and heart diseases, health incentives provided to PSU employees and the early onset of arteriosclerosis in the urban population due to the modern lifestyle are providing a conducive environment for corporate healthcare providers to flourish. PTI

WASHINGTON: Cardiologists at the Research Institute of the McGill University Health Centre (MUHC) say that the best way to determine the risk of heart disease is by measuring the amount of a protein called apoprotein B or apoB rather than by measuring the cholesterol level.

"The tradition in clinical practice is to look at the levels and ratios of cholesterol as predictors of cardiovascular disease, " says Dr. Allan Sniderman, MUHC cardiologist and first author of the study. "Because this test has its limitations, we decided to look at other possibilities". This study shows that apoB is a more robust indicator of cardiac events and we suggest that it is superior to looking just at cholesterol levels." ANI

Vitamin D & fractures

LONDON: Vitamin D supplements costing less than one pound ($1.58) a year could reduce fractures in the elderly by more than a fifth, UK researchers have said. Elderly people often suffer from osteoporosis, or brittle bone disease, but scientists at the University of Cambridge have shown that large doses of vitamin D taken every four months can cut the risk of broken bones in 65-85 year olds. Reuters