Asthma: the painful reality in India
Dr Shakuntala Lavasa

Bronchial asthma is a severe disease and many a times fatal, affecting a very large number of people.

The current level of asthma control in India falls far short of the universally accepted goal for long-term management. Despite the availability of highly effective asthma therapies, the state of affairs is surprising. The patients who are on regular medical treatment and supervision can surely have good quality of life.

Seven general goals for long-term asthma management are as follows:

1. Minimal or no symptoms, including night-time

symptoms.

2. Minimal episodes of asthma attacks.

3. No emergency visits for asthma.

4. Minimal need for quick relief therapy like Asthalin and Theophylin.

5. No limitations on physical activities and exercise.

6. Nearly normal lung function tests.

7. Minimal or no side-effects from medication.

The findings from patients in India in general are falling short of the goals.

Though the goal is minimal, 60 per cent patients have day-time symptoms and are awakened by symptoms at night. As many as 65 per cent have attacks of sudden severe episodes of wheezing, chest tightness, shortness of breath at least once in three months and almost one-third have it every day. This is far below the second goal. Nearly 30 per cent patients visit the emergency ward and are hospitalised.

The unscheduled visit to doctors due to urgency are much more whereas the goal calls for no emergency visits and no hospitalisation.

The goal calls for minimal need for quick relief medicines. By contrast, in India, 85 per cent patients are using quick relief medicines only. At least 86 per cent patients limit themselves from sports and recreation, 30 per cent miss work and school because of asthma, 78 per cent miss social activities and 88 per cent limit their physical activity whereas an asthma patient, if on proper treatment, need not restrict physical activity and exercise.

The majority of the patients do not visit doctors when they have minimal symptoms and keep on doing self-medication until they have asthma attacks. They do not undergo lung function tests due to many reasons.

Patients feel that because of the tests the cost of treatment unnecessarily increases. They should realise the gains from scientific treatment.

Inhaled corticosteroid is the most effective and safe long-term medication required for asthma control but only 2 per cent of the patients take them as instructed.

The picture is gloomy not because of resources but because of poor knowledge, attitude and behaviour of patients and health care providers. The patient’s perception of asthma control is different from what it actually should be. They are unaware of the potential for improvement. They fear inhalers and consider cortcosteroids as harmful. They visit a doctor when there is an emergency. They want to stop medicines even if medicines improve their quality of life and cause no side-effects. A cost-benefit analysis of treatment is not a consideration at all.

The patient alone is not to blame. We doctors ought to update our knowledge and put it to patients’ use. We have to communicate to the patient better to improve his or her understanding of the disease and treatment modalities.

Drug companies ought to bring down the cost of medicines. The chemists and the paramedical staff should also play a positive role in patient education.

The patient’s interest in better understanding his condition and treatment can definitely improve the management scenario of bronchial asthma in India.

— The writer, who was earlier associated with the PGI, Chandigarh, is a consultant allergy specialist.

Avoid getting panicky
Neelam Sharma
Tribune News Service

Chandigarh: Asthma is not a disease but only a disorder, and if managed properly it can be a minimal hindrance in performing daily activities. Panic, say doctors, should be avoided but care should be taken to learn about how to manage the disorder in acute circumstances.

“Around 5 to 15 per cent of the Indians are asthmatic and the disorder generally begins in the childhood. The most important aspect is management of the disorder for maintaining the quality of life. There are several myths associated with asthma as some suggest that the affected persons cannot perform several tasks well. But there is not much truth in all these beliefs,’’ says Additional Professor, Advanced Paediatrics Centre, Dr Meenu Singh.

Changes in the lifestyle and dietary habits have led to an increase in the number of asthmatics over the years in India. According to doctors, certain kinds of cooking oils, like sunflower oil, which have an imbalance of fatty acids, are responsible for causing the disorder. Also, the changing season, especially March-April and September-October are harsh for the affected persons because of the wind laden with pollen particles.

But the genes are now believed to be the main cause of asthma. “It is established that if one of the parent is asthmatic, the chances of the child getting asthma is 30 to 40 per cent, and if both parents are asthmatic the chances of their child too suffering from asthma rises to 70 per cent. Researchers are trying to find the gene that is responsible for asthma so that gene therapy can be an effective line of treatment,’’ adds Dr Meenu.

Working in this direction, the PGI, Chandigarh, has collaborated with the All- India Institute of Medical Sciences (AIIMS), New Delhi, to find out the genotype, which is responsible for causing asthma. The collaborative work is going on for the last six months, and the doctors are yet to track down the gene.

Keep the following in mind if you are asthmatic:

1. Avoid smoking

2. Follow simple and healthy diet; fish can be useful

3. Inhalers are very effective and have no side- affects;

4. Dust and fumes from mosquito repellents can aggravate allergy and should be avoided

5. In case of an attack, rescue puffs (short acting oral drugs) can be given. The doctor should be consulted immediately as short hospitalisation may also be required.

Knee replacement surgery — before and after
Dr Ravinder Chadha

The most commonly faced dilemma for an individual suffering from advanced knee arthritis is to decide whether to undergo knee replacement surgery or not. From the surgeon’s point of view, the indications are clear for knee replacement although the ultimate decision rests with the patient. A favourable response to the conservative treatment, a good range of knee motion and the ability to walk without pain do not favour knee replacement surgery.

If one is confined to a wheelchair and is in constant agonising pain, then it is worthwhile to go in for knee replacement even if it involves certain risks. Such patients have generally remained immobilised for some time leading to the softening of bones, weakening of muscles, etc, thereby making knee replacement surgery an arduous procedure. Ideal conditions for knee replacement surgery would be the failure to respond to conservative treatment and the patient’s age being over 60 years.

Knee replacement surgery being a complex procedure does entail certain risks. Most common complications are the formation of blood clots in the veins of the legs, risk of infections, etc.

It is ideal, rather imperative, for such patients to reduce their weight as every one kilogramme adds five times the load of the knee joint. One should avoid running and jumping activities and driving for four-six weeks after surgery

Exercises: It is crucial to make an individual aware regarding the necessity to remain active post-surgery but not to overdo physical activity. It is advisable to gradually increase physical activity and improve muscle strength over a period of a few months. The following post-surgery exercises are mandatory:

Quadriceps-set: Lying on the back, push the knee downward to tighten the thigh muscle. Hold for 5-10 seconds. Repeat this exercise several times a day.

Heel slide: In a lying position, bend one knee by sliding the heel backwards. Hold it in a bend position for 5 to 10 seconds and then straighten. Repeat it several times a day.

Straight leg raise: Sitting with back support, lift straight your leg about 12" from the ground. Hold for 5 to 10 seconds. Slowly return to the original position and repeat it several times a day.

Knee extension exercise: Place a rolled towel just above the heel or foot. Apply slow, sustained push down the knee for 5 to 10 seconds. Repeat it several times a day.

Walking is the best way to recover from knee surgery. Initially, one should walk with the aid of a walker or crutches. Later on a cane in the opposite hand should be used to walk comfortably. For climbing up the stairs, handrail for support is required, as it becomes difficult to climb due to diminished muscle strength and flexibility. Climb up the stairs with the good knee and down the stairs with the operated knee.

Patients are advised to start with resistance exercises after 4 to 6 weeks of the surgery with the help of Theraband. Cycling and swimming are excellent activities to gain muscles’ strength and knee mobility.

People generally tend to live with knee pain, which is initially ignored and later thought of it as an inevitable part of aging process. The awareness that this long-term disability can be overcome if taken care of during the initial stages is also lacking. Ultimately, the only option left in the advance stages is knee replacement surgery. Apart from being a major surgery, it is also extremely expensive by available Indian health standards.

— The writer is a former doctor/ physiotherapist, Indian cricket team.

Fight depression with professional help
Dr Anju Soni

How to go about recognising symptoms of depression and at what stage is intervention by experts really required? People who are depressed may lose their appetite and lose weight as a result of this. They discover this by finding that their clothes have become baggy. They may have sleep disturbances: the onset of sleep may be delayed or they may wake up earlier than the usual awakening hours or they may wake up in the middle of the night and find it very difficult to go to sleep again. They may feel less energetic to do their day-to-day activities and are not able to enjoy things as much as they might have done in the past.

They may be engulfed with feelings of hopelessness and worthlessness and may come to believe erroneously that future does not have anything good in store for them and they may lose their zest for life. They may experience difficulties in concentration while reading the newspaper or watching the TV and may have memory problems. People who are severely depressed may have strange beliefs that either they or the world has ceased to exist or that their insides are rotting.

They may become unduly suspicious and come to believe that people are conspiring against them or planning to kill them. They may feel excessively guilty and may believe that they deserve to be treated shabbily. Fear of rejection may lead to the loss of motivation and will and may lead to social withdrawal. However this is just one side of the story. Contrary to this, some people may specifically tend to over-eat and sleep for long hours during the day. They may have craving for sweet things. These are symptoms of a typical depression and are more common in females specially during the winters.

So, if either you or somebody around you has these symptoms don’t panic. This is something which can be dealt with effectively sometimes by talking to a friend by yoga or going on a holiday or a week of indulgence or joining a gym for regular workouts. How-ever, if the problems still get on top of you and you are not able to function properly seek the advice and help of a good psychiatrist. Help is available in the form of medications and talking therapies.

When low mood threatens to overwhelm you medications provide symptomatic relief and help to lift up mood by restoring the chemical imbalance in the brain which happens during depression. But it is important to remember that medications take about 4 to 6 weeks to act but the side- effects appear much earlier. People are morbidly frightened of side-effects and so avoid taking medications. But it is vital to know that the onset of side-effects just means that medication has started acting on your system and in due course of time positive effects will also manifest.

No medications, not even the alternative remedies, are free of side-effects. In most cases the side-effect profile is not really known and it may sometimes take weeks or even months to appear as these remedies are mostly slow-acting and, therefore, people are not able to attribute side-effects to these remedies.

It is important to know that medications do not cause craving as they do not have addiction potential. But if these are abruptly withdrawn or a couple of doses are missed then this can lead to headache, nervousness, anxiety or restlessness. So it is important to take these medications under expert guidance and these should be tapered off slowly over several weeks.

All therapies help people to get better insight into their problems and aim to teach them a new set of problem-solving techniques.

So, if you are feeling devastated don’t just withdraw into a shell, seek professional help to explore the various options that you have to deal with your problems.

— The writer is associated with Barnet Enfield and Haringey Mental Health Trust, London.

Breast cancer breakthrough
Steve Connor

A new drug that can destroy tumours with minimal side-effects could offer a breakthrough in the treatment of breast cancer.

Tests on laboratory animals have shown that the drug prevents the growth of tumours so effectively that clinical trials on humans will start within months, scientists say. The drug is called a PARP inhibitor and is targeted to work against tumours caused by the inherited forms of breast cancer which result from mutations in the BRCA1 and BRCA2 genes.

Women carrying mutations in either of these two genes have up to an 85 per cent chance of developing breast cancer by the age of 70. There is currently no specific treatment other than a prophylactic mastectomy.

Nearly 41,000 British women are diagnosed each year with breast cancer and of these about 5 per cent are due to strong hereditary factors, such as mutations in one of the two BRCA genes.

However, the new drug might also be effective against other non-hereditary forms of breast cancer and so could end up helping as many as 20 per cent of breast cancer patients, said Professor Alan Ashworth, director of the Breakthrough Research Centre at the Institute of Cancer Research in London.

"This is a brand new therapeutic approach, centred on exploiting a specific deficiency in breast cancer cells - their Achilles' heel. This is only possible because of our ever-increasing understanding of the basic molecular biology of cancer," Professor Ashworth said.

— The Independent