Wednesday, Wednesday 22, 1999

How to get a good night’s sleep
By Dr Rajeev Goel
Not again the tossing and turning during night. You are not the alone, sleepless head. There are so many people who have serious bouts of chronic insomnia at one time or the other in their lives, but very few seek medical advice.

Surgery: many strides and sprints
By Dr J.D. Wig
The surgeon of today is in fact the product of a series of events that began to get under way scarcely a 100 years ago and did not reach the state of full flowering until 50 years ago. We, the surgeons of today, have little connection with our predecessors except through the knife and the hands.

Medicines can cure and kill
By Manju Wadwalkar
A girl of nineteen takes an examination at a college, decides to walk down to her house, develops pain on the way in the abdomen and goes to the nearest clinic of a qualified private practitioner. After examining her, he gives her an injection of a pain-killer. She complains of restlessness and dies within minutes. Shocking, heart-rending and tragic that a young life was lost so easily!

Eat, drink and stay fit
New millennial health hints for senior citizens
By Dr M.L. Kataria

What to eat? What not to eat? How much to eat? How many times a day to eat? What is a balanced diet? What are vitamins, minerals and fibre? What is their role? How much water should I drink? I am a diabetic. I am hypertensive. What are my dietary dos and don'ts? I am 70 plus. I am 80 plus. I am fond of food. Pity, I can't digest. What should I do? I am gaining weight. I am losing weight. Give my dietary diction. I love my evening's two "chhotas". Is it ok? I am a three meal non-vegetarian. Do you agree? I can't eat. I can't sleep. I am worried. What should I do?

These, and, many more are the common queries raised by the elderly in the weekly geriatric clinic of senior citizens health-care centres.

The answers are simple. The remedies are even simpler. But their implementation is as difficult as they are simple. Let us peep within. How firmly do I rein in my mind? And, through my mind, my sensory organs? Especially sight, smell and taste. In fact, the very thought of things delicious!

This is not only the first step but also the last step in any dietary exercise. Should I eat to live or live to eat? At this stage of my "sermon" if "Mr Eat Drink and Be Merry", one of our poetic senior citizens, is present, he must invariably quote Ghalib:

Go haathon mein jumbish nahin aankhon mein to dum hai,

Rehne do abhi saaghar-o-meena mere aage.

Obesity is an acknowledged risk factor and an undesirable lodger for many an ailment. To be thin and smart is desirable at all ages — also in old age. A 10-year study published recently in the New England Journal of Medicine has shown that persons who live longer usually have a Body Mass Index (BMI) ranging from 19 to 22. This is rather on the thin side. A person five feet and four inches tall and weighing 66 kg has a BMI of 25. At 75 kg, the BMI will be 30.

According to this study, in a 10-year follow-up of persons 60 to 75 years of age, 38 per cent thin but 44 per cent overweight persons died.

For every kilogram of excess weight the heart has to pump blood through 400 kilometres of extra vasculature. This is a preventable extra strain on the heart and other vital organs of the body at the cost of longevity.

Therefore a judicious balance between the quantum of food (intake) and the daily physical activity (output) has to be so regulated as to maintain the optimum BMI.

A balanced diet should achieve this balance. It should include all the constituents of food. These are carbohydrates, proteins, fats, vitamins, minerals and plenty of water.

Physical activity dwindles in direct proportion to every decade after 60. There is also a steady reduction in the bone mass. Therefore, a diet ranging from 1500 to 1800 Kcals a day, in most cases, should suffice to maintain the optimum BMI in old age.

Energy requirements recommended by the Indian Council of Medical Research for a man below 50 years weighing 55 kg and engaged in light work are about 2400 Kcal and for a woman at 60 weighing 45 kg these are about 1900 Kcal. Physical activity, the bone mass and the basal metabolic rate dwindle in direct proportion to every decade after 50. Therefore, energy requirements are also correspondingly reduced.

According to the FAO and the WHO, after the age of 40 years the energy requirements should be reduced by 5 per cent decade till 60, and by 10 per cent per decade till 70 , and by a further 10 per cent after 70.

Carbohydrates, proteins and fats yield four, four and nine Kcals per gram respectively. That total energy requirements in a balanced diet must be made up in the recommended ratio of 50, 35 and 15 per cent from carbohydrates, proteins and fats respectively in order to maintain a balanced composition of the human body at proteins 17 per cent fats, 12 per cent minerals 7 per cent, carbohydrates one per cent and water 63 per cent.

Proteins provide building material for all the body tissues like muscles, blood, enzymes, antibodies and also their replacement due to their wear and tear.

The main sources of animal proteins are eggs, milk meat, fish, chicken etc. The vegetable sources are pulses, cereals, beans, including, soyabeans, nuts and oilseeds.

The dietary proteins include a total of 22 alpha aminoacids. Out of these eight are essential amino-acids, which are not synthesised in the body and hence must be ingested from a wide variety of protein sources.

Carbohydrates are the main sources of energy. They are essential for oxidation of fats and synthesis of certain non-essential amino-acids. Therefore, most of the ingested carbohydrates are burnt up in the body furnace to produce energy. Three main sources of carbohydrates are starches (cereals, millets, roots and tubers), sugars (mono saccharides like glucose, fructose, gelectose, and dissarchharides like sucrose, lactose and matose) contained in all fruits, sugarcane and cellulose (the fibre element lining fruits, vegetables, cereals etc).

The prolonged deficiency of fibre in the diet may cause constipation, colon caner, atherosclerosis and coronary artery disease, appendicitis and gall-bladder stones.

Fats are concentrated sources of energy and provide vitamins A,D,E and K. They are the source of essential fatty acids, which play an important role in several metabolic reactions. As the human body does not synthesise these essential fatty acids, their deficiency in diet may cause certain skin and gastrointestinal ailments. Cholesterol levels in blood depend on the quality and quantity of the fats consumed and are related to atheromatous and ischaemic heart disease.

Saturated or animal fats (ghee, butter or curd) are not rich in essential fatty acids, except in certain fish oils. They are rich in retinol and cholecalciferol, precursors to vitamins A and D. On the other hand, unsaturated or vegetable oils (groundnut, gingerly, mustard, cotton seed, safflower, rape seed, coconut oils) are rich in essential fatty acids, but lack retinol and cholecalciferol. Therefore, 20 per cent of the total fat requirements is recommended to be from the animal fats.

Hydrogenation of vegetable oils to solidify them destroys the essential fatty acids considerably. As these oils lack vitamins A and D, these have to be added under government regulations.

Vitamins act as catalysts for various processes in the body. About 15 different vitamins have been identified so far from diverse food items. They are complex bio-chemical substances. As they are not synthesised in the body. They have to be ingested through a wide variety of animal and vegetable food items in the daily diet.

Vitamins are either fat-soluble (vitamin A, D,E,K) which are heat stable) or water soluble (B group of vitamins and vitamin C, which are heat-labile).

Even though required in very small quantities, their prolonged deficiency in diet may cause several ailments peculiar to each category of vitamins.

Minerals and trace elements are essential items for the formation of bones and teeth, the maintenance of osmotic pressure of body fluids and the formation of blood. The body requires about 24 minerals and trace elements. The important ones include calcium, phosphorus, iron, sodium, potassium, chlorine, sulphur, magnesium, iodine, zinc, manganese, molybdenum, cobalt and selenium.

Minerals are so widely distributed in food items that only a well-balanced diet from a wide variety of sources can include them all in sufficient quantities to meet the body's requirements.

The body is a complex autonomous biochemical laboratory par excellence. It functions non-stop from "womb to tomb" in a person's life-span. During its life support-function it also throws up certain harmful byproducts called free radicals. Their elimination from the body being sluggish in old age may have cumulative ill effects. A supplementary intake of vitamins, including A,B complex, C and E, in old age may act as antioxidants to neutralise their consequences.

Water constitutes 63 per cent of the body weight. It is the most essential vehicle for all biochemical processes in the body. Yet this freely available (hopefully not polluted) elixir is often under-ingested. Due to lack of physical activity in old age, thirst-nature's signal to drink water — — is dull. So, many elderly people consume little water and are often constipated. As a rough guide, more than two litres of water a day, including the intake of all fluids, should be ensured in between meals, thirst or no thirst.

Alcohol, every drop of it, is a protoplasmic poison. The body has to deal with it and eliminate it. This brunt is borne by the liver and the kidneys. What exhilarates after the coveted 30/60 ml (one or two "chhotas") is in fact an ab initio toxic benumbing of higher controls, letting loose the reins on the lower controls in the central nervous system. The higher the dose, the more intense the next morning hang-over. Is it worth it? Even the best of India-made foreign liquors are inadequately distilled and not sufficiently mature. Therefore, they are quite rich in impurities. They do sink sorrow, but they also sink good health.

The degenerating effect of the prolonged use of alcohol on the most sophisticated cells of the brain, the retina, the cardio-vascular system, the hepato-renal system, amongst many others, cannot be denied. It is a common experience in our geriatric clinic to see the mercury column and the blood sugar curve shooting up in the case of hypertensives and diabetes, after the previous evening's alcoholic "well-being".

Diabetics, with a well regulated diet, drug, exercise, weight and blood sugar levels, should eat every thing within the prescribed total caloric limits, conforming to the principles of a balanced diet.

Hypertensives need to restrict only the intake of salt and fat to maintain the blood pressure, lipidogram and weight within the normal limits, with the prescribed dosage of drugs, if any.

Vegetarianism — religiosity, spiritualism and moralism apart — is a scientifically preferred life-style, with no alcohol and no smoking. Let us not forget that milk and its products are all animals proteins. Fruits, vegetables, legumes, cereals and grains, with their copious fibre, move the bowels, reduce the chances of gut malignancy in old age, maintain a healthy lipidogram, normal blood pressure and put a less load on hepato-renal and cardio-vascular systems. These are conducive to healthy longevity. Almost all the 90-year-and-above members of the Chandigarh Senior Citizens' Health-Care Centre are vegetarians and teetotallers. Sherali Farzali Musslimov of Azerbaijan died at 142, a few years ago. He left behind numerous wailing widows, innumerable children, grand and great grand children, whom he did not know. He rode on horse back till his last day. He was a pure vegetarian, a non-smoker and a teetotaller.

To be merry is the most essential ingredient of all diets and nutrients in old age. And yet this imperative" is invariably lacking in almost all cases, though variably. Besides age related physical ailments, there are numerous financial, security, social and domestic irritants. These act as deep, smouldering psychological ailments. They sooner or later manifest as somatic and physical ailments. Thus a vicious circle is caused. Insomnia, hypertension, tachycardia, aggravation of diabetese, anorexia (loss of appetite) and loss of weight, are only a few amongst many more.

The worst is depression — a definite disease entity, which needs reference to a clinical psychologist and a psychiatrist. In the worst cases, even psyche elevators, anxiolytics and antidepression drugs may have to be administered. But for how long?

The remedy lies elsewhere. Nip the evil in the bud. Don't continue to live with it. Consult the specialist if you have to, well in time. Eliminate the irritants if possible. Surrender gracefully where it is not possible to do so.

Auto-analysis, introspection and grey wisdom should sparkle through the dark tunnel. The dim dusk of life's evening should glow into a golden dawn with contentment, surrender and "simran":

Jeh jeh bhana teh teh rakhe!

Nanak, sabh kuchh Prabh ke hathe!!

Dr (Brig) Kataria is a living legend. He has dedicated his life, time and resources to the all-round care of the elderly and the slum-dwellers.

How to get a good night’s sleep
By Dr Rajeev Goel

Not again the tossing and turning during night. You are not the alone, sleepless head. There are so many people who have serious bouts of chronic insomnia at one time or the other in their lives, but very few seek medical advice.

As age advances, fewer people get a good night's rest. Contrary to the myth, it is not that you need less sleep as you get older; it is simply that you get less.

Why? Many things can cause sleep loss — medical conditions such as sleep apnoea, menopause which may bring middle-of-the night hot flashes, depression, anxiety and just plain bad sleep habits, to name a few. Besides, excess mental work and less physical work may also create difficulty in sleeping.

Environmental factors like excessive heat or cold, exposure to noise and the change of environment also lead to sleeplessness.

Not getting sleep can really make you sick increasing the rate of heart disease, hypertension, stroke, lung diseases, confusion, short-attention span, hyperactivity, irritability, depression, impotence, traffic accidents and on-the-job injuries. You may complain of general weakness, constipation and indigestion.

Broadly speaking sleep is a complex amalgam of physiological and behavioural processes. A normal healthy person should sleep for about six hours a day. There are people whose professional requirements keep them awake at night. They should make good their sleep during day time. To get a good night's sleep, all you need to do, first of all, is to make changes in your life-style.

(a) Change the habits which disturb your internal body clock. Stop turning in at irregular hours, napping more than an hour a day or excessive drinking of tea, coffee, soft drinks, cocoa or other stimulants. These must be avoided particularly before going to bed.

(b) Use relaxation tapes or other techniques (like meditation) to reduce stress, which keeps your mind racing long after your body has slowed down. Leave your worries behind while going to sleep. Avoid psychic factors producing stress and strain. The recitation of a mantra or a word for a few minutes while lying in the bed also results in good sound sleep.

(c) Exercise regularly, but make sure you do it at least three hours before bed-time. Otherwise, post-workout alertness may keep you awake. A brisk walk in the morning is very useful.

(d) Consume as little alcohol as possible. A nightcap may help you fall asleep a bit more quickly, but it can make you more restless later in the night.

(e) Studies have shown that taking calcium (1000 mg) and magnesium (500 mg) before going to bed helps in relaxing muscles and calms your nervous system.

(f) Check the medicines which you are taking. Some, including asthma drugs and decongestants, can affect sleep. And if you suspect that your medication is interfering with your sleep, do not stop taking it. Consult your doctors for an option.

(g) Treat other health problems. Painful arthritis, lung or heart diseases, nervous disorders, urinary-tract infections, an enlarged prostate gland or a blockage in the breathing passage may often wake you up during the night.

(h) Observe the movement of your incoming and outgoing breath meticulously for a few minutes lying in the bed.

If the life-style changes do not work, you should consult your physician. He may prescribe you sleep aids such as diazepam. These generally produce drowsiness and may also cause side-effects like grogginess the following day. There are certain other drugs such as barbiturates, benzodiazepines and imidazopyridine etc. These generally slowdown the central nervous system, which reduces the time it takes to fall asleep. These should only be taken when directed by the doctor and are usually not taken or prescribed for long periods. One should never increase the dose without one's physician's instructions.

Take the medicines only when your schedule permits you to sleep seven to eight hours. Otherwise, you may feel groggy and confused when you wake up because the after-effects will not have time to wear off. The drugs that produce daytime drowsiness should be avoided especially by the "older adults" to prevent accidents and falls. One must not drink alcohol while taking these sleep-inducing medicines. Try the above-mentioned tips and have a good night's "shut eye".

When to see the doctor

Are you just restless or do you have a real sleep problem? Answer, saying true or false the following questions:

* I regularly wake up confused or irritated.

* I easily fall asleep at inappropriate times on the bus, in the office, in the movies and just before dinner.

* I often feel fatigues or depressed.

* I lack energy for the activities that I once loved.

* It routinely takes me more than half an hour to fall sleep.

* I snore or kick a lot while sleeping.

* I wake up frequently during the night

If your answer is true to one question or more, make an appointment to discuss your sleep patterns with your doctor.

Surgery: many strides and sprints
By Dr J.D. Wig

The surgeon of today is in fact the product of a series of events that began to get under way scarcely a 100 years ago and did not reach the state of full flowering until 50 years ago. We, the surgeons of today, have little connection with our predecessors except through the knife and the hands.

It took a particular kind of man to do this work—amputating arms and legs, incising boils, and applying red hot coutery iron to the open stumps of the rotting or freshly injured legs which were sawed off. The patient must be screaming in agony and struggling with the muscular attendants hired to hold him down.

A surgeon of today is not the kind of man who neither knows nor cares about anything involving his patient except the immediate problem he has been summoned to treat.

Surgery thus remained a career for the few who could inure themselves to the screams of their struggling patients. They presumed that their only clinical responsibility was the operation itself and the local care of the resultant wound. A surgeon now is patient-friendly.

Pain, haemorrhage (bleeding) and infection—the three great evils which had always embittered the practice of surgery and checked its progress—were robbed of their terrors in the 20th century. Probably more has been accomplished to place surgery on a truly scientific basis than in all the centuries which have preceded this wondrous period.

General anaesthesia became a reality and was widely accepted. Lister introduced the concept of antisepsis. German surgeons developed instruments to achieve haemostasis. Germany was the first country to adopt antiseptic surgery.

Infection continued to kill patients. Initially, surgeons thought that wounds required the presence of pus to heal ( the laudable pus). In 1867, Joseph Lister's work eventually changed everything concerning the notion that pus was necessary for wound-healing disappeared. Lister showed that bacteria caused infection.Carbolic acid killed bacteria, antisepsis was born and asepsis inevitably followed. Surgeons started washing their hands and the operation site, debrided necrotic and loose tissue, and stitched up the wound so that they healed cleanly.

Surgeons started following nature. With the development of asepsis, new operations could be performed.

The development of antiseptic techniques have made operative procedures safer and more feasible.

Surgery without safe anaesthesia was nothing but a crude form of butchery. October 16, 1846, was the day that was to have changed everything in surgical practice. No more screaming and struggling patients. On that day ether was used publicly for the first time as an anaesthetic agent. The number of procedures increased dramatically after the introduction of anaesthesia.

There has been tremendous development in this field.

The treatment of pain after surgery is central to the care of the post-operative patients. Understanding pain is essential to the goals of medicine, namely to preserve and restore health and relieve suffering.

Tremendous advances have been made to relieve post-operative pain and efforts to obtain more effective and safer pain killers are continuing. The prevention of pain is more effective than its treatment. Prevention of pain now begins preoperatively and continuous intraoperatively and postoperatively. The improving efficacy and safety of continuous or intermittent drug delivery systems have increased the use of such devices for pain relief.

The use of technology in surgery since World War II has introduced revolutionary changes in surgical practice. Surgical intensive-care-monitoring, open-heart surgery, transplantation, computed tomography, magnetic resonance imaging, pacemakers, and minimally invasive surgery (laparoscopy) are examples of such progress.

Technology has improved the quality of research and patient-care.

Technological advances are making established procedures easier and safer and allowing the development of innovative approaches to old problems.

New optical technologies are poised to play a major role in the detection and therapy of tumours ( endoscopy). The advent of minimalist surgery has permitted and is promoting a gratifying subspeciality. We can now visualise anatomy and diseases in a fashion that surprises most of us.

Surgeons can accomplish technical feats that inflict less stress upon the patients.

Electrocautery, staples for sutureless anastomosis and prosthesis (joints) are a few of the technological innovations that have stood the test of time.

The golden age of surgery where the outcomes of a surgical procedure were solely determined by the manual skills of the surgeon is over. Surgery will no longer be limited to what can be seen by the naked eye, or felt by the human hand. The development of anaesthesia, antiseptic techniques and antibiotics at the turn of the 20th century have made operative procedures safer and more feasible. Technology has and will continue to alter the surgical landscape and will continue to do so at an accelerating rate. Surgical innovation and technology, aided by rapid advances in anaesthetic management, has allowed for an explosion in surgical treatment.

Dr Wig is a renowned surgeon and medical teacher based at the PGI, Chandigarh.

Medicines can cure and kill
By Manju Wadwalkar

A girl of nineteen takes an examination at a college, decides to walk down to her house, develops pain on the way in the abdomen and goes to the nearest clinic of a qualified private practitioner. After examining her, he gives her an injection of a pain-killer. She complains of restlessness and dies within minutes. Shocking, heart-rending and tragic that a young life was lost so easily!

"Cured yesterday of my disease, I died last night of my physician", says Matthew Prior, a celebrated pharmacologist, while talking about the deleterious effects of drugs in his book, "The Remedy Worse Than the Disease". There is no dearth of patients dying of misguided treatment.

The most upsetting aspect of modern medicine is the creation of disease in a patient who is suffering from a temporary disorder bound to disappear in a short duration.

In this era of drugs we must familiarise ourselves with the term "iatrogenic disease (physician- caused ailment)". When a physician administers medicines without a complete understanding of the patient's condition, drugs play havoc. A person may become the victim of a worse disease or even lose his life.

The girl whose body was later brought for post-mortem to a government hospital was found to be pregnant. Had the doctor known about her pregnancy, he wouldn't have given her pain-killer. He would have used some other drug. With Analgin, for instance, special precautions should be taken in case of pregnancy, bronchial asthma, renal and hepatic dysfunctions and blood-related disorders. It has been banned in several countries, including the USA and Sweden, because of its unexpected and negative effects that lead one even to death through an anaphylactic shock. An anaphylactic shock is a process that leads to a severe fall in the blood pressure, bronchoconstriction, the swelling of blood and lymph vessels and sometimes death because of the loss offluid in these vessels. Anaphylaxis usually occurs sudddenly, in minutes after the administration of a drug. The well-known drug, penicillin, and many other drugs, may cause anaphylaxis.

The term "side-effects" is a part of an ailing lay man's vocabulary but adverse drug reactions are known only to a more aware and literate patient.

Ciprofloxacin, when given for an ear-infection, may cause vertigo and amoxycillin, while fighting a throat infection, may hurt the stomach. Similarly, while chemotherapy given for cancer may lead to indigestion and hair fall, steroids administered continuously may lead to obesity and diabetes.

Drugs are meant to eliminate disease. In the quest for avoiding the misery of sickness, man has invented medicines that may themselves cause diseases. The illness caused by a drug may be short-term or long-term. Side-effects are short-term and predictable. The unpredictable and bizzare reactions are termed as adverse reactions. A variety of drugs cure many ills but are also known to cause irregular heart beat and even sudden death. Some of the examples are of anti-histamines, antimicrobial and antimalarial drugs (quinine) and antipsychotic ones like thiroidazine and chlorpromazine.

A 68-year-old man, with a five-year history of Alzheimers's Disease and cervical spondylosis was admitted to a psychiatry ward for deterioration in his mental state. He had no history of any heart disease. When treated with thioridazine, an antipsychotic drug, along with the medicines he was already taking, his behavioural problems improved initially. But five days later, he was found dead by the hospital staff. Two hours earlier, he had been in his usual state. The certified cause of death was heart failure. Thioridazine was considered as a contributing factor. This case was published by the WHO.

Quinine, a drug commonly used for malaria and leg cramps, is also found in some cold drinks to give them a bitter taste. A 79-year-old woman was admitted to an emergency wared as she had a sudden drop in blood pressure and suffered from internal bleeding. Three months earlier, she had taken quinine sulphate for leg cramps with no negative reaction. Two days before admission, she had taken it again. Within 12 hours, she found bruises on her skin. Blood was found in her urine, stool and sputum. She improved after she was given six packs of platelets, two units of fresh frozen plasma and another medicine intravenously. One week later she was discharged from the hospital and was advised to avoid quinine. This case was published in a recent issue of the Postgraduate Medical Journal of UK. Medical literature is full of such instances of commonly used drugs causing fatal reactions.

A strong sense of responsibility on the physician's part and an attitude of extreme caution on the patient's part can substantially help in covering at least some of the risks of medicines, if not all. There are many factors that help a doctor in his choice and use of the drug. The medical history of a patient, age, sex, personality, environment and education contribute in deciding the course of treatment. The very old and the very young are likely to suffer as their bodies are less tolerant. Older children may sometimes be more tolerant than the adults. The elderly tend to respond better to standard drug dosage. But the lower body size, slow blood flow to vital organs, decreasing metabolic capacity and tendency to multiple physical problems contribute to adverse reactions.

Pregnancy and lactation in a woman are very important factors in the choice of drug. The prescriber has to administer a drug safe for the child and yet effective. Similarly, asthma and cancer patients have to be cured of minor problems keeping in mind their major illness.

Doctors are prescribers, patients as receivers, and pharmacists as dispensers should use knowledge and caution while dealing with medicines.

Medical institutions the world over have opened drug information units that provide complete and updated information about drugs to the users. The Postgraduate Institute of Medical Education and Research, Chandigarh, has recently opened one such unit in its Department of Pharmacology. Drug information counters should be opened at all important medical centres of the country so that people become more and more aware of the negative effects of drugs along with their healing properties.