Wednesday, October 13, 1999

Stammering
Learn to conquer
Stammering, termed stuttering in medical parlance, is a complicated yet a common speech disorder among adolescents and adults. Over half of those who suffer from any type of speech disorder or voice defects are stutterers.

Global TB trends-III
The problem patients
Public health conscious Western countries can go any length to track down their problem patients so that the rest of the society can breathe more easily. At times this may look and sound oppressive but when it comes to curing diseases, an iron hand should not be resented and may even be desirable.

Cold can get worse by blowing nose
SAN FRANCISCO, Oct 12 — Blowing your nose could blast infected mucus back into the sinuses, making a cold worse and perhaps leading to sinus infections, researchers have said.

Cutting edge of medicine

Obesity
Right way of managing
By Dr G.D. Thapar

The consequence of the combination of overeating and physical inactivity is obesity. The extent to which obesity can adversely affect the health and well-being of a person is best exemplified by the modern day Nauruans, a small nation of 7000 once-happy-and-healthy people of a tiny, 20-square-kilometre island country of Nauru in the Western Pacific.

Their small island was an equatorial paradise with lush green forests and waters full of fish. It had enough for everyone. Unfortunately, they suddenly found themselves rich beyond belief. Huge deposits of high-grade phosphate had been sighted in the island in the 19th century. In the past three decades, since independence, they have recklessly mined their country for phosphate for export and converted their beautiful country into a barren uninhabitable land.

With the money pouring in millions of dollars, they imported an incredible number of cars, gadgets and junk food for easy and luxurious living and human labour to work for them. With plenty to eat and no work to do, the nation of active healthy people have converted themselves into sick and lethargic, fat and flabby men and women, many of whom weigh over 135 kilograms.

It is frightening but true that over 50 per cent of the population has become diabetic, and there is rampant hypertension and ischaemic heart disease, cutting short their life-span to an average of only 55 years. Now that the phosphate deposits have all but disappeared, their country converted into a barren wasteland and money no longer pouring in, it is not difficult to imagine their fate.

Though less glaring, the story of neoaffluent families in other countries, including India, is not very different. Quick prosperity with physical inertia is a risky proposition.

Watch your waistline

Since the collection of fat in the abdominal area is the most harmful part of obesity, it is important to watch your waistline. Waist measurement is probably more important than weighing yourself on the weighing machine and is much simpler. Measure at the level of the naval. The belt of your trousers should be your guide; if it has become too tight, it means you have added fat; immediately measure your waist as well as weigh yourself. Do not go to your tailor to get the belt loosened; instead, you should adjust yourself into your pant by losing some weight.

The following measurements of the waist, taken at the level of the naval, are considered ideal:

Men: 94 cm (37 inches)
Women: 80 cm (31-1/2 inches)

Health risks increase progressively with the increase in the girth (and weight) beyond the ideal figures. An increase in girth to more than 102 cm for men and 88 cm for women, or an increase in weight by more than 10 per cent or 8 kg make the risk to health such that the reduction of weight becomes imperative. Otherwise the person loses buoyancy, becomes breathless on exertion and his/her joints start creaking and develop arthritis. Arthritis not only causes pain but also restricts the movement and physical activity, and thus adds further burden of fat to the already overloaded body.

The waist circumference is the best indicator of change in the quantity of intra-abdominal fat during weight reduction (or gain) and is a simple and useful predictor of health risk from obesity.

Health risk

Obesity predisposes a person to, and is associated with, many serious diseases and disorders, some of which have already been mentioned in the story of Nauru above. Obese persons have to carry an extra load of inert fat. It is like carrying an extra load all the time. It is a burden on the heart and lungs and leads to breathlessness and sluggishness.

These effects further reduce the physical activity and lead to greater obesity. The unburnt calories raise the blood sugar and cholesterol, and elevate the blood pressure. It is a vicious circle of overeating, physical inactivity, obesity, hypertension, high blood sugar and cholesterol, all conspiring to affect the coronary arteries adversely by fatty deposits and causing ischaemic heart disease (IHD) and strokes. It will be appreciated that fundamental cause of all these problems is a combination of overeating and physical inactivity.

Weight reduction

Weight reduction is achieved by suitable changes in the diet and making life physically active, including regular exercise. Weight reduction has a beneficial effect on the lipid profile, blood pressure and blood sugar.

All these effects lower the risk of IHD. The breathlessness disappears and the person becomes more agile and active. Increased activity, so achieved, has further conditioning effect on the cardiovascular system.

It is important to emphasise that it is never right to go up and down the scale, sometimes losing and then regaining weight. Once you have reduced weight, stay reduced. When you shed weight, not only fat but some muscle may also be lost. If you now add weight, you only put on fat.

To prevent losing muscle while reducing weight, it is important to eat enough of proteins such as cheese, chicken and fish! — and do vigorous exercise.

Obesity develops only when there is a sustained imbalance between the amount of calories consumed and the amount used up in physical activity. The strategy to lose weight has therefore to be targeted both at the reduction of calories as well as at the increase in physical activity and exercise.

Reducing diet

The aim should be to do away with empty calories, and this means fats and sugar; they contain few or none of the other nutrients like proteins, vitamins and minerals. Both of them are fattening. To produce results, a drastic reduction in their consumption is called for. This can be achieved by doing away with sweets and sweet dishes as well as fried and deep fried items of food, and by consuming no or little sugar in beverages. You can take the help of artificial sweetners for a while, although their long-term use cannot be termed healthy; they are after all chemicals.

Calories should be provided as far as possible complex carbohydrates in the natural form, i.e. fresh vegetables, lentils, dals and fruits. In this form you will get plenty of vitamins, minerals and fibre. In addition, you should have enough of body-building proteins in the form of milk and its products.

Keep the milk in the fridge after boiling; after a few hours remove the upper creamy layer for making ghee and butter, and consume the lower part that has a low fat content. You can add some chicken or fish to this diet for more proteins. Red meat, i.e mutton, beaf or pork, might be used occasionally and organ meat like brain and liver should be avoided because it is very fatty and its cholesterol content is very high.

Eggs also contain a high amount of cholesterol; they should be avoided if your blood cholesterol is above 220 mg%; otherwise three to five eggs a week may be in order.

The cooking medium, which is usually ghee or vegetable oil, should be consumed sparingly. All foods that can be relished either in an uncooked state such as salads, or as boiled without ghee or oil, should be consumed in that state. For other food-stuffs use the minimum of ghee or oil in the ratio of one to three. This ratio will keep the blood cholesterol low.

A diet of 1,200 to 1,400 calories per day may be adequate to reduce weight. Once you have reached your target weight, about 1500 to 1800 calories a day may keep you at the desired level.

Do not practise crash diets; they are harmful. Aim at reducing about 1-1/2 to 2 kilograms per month. This is a realistic target and is unlikely to give you any problems. Fasting on specific days of the week may be helpful, provided you do not overeat on the next day. However, long periods of fasting at a stretch is inadvisable.

Exercise

Exercise is an integral part of any weight-reducing programme. Whenever you reduce your diet, you not only do away with some fat but lose some muscle mass also. Exercise builds up muscles and prevents this loss. It raises the metabolic rate of the body, which continues for quite some time after the exercise, expends more calories and helps in weight reduction.

Forget about weight-reducing drugs as none that is safe and effective has been invented yet.

It is a good idea to take a tablet or a capsule of multivitamins daily to guard against any vitamin deficiencies that may occur consequent on dieting.

Dr Thapar is a well-known clinician, administrator and author. He is based at Ambala.

Stammering
Learn to conquer

Stammering, termed stuttering in medical parlance, is a complicated yet a common speech disorder among adolescents and adults. Over half of those who suffer from any type of speech disorder or voice defects are stutterers.

The lower animals produce voices but are unable to speak. Speech — the voice conveying ideas — is the prerogative of the humans alone. With speech originated stuttering — a universal ubiquitous phenomenon affecting people of all ages, races, cultures and language groups. It shows no respect for any socio-economic status or position in life. King George VI of England stuttered severely. Aristotle, the great thinker, too was a stutterer. Interestingly, stuttering occurs four to five times more frequently among males than among females. Reasons for this disparity have not been made clear so far.

Stuttering is characterised by abrupt, involuntary interruptions in the flow of speech and there may be repetition of sounds and syllables. Stutterers have difficulty in starting a sentence and they repeat spasmodically a sound—usually the first syllable of the first word or even the whole word.

There could also be pauses in speech which may be filled with grunts and repetition of a word or syllables. The words difficult to pronounce or where stuttering occurs more often are those starting with b,d,l,k,p and q. When stuttering is severe, it accompanies grimacing, head-jerking and even body-contortion.

By and by, stutterers develop their own control techniques. Some find that singing is easier than talking and take advantage of this to modify the pitch of their speech whenever a problem crops up.

Stuttering initially, was considered merely an indication of neurosis or a disorder of rhythm. There are many other causes of stuttering and not all are fully understood yet. There is considerable disagreement among the experts on many finer aspects of this speech malady. In many cases, stuttering seems to be precipitated by emotional shocks which may originate from fever, fright, a radical change in the environment or sibling rivalry or even a consequence of the accumulated impact of a neurotic environment (Columbia Encyclopaedia).

Many psychologists believe that stuttering is the result of an unconscious conflict between the desire to speak and a preference to remain silent.

Many studies, however, indicate that persistent stuttering is a neurotic symptom that results from non-adjustability during childhood. Some investigators hold the view that among children stuttering is caused as a result of the delayed development of speech centres within the brain. Stuttering per se does not result from a structural or anatomical defect in the larynx or the voice box even though a few still firmly attribute organic factors to it and believe that this is primarily caused by "incoordination of muscles around the voice box". Besides, stuttering does also have a genetic component. It tends to run in families. Over 60 per cent of the stutterers show family history and also share familial stuttering characteristics.

Stuttering is common to all infants of two to three years of age. In fact, infantile stuttering signals an attempt of the child to speak and should, therefore, be welcome. This gradually but surely disappears soon thereafter. This child stutters start stammering before four or five years of age and if it persists beyond six to seven years, medical attention is warranted. The help of a competent therapist rather than that of a physician could be more rewarding. Even at this stage when a child does not yet have an adequate vocabulary, repetition of words and initial hesitancy in speech leading to a little bit of stuttering could be ignored. Reformatory criticism, from the parents or elders and ridiculing of this defect by the persons around are known to transform a primary stutterer into a permanent one.

Relaxed homely atmosphere and understanding parents can help more than even a speech therapist or a psychologist. Most often, stuttering makes its appearance when children are beginning to speak and start making sentences. The child learning to speak requires patience and not the active help from the adult listeners; they should apparently ignore this speech discrepancy in a child and desist from finishing the child's sentences when he is stuck.

This early hesitancy in speaking in most cases vanishes gradually but surely within a few months. Only in about 10 per cent children, early stuttering persists till later childhood. Out of these, approximately one to two per cent turn not to be permanent stutterers. While stress certainly aggravates stuttering, it by itself is not the cause of this speech disorder.

Also stuttering does not develop from a child's exposure to another stutterer. Imitation as a cause of stuttering is ruled out by experts. Further, it is of paramount importance that stutterers are persuaded to accept the condition and cease trying to cover up the feeling of inadequacy and speech blocks through a pseudosense of self-esteem. This aggravates stuttering further.

Stuttering usually originates in childhood but rarely makes its first appearance in adolescence or even in later life. Childhood stuttering mainly is physiological in origin i.e it mostly occurs as a result of incoordination of muscles around the voice box. But the persistent type more often, if not invariably, is psychological in origin. This is not to say that the emotional factors do not exacerbate the first condition.

It is believed, wrongly though, that left-handed children stutter more than the right-handed ones. Generally "operation rehabilitation" enforcing the transformation of the left-handed child into a right-handed one, proves counterproductive and such children start stuttering. The best advice to such parents is to be patient yet watchful and abandon reformatory attempts.

While treating stuttering, distinction needs to be made between primary stuttering before a child has become conscious of it and secondary stuttering when the stutterer is aware of this inadequacy and has already suffered personality deviation. In case of primary stuttering, the elimination of stressful environment, relaxed homely atmosphere, understanding parents and appropriate counselling by a speech therapist help a lot. In the later case, however, intensive, often prolonged, psychological management is needed.

Remember, therapy for the management of stuttering is most effective and productive when parents are considerate and get positively involved in promoting self-esteem in the child rather than be over-reactive and subject the child to ridicule.

Prof. K.C. Kanwar is the former Chairman of the Department of Biophysics, Panjab University, Chandigarh.

Global TB trends-III
The problem patients

Public health conscious Western countries can go any length to track down their problem patients so that the rest of the society can breathe more easily. At times this may look and sound oppressive but when it comes to curing diseases, an iron hand should not be resented and may even be desirable.

It was noted that from 1985 to 1995, the proportion of all Santa Clara County, California, TB cases among recent immigrants climbed by a whopping 73%. This kindled the curiosity of to Catlos EK et al of Santa Clara Valley Health and Hospital System; County of Santa Clara, along with Public Health Disease Control and Prevention, TB Clinical Services, Division of Infectious Diseases, and TB Clinic, Santa Clara, California, to study all immigrants entering the country from October 1995 to June 1996.

They sent letters to them promptly on the notification of the quarantine department, followed sequentially by phone calls and home visits. They screened 314 of 323 (97.2%) immigrants including 79 to 323 immigrants who presented prior to interventions, 213 of 314 (87.3%) who responded to letters, 17 (7%) to phone calls, and 5 (2%) to home visits. Of 283 immigrants screened 16 (5.7%) had active TB. To locate one immigrant cost $ 9.90 by letter, $ 43.25 by phone, and $ 129.88 by home visit. Locating one TB case cost $ 175.88 by letter, $ 696.26 by phone call (American Journal of Respiratory & Critical Care Medicine 1998, 158:1037-41).

How we wished our tracking systems are half as good!

Sputum: Coax or coerce?

As a biological specimen for diagnosing respiratory pathogens, the sputum has always been a tricky customer. Especially in tuberculosis a poor sputum specimen can ruin a diagnosis just as a poor sputum examination technique carried out by a poorly trained technician with poor motivation. That is the reason why doctors have felt tempted to look for other specimens to diagnose. TB, but sputum is something that can be coaxed if not coerced to come out if only we use the right tactic.

Against this background, microbiologic confirmation of pulmonary tuberculosis among patients whose sputum smear is negative is increasingly important because of greater incidence among immunocompromised hosts and emergence of drug-resistant strains. Dr Anderson and coworkers from the Department of Medicine, Montreal Chest Institute, McGill University, Canada. (American Journal of Respiratory & Critical Care Medicine

1995, 152: 1570-4) prospectively compared sputum induction to fibreoptic bronchoscopy in the diagnosis of such patients. Consecutive patients referred for investigation of possible active pulmonary tuberculosis underwent sputum induction with hypertonic saline delivered by an ultrasonic nebulizer between 2 and 48 h before transnasal fiber-optic bronchoscopy. All specimens were examined for acid-fast bacilli with fluorescent microscopy and cultured for mycobacteria. Clinical information was abstracted from patient records, and X-rays were reviewed by two blinded readers. Among 101 participants, sputum induction was well-tolerated without complications and provided adequate samples in 93. Sensitivity of direct acid-fast bacilli smear of specimens from both techniques was low. Sensitivity and negative predictive value of culture from bronchoscopy specimens was 73% and 91% compared with 87% and 96%, respectively, for sputum induction when a specimen was obtained.

Direct costs for bronchoscopy totalled Canadian $ 187.60 compared with Canadian $ 22.22 for sputum induction. Sputum induction was well-tolerated, low-cost, and provided the same, if not better, diagnostic yield compared with bronchoscopy in the diagnosis of smear-negative pulmonary tuberculosis.

So, the next time you get a smear negative case, simply don’t take the result on its face value. It is worth the effort to try to little extra hard to get that tough sputum sample and have another look.

Did you know?

If only TB were to be controlled well, even if not eradicated, throughout the developing countries, their economic output will go up by $ 24 billion every year. In rupees, that works out to roughly Rs 10,00,00,00,00,000. Don’t worry if the number of zeroes is one or two here and there — it sure is a whopping number, alright. No wonder they say, health is wealth!

* * * * *

It was in the early sanatoria that anti-TB drugs made history. The euphoria of streptomycin’s efficacy soon gave way to the despair of resistance development with monotherapy. Thus came the simple wonder drug isoniazide, into the picture. It has outsurvived streptomycin and even as we enter the twentyfirst century enjoys a pride of place in chemotherapy, whether for cure or prevention. But questions are now being asked about INH monotherapy as prophylaxis in HIV-infected patients. — Projection: K.P.S.
(Concluded)

Cold can get worse by blowing nose

SAN FRANCISCO, Oct 12 (Reuters) — Blowing your nose could blast infected mucus back into the sinuses, making a cold worse and perhaps leading to sinus infections, researchers have said.

Coughing and sneezing do not propel mucus back into the sinuses, according to the researchers from the University of Virginia and the University of Aarhus in Denmark.

“Nose blowing is the mechanism by which nasal fluid is propelled into the sinus,” the researchers told a meeting sponsored by the American Society of Microbiology.

Dr Owen Hendley of the University of Virginia and colleagues studied 14 volunteers who had a cold.

They measured the pressure in their sinuses and checked to see how much mucus was up in there.

They put a special imaging dye into the noses of their volunteers, had them blow, and then did a CT (computed tomography) scan of their sinuses.

The dye appeared in the sinuses of all four volunteers who blew their noses for the tests, but none of those who simply coughed and sneezed.

Earlier studies have shown that adults who have colds blow their noses on an average of 45 times a day for the first three days.

Dr Hendley’s team suggested using over-the-counter medications as early as possible in a cold to dry up the mucus.

Cutting edge of medicine

AIDS: more hope at lesser cost
Patients with HIV infection now have a cheap option for reducing problems that occur in them because of reduced immunity. According to a study carried out by Dr Ajay Wanchu of the Department of Internal Medicine, PGI, the use of a drug called Pentoxyphylline can reduce the risk of opportunistic infections.

Speaking at the AIDS Update at the PGI on Monday, Dr Wanchu described the findings of the study and said that the drug interfered with the function of a molecule called the tumour necrosis factor. Since the latter increased the speed of growth of the virus and also mediated in several opportunistic infections, the inhibition of its function reduced such infections.

Dr Wanchu studied 33 HIV-positive patients whose CD4 counts were less than 5,000 levels at which the risk of these infections are the highest. In a follow-up, which in some cases has extended beyond one year, gain in weight has been near universal and has been sustained over this period of time.

Most were losing weight prior to recruitment in the study.

These have been two opportunistic infections so far, despite the fact that their CD4 counts were critically low.

There patients have been able to sustain their CD4 counts on follow-up. Costing only about Rs 8 per day, this can be affordable to a large section of the patients. The therapy, according to current international guidelines, costs about Rs 25,000 per month. — K.P. Sinha

Nature’s weapon against mosquito
LONDON, Oct 12 (Reuters) — British and Nigerian scientists have discovered a compound in a garden bush which could provide a cheap weapon for developing countries to fight mosquitoes.

Seeds from the summer cypress, or burning bush, produce an oil which can be converted into a compound that attracts disease-carrying mosquitoes.

“Researchers from Britain and Nigeria have turned oil from the plant’s seeds into a Pheromone. This biological messenger, which is odourless to humans, could lure female mosquitoes away from the places where people live,’’ New Scientist magazine said yesterday.

It claims New York health officials could have used the new weapon to combat mosquitoes carrying West Nile virus, a disease that attacks the nervous system, which has killed three people in the city.

“The bush might also provide a cheap way for the world’s poorest countries to fight filariasis, a disfiguring parasitic disease that affects 15 million people in Africa alone,’’ the weekly magazine added.

Tests of a synthetic version of the pheromone in Africa, Japan and the USA have shown it works but is very expensive to produce.

The scientists said their work is still in the research stage but they believe the burning bush could provide a cheaper alternative to the synthetic pheromone.

New ‘cure’ for migraine
WASHINGTON, Oct 12 (ANI) — Researchers have claimed that small facial injections of the botulism toxin which is a common cause of food poisoning, can help in treating migraine headaches.

Dr William Binder, a Los Angeles plastic surgeon who made the finding, said yesterday that his tests on a number of patients with injections of botulism toxin had stopped or lessened their migraine headaches.

Migraine headaches, a debilitating disorder characterised by severe pain, vertigo, nausea, vomiting and light sensitivity, affects 17 per cent of all women and 6 per cent of men.

Dr Binder and three other physicians in New York and San Francisco again conducted formal tests on about a 100 more patients before reaching a conclusion.