118 years of trust

Wednesday, July 29, 1998


Coping with diabetes
By Jayant Banerji
THERE is an epidemic of diabetes sweeping the world. This a strong but true statement.
Agonising pain of anal fissure
By Sanjay and Savita Aggarwal
Doctors commonly find patients complaining of unbearable, agonising pain while passing stools. Pain stays for hours after passing the stool.
Pills to be rendered obsolete?
IN a major breakthrough, chemists in Delhi University have produced the tiniest "polymeric nano-particles" which, they claim, can revolutionise oral drug delivery system.
New way to treat hip dislocation
A Calcutta-based medical practitioner has devised a new surgical method to treat babies with congential hip dislocation, an orthopaedic malady hitting about 30 infants per thousands live births in the country.
Medical notes


Coping with diabetes

By Jayant Banerji

THERE is an epidemic of diabetes sweeping the world. This a strong but true statement. One always assumes that epidemics refer to infectious diseases like dengue fever, tuberculosis etc. There are estimates to suggest that between 9-12% per cent of the population of India will be diabetic after the age of 40 by the time we march into the 21st century. Though awareness of this disease is increasing many myths still surround it.

One of the very said things about diabetes is that there is no cure. In a certain type a very complicated surgery involving a transplant of the gland called pancreas may be done but the majority of diabetics will remain with this disease throughout their life. Thus it becomes imperative that our understanding of this disease is good.

There are predominantly two types of diabetes. Type I usually means that the person needs insulin to survive and this is found in younger patients. In this the cells which secrete insulin from the pancreas called beta cells decrease in number or die out all together.

Type II diabetes occurs in older people and these patients may be controlled with diet and oral medications. Surprisingly the level of insulin in these patients may not be deficient but they may develop a resistance to this hormone which is required to take up the glucose from the blood stream into the cells of the body where it is used.

There are certain other special types of diabetes but special mention is made of gestational diabetes which affects pregnant women. This is very important because these women need a much better control of blood sugar and if uncontrolled can damage the mother as well as the baby. Also some of these women may go onto develop proper diabetes later in life.

There are many myths which surround diabetes and it is important to stress two things. Firstly it is not possible to cure diabetes but a good control of diabetes can decrease the complications of this dreaded disease remarkably. Secondly it has been seen that diabetics may go around for many years before they develop symptoms and thus be diagnosed diabetic.

Thus it is important to screen the population, especially those at risk, for diabetes regularly. These include first degree relatives of diabetics, women with large babies at birth, those with increased appetite, increased urination or thirst, those who are overweight, people with recurrent infections and actually everyone over 40 years of age should be screened with a blood sugar atleast once in three years.

Many diabetics may go through a honeymoon period after diagnosis and blood sugars which were high may become normal for up to two years. This is the time that quacks may use to try their medicines. Others may try "desi" medicines. These too may have some effect but more often than not they may contain heavy metals or steroids which may cause long-term harm. Some quacks may do a urine test to show no sugar in the urine. This may be false as it is the blood sugars which need to be controlled and a urine test may give a false assurance while the blood sugars remain high.

No two people respond the same way to diabetes. In fact the father of modern diabetes Joslin said the "each patient is a textbook of diabetes. This article naturally cannot purport to be a textbook as the topic is very vast. Some people may go through life with uncontrolled blood sugars and never develop any complications and others may already have complications when they are first diagnosed. So do not compare yourself with your neighbours and friends. Also the dose of medicines may vary from person to person.

Another concept which is fast emerging is that of omega-3-fatty acids. It has been seen that the polyunsaturated oils-the so called zero cholesterol oils-have a very poor content of these omega-3 acids and the ratio of these acids to omega-6 acids is actually very poor. The traditional cooking media like coconut and groundnut oil, desi ghee etc. have a much more beneficial ratio. Thus it is important to use atleast 15-30 per cent of these latter cooking media in ones diet especially in North India where fish is not eaten.

Fish is a very good source of omega 3 acids. The low content of this acid actually predisposes to diabetes and thus causes the same problems as one was trying to avoid by using PUFA containing oils.

There are three cornerstones of diabetic management — diet, exercise and drugs. The diet allowed now allows almost every thing except for sugars. The aim is to control calories rather than restrict the type of food. Fruit in small amounts is an integral part and about 100 gm of a fruit should be had every day. A mix of carbohydrates and proteins along with a small amount of fat is allowed and a diet chart should be obtained from your doctor.

Exercise helps in sugar utilisation and weight reduction, and this should be carried out four to five times a week. Actually diabetes is a disease of starvation amidst plenty. The blood sugars are high but the sugar cannot go into the cell where it is required to do its job and produce energy.

Drugs are of two types. The oral ones and insulin. The latter is available only as injections. It is required in all Type I diabetics and also in the uncontrolled Type II diabetics. It is also needed in times of stress such as pregnancy, infections, surgeries etc. Oral drugs are of different kinds and need to be balanced by your doctor. They may be combined with insulin. Certain drugs may help to prevent absorption of sugar from the gut and may be used too.

The one question that everyone wants answered is whether diabetes can be prevented. No one knows, but if one can follow a good healthy lifestyle without being overweight, eat the right food and exercise regularly diabetes may not harm one as much as others even if it develops.Top


Vital role played by pancreas

The pancreas and the spleen lie just behind the lower part of the stomach. The pancreas is responsible for secreting digestive enzymes into the duodenum. The pancreas is the second largest gland in the body and is both an endocrine and an exocrine gland. Its exocrime gland. Its exocrine function is to produce digestive juices (pancreatic juices) and release them through a tube, the pancreatic duct, to the intestine.

The endocrine function of the pancreas is controlling the amount of sugar in the blood. The cells that control blood sugar levels are called islands of Langerhans. These islands are microscopic clumps of cells scattered throughout the pancreatic tissue among the other pancreatic cells but are concentrated somewhat in the tail of the pancreas.

There are two kinds of cells in the islands: alpha and beta. The alpha cells secrete a hormone called glucagon and the beta cells secrete insulin. Insulin and glucagon work as a check and balance system regulating the body’s blood sugar level. Glucogon accelerates the process of liver glycogenesis (a chemical process by which the glucose stored in the liver cells in the form of glycogen is converted to glucose. This glucose then leaves the liver cells and enters the blood). This process tends to increase the concentration of glucose in the blood. Insulin is an antigen to glucagon. It decreases the amount of blood glucose concentration.

Insulin decreases blood glucose by accelerating its movement out of the blood, through cell membranes, and into cells. As glucose enters the cells at a faster rate, the cells increase their metabolism of glucose. All sugary and starchy foods, such as bread, potatoes, and cakes, are broken down into glucose.

In this form they can be absorbed by every cell in the body, including the cells in the liver, one of whose major roles is to store sugar. Cells absorb glucose and burn it in structures called mitochondria, using the energy it contains and producing carbondioxide and water as by-products. This burning up process is the body’s principle source of energy. It cannot take place without insulin.

Diabetes occurs when the pancreas fails to secrete enough insulin and so fails to regulate the glucose concentration in the blood.

The normal glucose level for an average adult is about 80 to 120 milligrams of glucose in every 100 milliliters of blood. If the islands of langerhans secrete too little insulin an excess of glucose develops, a characteristic of diabetes mellitus the most common disorder of the endocrine system.Top


Agonising pain of anal fissure

By Sanjay and Savita Aggarwal

Doctors commonly find patients complaining of unbearable, agonising pain while passing stools. Pain stays for hours after passing the stool. The patients wrongly term it as having ‘piles’. They know little that constipation has put them into this trouble.

An anal fissure, as we define it, is an elongated ulcer in the long axis of the lower part of the anal canal. It is most commonly situated posteriorly in the midline.

The anal canal is a short terminal part of the gut which forms an exit for the stools. It curves backwards acutely at an angle just a few centimetres before its opening. During defecation the hard faecal mass presses at this acute angle thus traumatising the superficial epithelial lining of the anal wall. A reflex action of the surrounding muscle below this lining plays a major role in production of pain. A circular muscle surrounds the anal canal which helps in the physiology of defecation. It is an involuntary muscle, meaning that this muscle can’t be controlled voluntarily. Fissure formation causes irritation and reflex spasm and contracture of this muscle which leads to the symptomatology. Other causes for this fissure formation include incorrectly performed surgery in the area, like that for piles. Also venereal infections may cause fissure formation in homosexuals. Diseases of the gut like ulcerative colitis and Crohn’s diseases, both of which are inflammatory in nature, may cause fissure formation.

The main symptom, as already mentioned, is pain during defecation. It is sharp and agonising, often overwhelming in intensity and lasting for an hour or more. It caeses suddenly later and the patient is comfortable till the next act of defecation. The patient tends to become constipated rather than go through the agony of defecation. It is a vicious cycle.

There my be bleeding with stools but normally it is slight with just a few drops or bright streaks on the stools. Constant discharge of mucus accompanies other symptoms in severe cases. Intensity of pain precludes examination by the doctor. Even a slight touch or stretch may lead on to pain. Examination is done under anaesthesia, be it local or general.

The pain of an anal fissure is so great that usually the patient demands relief and consequently many patients with an acute fissure present to the doctor early. The object of the treatment is to obtain complete relaxation of the circular muscle. The fissure slowly heals as soon as the spasm has disappeared.

Acute and early cases are managed with conservative treatment. Use of lubricant anaesthetic (5 per cent xylocaine) ointment relaxes the muscle. Regular use of stool softeners like ‘isabgol’ to avoid constipation helps. Regular bath i.e. sitting in luke warm water for about half an hour at least a couple of times a day provides tremendous relief with a help in healing of the fissure.

Intractable cases require surgical treatment which consists of either a forcible stretching and tearing of the circular muscle or a formal surgical sphincterotomy, in which an incision gives a clean cut in the continuity of the circular muscle. This relaxes the spasm and helps in healing up of the fissure. Conservative measures are continued along side this treatment.

Fortunately, this condition is less common in India, than the Western countries. But with the changing food habits, with more and more consumption of refined foods, constipation is becoming a frequent complaint. We should consume more of residue containing foods like green leafy vegetables.

Avoid stress, spicy food and alcohol. Keep yourself free from constipation to keep free from this agonising condition.Top


Pills to be rendered obsolete?

IN a major breakthrough, chemists in Delhi University have produced for the first time the tiniest "polymeric nano-particles" which, they claim, can revolutionise oral drug delivery system and potentially render the existing method of making pills and tablets obsolete.

The invention, which has attracted the attention of several drug companies, is awaiting a US patent.

The research was made possible with Rs 2.2-million funding from the Department of Biotechnology (DBT). These nano-particles are tiny spheres of biodegradable polymers, which can be filled with drugs or vaccines the developers say.

Because these liliputian drug carriers are designed to bypass the liver and go directly to the blood stream, side-effects are eliminated and smaller dosages will suffice.

These nano spheres are also "intelligent" because the rate of release of the trapped drug can be controlled by the environment. For instance, the drug release is slowed down inside the stomach, which is acidic and increased in the blood stream, which is neutral.

Also named "smart hydrogels", these were developed by Amarnath Maitra, Tapas De and Sanjeeb Sahoo of Delhi University, and P.K. Ghosh of the DBT.

According to Maitra, using their new method, spheres as small as 35 nanometres have been produced enabling their passage through the smallest of blood vessels. (One million nanometres make a millimetre).

Till now no one has produced nano-particles below the size of 100 nanometres. Spheres bigger than 60 nanometres cannot enter the blood stream when taken orally.

Existing drugs when swallowed get mostly absorbed by the liver leading to side-effects with only a fraction reaching the site where it is really needed. When given through injection, a drug no doubt directly into the blood, but is very quickly exerted through the urine.

The hydrogel carriers developed by Maitra’s team not only eliminate unwanted side-effects but stay in the blood for hours.

Maitra said in experiments in mice, orally delivered nano-particles were found circulating in blood for more than four hours while the maximum liver uptake was just 3 per cent.

"What we have developed is a polymeric envelope in which you can put drugs, vaccines or any thing you like as long as it does not chemically react with the polymer," said Maitra.

Taken orally, the contents of the envelope will be delivered with high efficiency, he said. Delivering of the anti-cancer drug "taxol" has been tested in mice and, "it works", he observed. — PTITop

New way to treat hip dislocation

A Calcutta-based medical practitioner has devised a new surgical method to treat babies with congential hip dislocation, an orthopaedic malady hitting about 30 infants per thousands live births in the country, reports PTI.

The surgery, a modification of the "open reduction process" earlier in vogue, uses thin bone chips to reinforce the hip joint of babies born with the anomaly, Dr N. De Mazumdar told delegates at the annual scientific conference of the Vivekananda Institute of Medical Sciences (VIMS) here.

Mazumdar, who has operated upon 12 infants successfully, said the method was novel since it reinforces the socket (capsule) in which the hip bone (femur) is cradled, with bone chips scraped from an adjoining bone (iliac) unlike traditional surgery which use bone grafts to fill this gap.

"The conservative treatment processes of splintage traction and closed reduction correct the problem in about 88 per cent of cases within two months of the child’s birth. But for children whose anomaly persists or recurs, the modified treatment can mould the capsule from a saucer shaped structure to the normal cup shape", he said.

The patients have to be operated upon very early in life between six months to an year of age, to prevent recurrence of the abnormality and also to enhance moulding of the capsule, he noted.

In a paper presented at the national paediatric orthopaedics conference at Pune recently, Mazumdar said the patients were followed up for an average of 38 months at the end of which the sutures in between the capsule and femur were found to be perfectly reinforced.

The operations carried out at VIMS and a private nursing home here involved initial screening through clinical tests, straight X-rays and ultrasonography.

Mazumdar took up 41 cases of which 29 were corrected through conservative methods and the remaining 12 by the modified open reduction surgery.

After the initial round of success, the surgeon has taken up further trials in a few more cases. "Patients not corrected even at the end of 18 months have to undergo bone surgery (osteotomy)", he added.

Medical notes

Vitamin B-6 and heart diseases

RESEARCHERS have found that people with the highest levels of vitamin B-6 are at the lowest risk of heart diseases. These people are at about one-thirds the risk compared to those with the lowest levels, according to ANI.

Aaron Folsom, who headed the team of researchers, said they were trying to see if homocysteine chemical could increase the chances of heart diseases and found there was no such links.

Earlier studies had suggested that high levels of homocysteine could cause heart disease. The present study was conducted on 759 persons in the 45-64 age group between 1987 and 1995. Folsom said 232 of them developed heart diseases over the years. He said a higher level of homocysteine may be the symptom of lower levels of vitamin B-6 thereby increasing the risk of heart disease. Homocysteine is not the cause of any heart disease, he observed.

Another study in February had said that there was a 45 per cent less risk in women who had more intake of vitamin B-6.

Organ transplant drug & AIDS

A RESEARCHER employed with the Aaron Diamond AIDS Research Centre at New York’s Rockefeller University has claimed that an organ transplant drug can possibly eliminate the AIDS virus from the body, reports ANI.

David Ho, one of the developers of the drug "cocktail" approach that has made HIV infection a controllable disease for many people, said the drug could take out bits of the virus known to lurk in the body for years.

Writing in a commentary in the journal Science, Ho said the immune system needed to be activated to flush out the HIV. He specifically named a mouse antibody known as OKT3 (muromonab-CD3) as being capable of flushing out HIV-infected cells. He said he was now working on a human version of OKT3.

OKT3 is made by Ortho Biotech, a subsidiary of Johnson &Johnson.

Malnutrition among children

THE per capita availability of pulses, the major source of proteins for Indians, has fallen by half since Independence, reveals a report released by the government, reports UNI.

The publication entitled "Food based dietary guidelines for Indians", released recently by the Union Human Resource Development Minister, states that despite India’s success in food production, the average per-capita availability of food has not changed appreciably since Independence.

While the per capita consumption of foodgrains was 394.9 gm per day in 1951, it had risen only by about 100 gm to 498 gm per day in 1996.

While the availability of cereals had inched up from 334.2 gm per day to 464 gm, that of pulses had actually fallen from 60.7 gm per day in 1951 to 34 gm per day in 1996.

The report ascribed the "alarming growth in India’s population" as a major cause for the poor availability of foodgrains despite the country’s self sufficiency in production.

Describing malnutrition as a continuing health problem, the report said that chronic under-nutrition was causing stunting of children’s growth. According to a survey by the Department of Women and Child in 1995-96, stunted height was reported in 56.5 per cent of the children in the age group of one to five years. Twenty per cent children were found "wasting", while 49.2 per cent were found to be underweight.

Nutritional anaemia was an important cause of maternal mortality and the low birth weight of children.

Colour ultrasound’s value

The revolutionary invention of colour ultrasound is a breakthrough in medical imaging that has markedly increased the diagnostic value of ultrasound as it displays the image of body organs in colours, reports ANI.

Dr Zahid Pasha, a leading consultant sonologist of Pakistan, who has introduced colour ultrasound in the country, says colour ultrasound which is far superior to the black and white ultrasound in its diagnostic ability.

Dr Pasha says the human eye could appreciate up to 20 shades in a black and white image whereas it could distinctly differentiate 16 million shades if the same image was in colour.

He says that diagnosis of diseases by ultrasound depended upon ability to produce variation in shades. With colour ultrasound, a slightest difference in shades is clearly evident as a variation in colours, whereas black and white ultrasound is not as sensitive.

Numerous diagnostic advantages of using colour ultrasound can be highlighted in all medical fields, including gynaecology, obstetrics, surgery and medicine. He said colour ultrasound was not the same as the colour doppler ultrasound.

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