A Matter of the Heart
Count your cholesterol
By Dr G.D. Thapar
Cholesterol is implicated in the production of ischaemic heart disease, angina and heart attack. It is the main ingredient of atheroma, the fatty deposit in the arteries that clogs them and obstructs the flow of blood. The deposit comes from the cholesterol circulating in the blood.

Innovation
Unhygienic toothbrushes get the brush-off
The Ozone toothbrush, designed in Britain by Jonathan Savitt and dentist Charles Taylor and developed by Ozonex Limited of London under official supervision is an ultra-hygienic toothbrush that ensures food debris, plaque and toothpaste are rinsed clean away. The toothbrush has an aperture in the centre of the brush head which allows all excess food and toothpaste residue to be easily flushed through it, resulting in a cleaner toothbrush and improved oral hygiene.

Why are our hospitals sick?
By J.C. Mehta
Our hospitals are sick. Poor institutional environmental health standards and practices have a direct impact on the comfort and recovery of patients. This, in turn, increases the operating costs of hospitals and reduces the turnover of patients: both straining the already crumbling health-care delivery systems at all levels.A British study reveals the increasing investment in any hospital project for buildings, engineering services and equipment. Nearly 20-30% of the annual budget of a hospital goes in for the maintenance and operation of these services. This is because of the fast-changing medical technology and sophistication.

A futuristic nightmare
By Dr J.D. Wig

Breast cancer (BC) can sometimes have a familial basis. In the mid-1800s, a French surgeon documented hereditary breast cancer within his wife's family, in which 10 out of 24 females, including his wife, were afflicted with this condition. In 1976, the British Government documented clear evidence that first-degree relatives of woman with BC had a greater risk of developing the disease. Systematic epidemiological studies have firmly established that first-degree relatives of the affected individuals have a significant risk of BC.

Hereditary or familial BC accounts for only 5-10% of the overall cases. The cancer makes its appearance at an early age and is often bilateral. The majority of familial breast cancers can be attributed to high-risk cancer genes — BRCA I or BRCA 2.

At present genetic testing is not available. It is being "carried out" in a few centres in the context of research protocols. Women who carry these mutations are at an increased risk of developing the bilateral disease. The risk of developing contralateral breast cancer may be in the order of 60-80%. A careful assessment and follow-up of contralateral breast are thus required.

In view of the more aggressive tumours in these situations, both local and systemic treatment needs to be tailored accordingly.

Physicians and surgeons are gradually becoming more aware of the importance of hereditary cancer syndromes. More women are encountered who have multiple relatives with breast cancer. A woman in good health with a strong family history of cancer may ask: "When am I going to get it and what does the future hold for my daughter?"

The problem is: how to manage the woman who is in good health and asymptomatic? She needs guidance in connection with the need and nature of a diagnostic work-up and/or treatment. The "best strategy" is still undefined. The goal is to identify, before cancer develops! Timing is crucial for determining when the individual needs therapy — too early (risks of an operation) or diagnosing too late. There are no studies examining the best modalities to evaluate patients at an increased risk for breast cancer.

Who is at risk? There are no clear studies to define this point. The following may be at an increased risk: a woman who has two or more first-degree relatives with breast cancer, a woman with one first-degree relative diagnosed with breast cancer at an early age or a woman with more than two second-degree relatives with breast cancer, one of whom had cancer at an early age.

The options for the management of increased breast cancer risk include the following:

Surveillance should begin 10 years before the earliest diagnosis of cancer within the family. It should consist of mammography. The utility of more recent technologies — digital mammography and breast magnetic resonance imaging — remains to be proved. One should try to get a feeling for the pace and character of the disease in a particular family and determine the timing and tempo of the surveillance. Some families develop cancer at a late stage while others get it at an early age. For the high-risk group a yearly mammogram and clinical breast examinations starting at the age of 35 are advised. Breast self-examination (BSE) should be done every month. The best time for BSE is 7 to 10 days after period starts. The breasts are the least tender and least swollen at this time.

The threshold size for detecting breast tumours by mammography is approximately 1 to 2 mm whereas the threshold size for detecting breast tumours by palpation is approximately 1 cm. High-risk groups should be encouraged to undergo genetic testing for hereditary susceptibility to breast carcinoma. If the testing conclusively shows that she does not carry a deleterious mutation, it is most likely that she is no more at risk.

Prophylactic mastectomy (removal of breasts) has been found to reduce the incidence of breast cancer. It reduces significantly the risk of death from breast cancer. This option should be made available to women who wish to consider the range of options available to them.

Prophylactic surgery may not be completely effective in preventing breast carcinoma. When should this surgery be performed is not clear. Such mastectomy should be considered only when a woman carries deleterious mutations. All women considering surgical options for risk-reduction should have a clear assessment of their risks of developing breast cancer.

The impact of prophylactic mastectomy on a woman's self-esteem should be directly addressed. Bilateral prophylactic mastectomy reduces the risk of death from breast cancer by 80%. The woman concerned should be offered a simple mastectomy rather than a subcutaneous mastectomy.

Chemoprevention is defined as the utilisation of a drug or a chemical to prevent the development of cancer. Breast-cancer-prevention trials have suggested that tamoxifen is effective in preventing the disease. At what age tamoxifen treatment should be initiated, for how long it should be continued, or what the "long-term" will be cannot be stated at this stage. Chemoprevention has only recently been offered as an option. Tamoxifen, a synthetic oestrogen receptor modulator, reduces the risk of oestrogen-positive breast cancer by nearly 50 per cent. Chemoprevention is in its infancy and its efficacy in the population of inherited predisposition is not known.

In high-risk groups with gene mutations, one must discuss the pros and cons of screening, chemoprevention or the prophylactic removal of the breast with the woman coming for consultation. Intensive screening is advocated. Prophylactic mastectomy is a useful part of the treatment protocol. Careful discussion is essential in the management of these women. Collective studies too need to be performed to answer this question.

Dr J.D. Wig is a renowned surgeon, clinician and teacher at the PGI, Chandigarh.

A Matter of the Heart
Count your cholesterol
By Dr G.D. Thapar

Cholesterol is implicated in the production of ischaemic heart disease, angina and heart attack. It is the main ingredient of atheroma, the fatty deposit in the arteries that clogs them and obstructs the flow of blood. The deposit comes from the cholesterol circulating in the blood.

Sources of cholesterol: Cholesterol is a sterol and is a normal constituent of cells of animals, including man. It is manufactured in their livers. It occurs widely in animal tissues such as egg yolk, brain, kidneys and liver and animal fats such as ghee, butter, lard, suet and cream. Organ meat, eggs and animal fats are therefore rich sources of cholesterol in our diet and therefore, in blood, in addition to the cholesterol manufactured by our liver.

It is interesting to note that plants do not manufacture cholesterol, and therefore, all vegetable oils, nuts and seeds, howsoever fattening they may be, are free of cholesterol.

Cholesterol in blood: Cholesterol circulates in the blood in combination with lipoproteins, which are of varying densities, high, low and very low. Low (and very low)— density lipoprotein cholesterol or LDL-C is bad cholesterol, because it produces atheroma and clogs the arteries, the cause of heart attacks. On the contrary high-density lipoprotein cholesterol or HDL-C prevents the deposition of cholesterol and is therefore good cholesterol that protects the heart.

Physical activity and exercise as well as small amounts of alcohol elevate blood levels of good cholesterol. In addition, exercise burns off cholesterol like any other fat and reduces total and LDL cholesterol levels.

Saturated fats increase low-density lipoproteins and total cholesterol. Cigarette smoking, sloth and inactivity not only raise LDL-C but lower the good cholesterol levels, and are, therefore, risk factors for the heart. The convenience and pleasure of sitting in a car, coupled with roads that are dangerously choked with traffic, have made walking an unattractive proposition. This is an important reason for our physical inactivity, consequent rise in blood-cholesterol levels, and the resultant rise in the number of heart attacks and strokes.

How to lower cholesterol levels?: Increased physical activity and exercise to a reasonable level and consumption of vegetable oils that do not solidify in North Indian winter in preference to animal fats (such as eggs, ghee and butter) will help lower the cholesterol levels. Restrict the use of butter for toasts and ghee for chapatis.

Reduce the consumption of eggs to three per week and avoid organ meat, particularly of brain and liver. In a few months, blood cholesterol levels will gradually come down. However, if after a trial of six months the level does not fall below 220 mg%, the question of instituting cholesterol-lowering drugs like Lovastatin may have to be considered by your physician.

Cholesterol in the aged: Age has an important effect on many risk relationships. Policies that make sense in one age group may not be justified in another. This is true of cholesterol also. It has been found that the risk relationship between high blood cholesterol and IHD, apparently disappears after the age of 70.

In fact, in old people the high consumption of polyunsaturated fat and the avoidance of animal fats appreciably increase the incidence of cancer and other non-cardiac deaths. Such a diet should be taken only by those who have documented heart disease (such as survivors of heart attacks). For others, moderation is the keyword. In them, a blood-cholesterol level of 250 mg% may be considered as adequate.

Some clinical lab tests

Q. What are the various clinical laboratory tests commonly performed on patients suffering from heart diseases?

A The most commonly performed tests are:

* Blood lipid (fat) estimation.

* Blood sugar estimation.

* Blood uric acid estimation.

* Cardiac enzyme-levels estimation.

* Urinalysis.

* White blood cell count.

* Erythrocyte sedimentation rate estimation.

Q. Fats are generally implicated in the causation of ischaemic heart disease. Please tell me about their presence in the blood.

A. Two types of lipids (fats) have been implicated in the causation of atheroma (fatty deposits) in the arteries, namely, cholesterol and neutral fats called triglycerides. Cholesterol is the fatty substance that gets deposited on the arterial wall and obstructs the flow of blood. A high intake of cholesterol containing foods (eggs, ghee, butter and organ meats from brain and liver) keeps the blood cholesterol level high and, over the years, it gets deposited on the arterial wall. You will, therefore, appreciate that the adverse effects are the result of prolonged high cholesterol levels in the blood, and just one egg or slight variations of cholesterol levels cannot make any immediate difference to the health of the person, nor can it precipitate a heart attack. The blood cholesterol levels are as follows:

Normal 150-220 mg%

Borderline 220-260 mg%

High above 260 mg%

There are two types of cholesterol. HDL (high-density lipoprotein) cholesterol and LDL (low-density lipoprotein) cholesterol. It is the LDL cholesterol which tends to get deposited on the arterial wall, while the HDL cholesterol is protective and beneficial.

HDL cholesterol level: Normal 30-90 mg%

It should not be less than 25% of total cholesterol level.

The role of triglycerides (neutral fats) in the causation of IHD is not yet clear. The triglyceride levels are as follows:

Normal 35-150 mg%

Borderline 150-190 mg%

High above 190 mg%

The author is a clinician, medical teacher, administrator and public health educator of international fame. He is based now in Ambala Cantt.

Innovation
Unhygienic toothbrushes get the brush-off

The Ozone toothbrush, designed in Britain by Jonathan Savitt and dentist Charles Taylor and developed by Ozonex Limited of London under official supervision is an ultra-hygienic toothbrush that ensures food debris, plaque and toothpaste are rinsed clean away. The toothbrush has an aperture in the centre of the brush head which allows all excess food and toothpaste residue to be easily flushed through it, resulting in a cleaner toothbrush and improved oral hygiene.

Dr Taylor, one of the designers of the Ozone, said: "With conventional toothbrushes there is a natural tendency for saliva, toothpaste, food and bacteria to accumulate with increased usage. Normal attempts to clean toothbrushes under a running tap are unsatisfactory as the force of water drives toothpaste residue and food debris deeper into the tufts of the bristles, with a majority of the sediment remaining in the middle of the brush head."

The Ozone toothbrush provides improved brushing of teeth and gums combined with the additional advantage of maintaining a cleaner toothbrush. Additionally, it promotes the correct 45-degree brushing angle as recommended by dentists, by providing a recess into which the cusps of the teeth fit naturally. — Jonathan A. Savitt, 43 Chase Side, London. (Courtesy British Information Service)

Why are our hospitals sick?
By J.C. Mehta

Our hospitals are sick. Poor institutional environmental health standards and practices have a direct impact on the comfort and recovery of patients. This, in turn, increases the operating costs of hospitals and reduces the turnover of patients: both straining the already crumbling health-care delivery systems at all levels.A British study reveals the increasing investment in any hospital project for buildings, engineering services and equipment. Nearly 20-30% of the annual budget of a hospital goes in for the maintenance and operation of these services. This is because of the fast-changing medical technology and sophistication.

The birth of hospital engineering in India: In 1969, the late Drs S.S. Anand and P.N. Chhuttani requested the late P.L. Varma, a visionary technocrat, to help the PGI whose technical services were under diversified control including that of the U.T. Engineering Department.

After an intensive interview, the Ministry of Health selected the author of this article and Dr M.S. Randhawa, ICS, then the Vice-Chancellor of Punjab Agriculture University, Ludhiana, was approached by the three professionals to relieve me from the PGI. Facing severe criticism in Parliament on the chaotic conditions in Delhi hospitals, Health Minister Karan Singh, aided by his Health Secretary, Mr K.K. Dass, ICS, appointed a National Working Group on April 22, 1971, under the chairmanship of P.L. Varma. The members consisted of a galaxy of IAS officers, and medical and technical experts. The author was the member-secretary. The group's recommendations were accepted by the MOH on March, 8, 1972. Thus the PGI and the city of Chandigarh became the birth place of this new speciality of hospital engineering. India was the 10th country in the world and the first developing South-East Asian country to recognise it at the national level.

The working group's findings.

Visits to hospitals, surveys and the analysis of buildings, plants, equipment, maintenance practices and their impact on poor patients brought tears into our eyes. CPWD/PWD architects designing hospital buildings were rarely knowledgeable in the specialised field of medical architecture, space standards, the multiple use of space and environmental considerations. More than 40% plants, machinery and biomedical equipment were awaiting repairs with a long "idle" period.

The specialist firms charged exorbitant costs. There was no central inventory of health estates. All Directors and Medical Superintendents were highly critical of the CPWD/PWD engineers. Delays, incompetence and corrupt practices were the main counts. Medical superintendents, who directly controlled some technical services, obviously had poor knowledge of their operations and complexities. They were being guided by ill-trained, low-level technical staff. The CPWD's financial norms for maintenance were inadequate. Few persons realised that a hospital worked for 365 days in a year and 24 hours daily. The management was diversified and uncoordinated. Nobody had a clue to preventive maintenance. Modern management techniques for running hospital technical systems and subsystems were completely missing. Many subjects like biometry, incineration, medical architecture, environmental health, ventilation, infection controls, environmental engineering, illumination, laundry engineering, sterilisation, radiation protection, solid and medical waste disposal, diagnostic engineering, safety engineering, etc, were not known to these engineers. And they did not take pains to pick up expertise. Deputationists would return at the first opportunity: the CPWD/PWD had remote controls in the PGI also.

Training facilities were not available. The tremendous wastage of human resources and funds was evident. This was the first-ever national group on the subject. The professionals will find it very educative even now. The group was ably assisted by Prof P.N. Dogra, then the Director of the IIT, Delhi, and his UK faculty.

The period of growth: A medical doctor is a human engineer and an engineer is a human doctor. The implementation of the working group report in the PGI itself was a process full of struggles. All recommendations again had to be processed through committees of the PGI and the MOH. I was in a hurry knowing well that when Prof P.N. Chhuttani and P.L. Varma would be away from the scene, the spirit would be diluted. Moreover, the PGI's infrastructure and medical needs were under strain. Our strategy was to implement a task for a year, establish better results and then demand. We started with 1/20th of the PGI's 1999 budget and staff. However, I must record my appreciation for a very understanding Administrative Officer, Mr S.S. Kakkar. The results achieved are briefly given here.

The entire department was restructured and unified with scientific job description and emphasis on productivity, accountability and targets. The five cardinal principles of W.G were followed concentrating all administration activities in one officer. Engineers/technologists were recruited from the Railway, the Navy, the Air force, Panjab University, etc, all unspoiled in PWD culture and Hospital Engineering, having degree M.Tech The first-ever Technical Inventory was printed under categories as in W.G Annual MMP and preventive maintenance manuals were printed. A new accounts manual was also written ensuring financial accountability.

The workshop was reorganised and augmented with each shop meant for repairs, fabrication and research. Clinical engineering laboratories were started for operationally critical areas in the hospital — like the OT, the ICU, saving 20% of the nurses' time. A high-powered Health Facility Planning Committee and a Sophisticated Equipment Committee were created for overall physical planning and development.

Technical stores were separated. Performance budgeting systems were introduced. In-house training programmes for continuous upgrading of skills were introduced at all levels in close collaboration with the industry, PAU, COA and the TTTI.

International literature on hospital engineering was a good guide and we started our own library. The medical architecture unit was active under Mr Rajiv Bansal (HAU). The master plan and the major projects were designed and presented to the Planning Commission. The unit offered consultancy service to other hospitals. The Union government's grants came for research projects.

Slowly up to 90% of the jobs were done in-house including capital work, repairs, operation saving 15% in cost 20?% on time, 30% on replacement budgets 9% on staff over heads (against the CPWD norm of 13-2% and 19/1/4%), reducing the idle period of equipment by 80% and the labour component to 25-30% (against the CPWD practices of 60-70%). Every technical man was a multi-trade person and we specially trained him. Everybody maintained daily diaries recording the work done every two hours. Round-the-clock maintenance services were started, including that for housing, hostels, etc. Service was at everybody's doorstep in the community. About 95% of the PGI doctors and staff will vouch for the services even today.

All good principles of industrial engineering, reliability engineering, safety engineering, rehabilitation engineering, quality management, energy conservation, clinical engineering, accident prevention and disaster management were inducted in the staff. Interior designs and environmental planning and landscaping were never ignored. We were deeply concerned about ecology.

The CAG's audit rarely pointed out any irregularity. This corporate culture was available two decades earlier. It is being searched now for the PSUs. The real cause of success was the dedicated team (between 20-40 years of age. Persons worked for 10 to 12 hours a day. They knew they were serving God by serving the patients.

(To be concluded)

The author, a Dubai-based consultant to hospitals and environmental organisations for 15 years, is a pioneer in the field of hospital engineering and planning in India. He worked at the PGI, Chandigarh, from 1969 to 1984.