HEALTH TRIBUNE Wednesday, October 4, 2000, Chandigarh, India
 


Think of the air you breathe
By Dr Dheeraj Gupta
C
all it a blessing or a curse of Mother Nature, we have to breathe in over 10,000 litres of air in a day (more than four million litres in a year) to remain alive. By making it essential for life, God has wished that we try to keep the air we breathe clean. Everyone can see the food that is not clean and perhaps refrain from eating it, but one cannot stop breathing even if one can feel the air to be polluted.

What does a patient want?
By Dr J.D. Wig
I
llness is a process that inconveniences patients and robs them of their freedom over time. They may no longer be able to do the things they used to do. Illness means varying degrees of vulnerability, a feeling of isolation and fear.

Double-drug attack
U
sing for the first time a two-drug treatment, researchers in the United Kingdom are pioneering a fresh approach which they hope may provide the key to halting the progress of auto-immune diseases such as rheumatoid arthritis and multiple sclerosis.

Knee joint surgery: a general view
By Major-Gen (Dr) Jaswant Singh, AVSM
W
ith increasing longevity, degenerative diseases have started getting greater attention of surgeons. The spectacle of middle-aged or elderly people walking slowly with side-to-side swagger is quite common. Painful knee is a pervasive complaint. Recently, I attended an orthopaedic conference at the Army Hospital (R&R), Delhi Cantt, where this subject was discussed lucidly.

North Zone surgeons to meet on Nov 10
A
three day conference for surgeons in North India Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir, and Chandigarh is being organised by the Department of Surgery, PGI, from November 10 to November 12, 2000. The emphasis will be on communication with a cancer patient (first-hour care of a traumatised individual), damage limitation strategies in surgical practice and occupational hazards.

Copyright error

 


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Think of the air you breathe
By Dr Dheeraj Gupta

Call it a blessing or a curse of Mother Nature, we have to breathe in over 10,000 litres of air in a day (more than four million litres in a year) to remain alive. By making it essential for life, God has wished that we try to keep the air we breathe clean. Everyone can see the food that is not clean and perhaps refrain from eating it, but one cannot stop breathing even if one can feel the air to be polluted.

Several harmful and noxious substances can contaminate the air we breathe.

Generally, much is said and written about outdoor air pollution, most of which is due to vehicular and industrial exhausts.

Given the fact that most of us spend over 90% of our time indoors, it is most important to recognise that the air we breathe in at home or in offices can be polluted. It can be a cause of ill-health. Air pollutants that are generally present in very low concentrations can assume significance in closed ill-ventilated places.

The indoor air pollution can lead to allergic reactions and cause irritation to the skin, the eyes and the nose. But as is logical to assume, the brunt of insult by pollutants is borne by the lungs. It can lead to the development of fresh breathing problems, especially in those who have allergic tendencies, or it can worsen the existing respiratory illnesses like asthma and bronchitis.

There can be several sources of indoor air pollution. Tobacco smoke is one of the most important air pollutants in closed places. "Passive smoking" or environmental tobacco smoke (ETS) pollution can lead to all the harmful effects of tobacco smoking seen in the smokers in their non-smoking companions. ETS as a health hazard has been unequivocally proven and is also getting social recognition now. One can occasionally see signs displaying the all-important message: "Your smoking is injurious to my health" in offices and homes. The children of smoking parents are among the worst affected persons.

The exposure of young children to ETS leads to increased respiratory problems and hospital admissions as compared to non-exposed children. Several studies, including those done at the PGI, have shown an increased risk of lung cancer among women exposed to passive smoking. ETS also worsens the existing lung diseases like asthma and bronchitis. It may be responsible for the development of asthma in children.

The next most important source of indoor air pollution is the allergens. House dust mites (HDM) are very small insects not visible to the naked eye and are the commonest source of allergy in the house. They are ubiquitous and thrive in a warm and moist atmosphere. They breed very fast and are very difficult to eradicate. Modern houses present ample breeding spaces for them in the form of carpets, curtains, mattresses, pillows, etc.

Briefly speaking

Important sources of indoor air pollution

1. Tobacco smoke                                            5. House dust mites

2. Animal dusts                                                6. Cooking and heating

3. Air conditioners                                            7. Toxic chemicals

4. Moulds, bacteria                                           8. Asbestos

Exposure to HDM can be prevented by the frequent washing of linen and by encasing the mattresses and pillows in a non-permeable cover. Pets form an important part of life for some of us. But they can add plenty of allergens to our indoor atmosphere. Cats are notorious for doing this. Fine particles from feline fur can remain stuck to the upholstery and carpets for a long time even after the removal of the animal and lead to the worsening of asthma and skin allergies. Fortunately, owing to religious and social customs cats are not very popular pets in India. Dogs, however, are quite popular and can be as troublesome. Pets should be kept out of the bedrooms and washed frequently. To remove the fur particles one has to use vacuum cleaners as the ordinary broom and mop are not effective.

Moulds, fungi and several other microorganisms thrive in damp conditions and can lead to allergies as well as infections. Humidifiers in the air-conditioning plants provide an ideal environment for certain types of bacteria and have led to major outbreaks of pneumonia. It is important to clean regularly the coolers, air-conditioners and damp areas of the house such as cupboards, lofts, etc to minimise this risk.

Toxic gases can also pollute the indoor environment. Biomass fuels (wood, cowdung, dried plants) and coal, if burned inside, can lead to severe contamination by carbon monoxide (CO). The poor quality of stoves and other cooking or heating appliances that cause incomplete combustion of LPG can also lead to the emission of CO or nitrogen dioxide. Formaldehyde (a gas) can be released from adhesives that are used for fixing carpets, upholstery and also in making plywood and particleboard.

The gases are very toxic in high concentrations as may be encountered during industrial accidents, but even in very minimal amounts, as may be prevalent in homes and offices, they can cause irritation to the skin or the eyes, rashes, headache, dizziness and nausea. Improving the ventilation is an important preventive measure, besides trying to eliminate the source that may not be always feasible.

Other indoor pollutants are toxic chemicals like cleansing agents, pesticides, paints, solvents and inferior-quality personal-care products, especially aerosols. Very old crumbling pipes, boilers, insulation or false roofing can also be important sources. Asbestos is a hazardous product that can cause cancer in humans.

It is important to realise that the air we breathe at home may not be clean always and we must try to eliminate the source of pollution. We should give due consideration to ventilation.

Dr Gupta, MD, DM, is Associate Professor of Pulmonary Medicine at the PGI, Chandigarh


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What does a patient want?
By Dr J.D. Wig

Illness is a process that inconveniences patients and robs them of their freedom over time. They may no longer be able to do the things they used to do. Illness means varying degrees of vulnerability, a feeling of isolation and fear.

The 20th century has seen remarkable changes in society. A literate public which reads newspapers, watches television and surfs the web is exposed to enlightening information. Doctors can no longer assume that their patients will accept their word without question.

The patient's desire for information must be balanced with the uncertainties that exist in any specific sphere. Communication skills are needed to navigate this situation.

An opportunity needs to be given to patients to express their emotion and articulate their concerns and fears. Patients need us to acknowledge their losses and accompany them, even for a short moment, as they face the sadness inherent in their predicament. They frequently want more advice and help in deciding rather than a lot of information and discussion of unlikely risks and alternatives.

The ability of the sufferers to understand what is going to happen to them does reassure them even if what is going to happen is really bad. In terrible-to-treat diseases we may consider reducing (nutrition) and/or preventing symptoms (pain and psychosocial concerns). More information in some circumstances may be confusing and frightening; these even impair rational patient-oriented decision-making.

Clean communication is an important part of good medical care. The patient as well as the doctor should be responsible for helping this to happen.

If the patient has a number of health problems, pick the most important ones. This will help the doctor to focus on what matters most to the patient. By making the best effort to communicate effectively, the patient becomes an active partner in his own health. We should be aware of the suffering person's understanding of the goals for the proposed procedure and the balance of benefits and burdens. Patients often have unrealistic expectations based on the marvels of science and technology. Few persons will opt for an extension of biological life if they cannot realise that some improvement is taking place in their condition.

As doctors, we are there to cure sometimes; to relieve often and to comfort always. We will give comfort to our patients only if we are good communicators. The technique of breaking bad news to the patient is often not what it should be and most people are left unhappy with the surgeon. Communication during the first visit, preoperative ward rounds, investigations and post-operative ward rounds should never be hurried. Effective communication requires a process of individually tailored explanation, problem-solving and acknowledgement of the patients' feelings.

Most people, when they become patients, want someone to listen to them. They want to feel accepted and to be treated with respect. They also want someone to care about them as an individual. They need careful interpretation of symptoms of treatment plans and of prognosis to help reduce their anxiety about the unknown.

William Osler once remarked that a doctor should be careful lest he should make the treatment of a disease more painful than the disease itself. Mistakes or less than ideal outcomes have become less acceptable. We need to learn how treatments are being evaluated by the patients and how some treatment has affected their illness. The attention to the wishes and preferences of patients at the time of decision-making enhances trust by showing respect and by valuing their definition of benefit.

We are living through an ear of extremely expensive, invasive and symptomatic treatment. How can we develop a system of health-care that can cope with the increasing public demands and the spiralling costs of medical technology? We need to return to the old basic skills of good clinical methods and communication, which have suffered during the period of the rapid growth of high-technology medical practice. The decline in abilities has been recognised and missed by our patients. We must learn how to listen again. We must treat our patients with kindness.

What does the patient really want? He knows that not every body can be saved, but the illness may be made tolerable or curable by the way the doctor responds to him. A sense of humour and personal appearances matter much. A knowledgeable patient who participates in his treatment gets better faster. Remember, patients' perspectives may vary. A particular patient may not be the necessary initiator of the information-seeking process. We must provide the initiation. Educated patients may welcome timely and frank discussion. Why not help them with knowledge and concern?

Dr Wig is a renowned clinician and surgeon based at the PGI.


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Double-drug attack

Using for the first time a two-drug treatment, researchers in the United Kingdom are pioneering a fresh approach which they hope may provide the key to halting the progress of auto-immune diseases such as rheumatoid arthritis and multiple sclerosis.

Patients suffering from rheumatoid arthritis have had their symptoms dramatically reduced in experimental trials carried out by rheumatologists Dr John Isaacs and Dr Ann Morgan at Leeds University in northern England.

In rheumatoid arthritis for reasons that are not yet fully understood the body's immune system attacks and swells the patient's joints.

In mice, it is possible to turn off similar diseases using drugs called monoclonal antibodies that attack helper T-cells, the white blood cells which appear to control the immune system. But this technique has only limited success with people and Dr Isaacs believes this may be no more than a problem of timing.

The problem with using mice as a model is that the disease is induced by immunising them with a joint constituent. As a result the process has probably been going on for months or even years. The longer that an immune response has to get established, the more aggressive it becomes.

The other problem is inflammation. This is one of the body's most primitive defences that encourages the immune response to become established. Rheumatoid arthritis is a classic example of inflammation in action.

"It occurred to us that while we are trying to switch off the T-cells, inflammation is doing the opposite," said Dr Isaacs. "To overcome this burden we decided to switch off the inflammation first with a different drug."

This drug blocks the actions of tumour necrosis factor-alpha, a chemical which appears to mediate the inflammation in rheumatoid arthritis.

Although it is not ethical to test the treatment on patients at the onset of the disease, a time when they may respond to more conventional treatment, the Leeds team members are endeavouring to treat patients at an earlier stage than experimental treatments are usually employed. This usually means a couple of years into the disease but this is several years earlier than when they started similar research some 10 years ago.

Small groups of patients are treated with the team taking a repetitive approach. This means that treatment that gives encouraging but transient results are modified and then given to the same group or to another group. Because the drugs are produced in limited quantities, only a few patients can be treated at one time and the studies are usually open (without placebo control).

"So far, the results are encouraging," said Dr Isaacs. "Although we have not achieved our stated aim of a cure, some of our patients have responded for several weeks after a brief course of treatment. Furthermore, we have been impressed by some of our patients now responding to conventional therapies which previously had not worked on them."

Although the Leeds team is the only one in the world using the double-drug approach, theoretically it could be used for treating other auto-immune diseases. The really exciting prospect is that, if this project is a success, it could revolutionise drug treatment of such conditions.

"Our approach is only possible because we are using a drug supplied by an academic unit," said Dr Isaacs, "Although several of the large pharmaceutical companies have drugs similar to one or other of ours, so far none have access to both. However, they are watching us carefully. If our method works we could well see these companies getting together and combining the application of their drugs for the first time."

Dr John Isaacs

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Knee joint surgery: a general view
By Major-Gen (Dr) Jaswant Singh, AVSM

With increasing longevity, degenerative diseases have started getting greater attention of surgeons. The spectacle of middle-aged or elderly people walking slowly with side-to-side swagger is quite common. Painful knee is a pervasive complaint. Recently, I attended an orthopaedic conference at the Army Hospital (R&R), Delhi Cantt, where this subject was discussed lucidly.

Usually patients report with pain in knee-joints, when getting up in the morning. The trouble is accompanied by stiffness. As the day wears off, both these complains abate considerably. Some patients have instability; a few have deformity of the joints. The mobility of the joints is restricted to varying degrees both bending and straightening. This is accompanied by various degrees of the wasting of the muscles around the joints.

Assessment: The assessment of each patient is carried out with detailed history, physical examination, x-rays of hips, knees and ankles while bearing body weight etc. The patients are scrupulously prepared for total knee replacement (TKR) but lesser options like arthoscopic debridement are carried out in a small number of cases. This requires immobilisation only for two days followed by movements of the knee joints. Decision-making is done after imaging modalities (CT scan which shows further details of the articular cartilage, torn discs, loose bodies....) Much like in 80% triple-vessel-block in heart begging for CABG, the arthritic knee presents an endstage look, wanting replacement.

The Army Hospital (R&R) joint replacement series: In a series of 105 arthritic knees were treated at this centre. Out of this 77 were osteoarthritic, 28 were rheumatoid, 28 were treated by arthoscopic debridement (passing a small instrument under vision into the joint through a very small incision removing all the debris, degenerated materials, closing it with only two days' rest to the joint). Seven persons underwent unicondylar knee replacement, a much smaller operation, and 74 underwent total knee replacement.

Operation options: The surgical management of the arthritic knee has become synonymous with total knee replacement (TKR) but, it is felt, these options vary with age, underlying disease, deformity, bone quality and the anticipated use of the joint.

(A) Arthroscopic debridement: Advocated in 1982 by O' Conner, it is an effective procedure for relief of pain and restoring function in osteoarthritic patients. Initially, it was done in patients under 60 years of age with diffuse joint pains, localising signs of torn menisci loose bodies with good joint-space on standing knee joint x-rays. The later procedure was extended over the age of 65 years. About 70% of the patients had relief from pain and long-term results are awaited.

(B) Unicondylar knee replacement: It is usually carried out in patients where one of the compartments, medial or lateral, is involved. In the Army Hospital series this operation was carried out in seven cases with excellent results in six cases in which movements were regained up to 120 degrees.

(C) Total knee replacement (TKR): It is the answer to the severely arthritic knee. It is done irrespective of age. This is especially true of rheumatoid arthritis where even a 40 years old patient was operated upon. The choice of the prosthesis depends upon the surgeon's training and experience but the type of bearing and fixation is often decided on the bases of bone quality and the use of the joint. In the Army Hospital series, 74 patients underwent total knee replacement with gratifying results.

The treatment of the arthritic knee is being carried out efficiently in the Orthopaedic Department of the PGI in Chandigarh and in the Government Medical College and Hospital by Prof Raj Bahadur (also in Chandigarh).

In the Armed Forces at Army Hospital Joint Replacement Centre, Col B.K. Singh, SM, and his team are doing marvellous work. This centre follows a protocol. Arthoscopic debridement is offered to young or elderly patients as a pain-relieving procedure. The unicondylar replacement is done in single compartment disease both in young and elderly patients where, with minimal intervention, a good range of movements is achieved.

Total knee replacement is reserved for severely arthritic knees where a choice of the type of bearing is available. The cost is a very important factor. In the Army Hospital serving personnel and their dependants are not charged any fee. Ex-servicemen have only to pay the cost of prosthesis which may also be re-imbursed by Army Group Insurance.

The writer is a practising surgeon based in Chandigarh. He has retired from active service after holding the highest post in his sphere.

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North Zone surgeons to meet on Nov 10

A three day conference for surgeons in North India Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir, and Chandigarh is being organised by the Department of Surgery, PGI, from November 10 to November 12, 2000. The emphasis will be on communication with a cancer patient (first-hour care of a traumatised individual), damage limitation strategies in surgical practice and occupational hazards.

There will be sessions on what the expert should do in situations which he encounters everyday but which are difficult to manage.

A unique feature of the conference will be a face-to-face debate (evidence-based). The event will cover the management issue as well as the skills required for hernia repair in a live demonstration. There will be an opportunity to view different applications of endoscopy in surgical practice.

Other highlights will include guest lectures, orations and a session for young surgeons.

Three "best papers" will be chosen for presentation at the All-India Surgeon's Conference. The faculty will comprise eminent surgeons from India, the UK, Japan and South Africa. Dr J.D. Wig is the organising secretary of the conference.

Copyright error
There has been an error regarding the issues of copyright and allied matters in the articles of Dr Robert Youngson, the internationally known writer on medical, scientific and other subjects, published in Health Tribune. The error, which occurred because of a grave impropriety on the part of an outside feature agency, is deeply regretted. The copyright for the articles lies with Dr Youngson

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