|HEALTH TRIBUNE||Wednesday, April 25, 2001, Chandigarh, India|
When the bed bugs bite — II
What to do when fever strikes?
Kidney failure is treatable now
IF you have weakness, lethargy, nausea, vomiting, the loss of appetite, breathlessness, headache, disturbance of vision, itching and pallor, beware! You may be having kidney failure.
The kidneys are a pair of bean-shaped organs located in the upper abdomen along side the spine, though 10% of the population have only one kidney. These act as a super selective filter so that unwanted metabolic end-products (toxins) are removed from the blood (the blood is purified).
To perform the above-mentioned functions, even two-thirds of one kidney are sufficient and , therefore, we can donate one of our two kidneys without any harm to our body.
Kidney failure or end-stage renal disease(ESRD), is a psychologically debilitating illness with considerable emotional morbidity — a disease that can block the patient's goal of life and precipitate a vicious circle of depression, mood swings and unfulfilled hopes. According to a rough estimate, about 90-100,000 patients develop ESRDin a year and need the renal replacement therapy either in the form of dialysis or kidney transplantation. Kidney transplant is preferred to dialysis if the patient is surgically fit as the quality of life is much superior later. Kidney failure is of two types:
Acute kidney failure and its causes:
Chronic kidney failure and its causes:
Some patients may have kidney failure due to hereditary conditions, obstructive uropathy (stones, prostate enlargement or the narrowing of the urinary system) or immunological diseases. A simple urine test to detect albumin and a blood test for creatinine will tell if the kidneys are getting affected in a number of patients. Also, the patient may have high blood pressure, decreased hemoglobin and high blood urea.
The management of chronic kidney failure:
1. Investigations to determine the nature of underlying kidney disease and to detect any reversible factors like high blood pressure, urinary-tract infection and urinary-tract obstruction with stones, the narrowing of the urinary passage or an enlarged prostate which exacerbate kidney failure. The correction of these factors may lead to the improvement of kidney function.
2. Measures designed to limit the adverse effects of the loss of kidney function and, when possible, to prevent furthers kidney damage.
3. In patients with the progressive destruction of the kidney tissue, there comes a point when supportive measures in the form of either dialysis or transplantation are required.
In patients with established irreversible kidney failure, a number of steps can be undertaken which reduce symptoms and slow the progression to terminal kidney failure.
Hypertension and cardiac failure:
Diet: Dietary protein should be restricted in an adult to approximately 40gm daily, with an adequate intake of carbohydrates and fat to provide an energy value of at least 1700 cal. They should avoid extra pulses, legumes, dry fruits and nuts, extra milk and milk products. These patients are usually severely anaemic because failed kidneys are not producing enough erythropoetin for red blood cell formation. So they require supplements in the form of iron, erythropoe tin injections and multivitamins.
Fluid: Approximately 500ml plus of urine output is recommended as the daily allowance in a patient of chronic kidney failure. Additional fluids are recommended when a patient is suffering from diseases leading to very high urinary output.
Electrolytes: In kidney failure there is always a tendency in the body to retain the potassium. So, the patient should restrict potassium in his diet by avoiding fruits and fruit juices, green leafy vegetables, salads and soups. He or she can take fruits like apple, guava and papaya in a small quality. Kidney-failure patients have decreased calcium due to the poor absorption that leads to demineralisation of bones. So, they suffer from bone pains and fractures. They are usually advised to take calcium supplements in the form of tablets and capsules. They should also restrict salt (sodium) in their diet as it leads to high blood pressure.
Lipids: In kidney failure, there is high cholesterol levels in the body. The patients should not have much saturated fats (ghee, butter and milk-cream, etc.) and fried foods and alcohol in their diet. Proper exercise is necessary.
These patients should avoid smoking as it increases the cholesterol level in the blood.
Treatment options for end-stage kidney failure:
1 Haemodialysis: In this method blood is purified by passing through a filter in the machine whereby waste products are removed.
2 Chronic ambulatory peritoneal dialysis (CAPD): In this method blood is purified and waste products of the body are removed by putting a special type of water (fluid) into the abdominal cavity. Then the fluid is taken out. The patient or his attendants can use this method at home after learning the technique from the expert transplant team.
3. Kidney transplantation: This is the best option as a successful transplant gives one superior quality of life.
When does the patient need kidney transplant?
For transplant a patient should be surgically fit and the best time is pre-end-stage renal disease — when the patient is going to require dialysis but has not undergone dialysis.
The advantage of such a policy is that it avoids major disruption of the life of the young patients at a critical stage in their education and career. The second best time for a transplant is any time after dialysis is started but as early as possible — when S.Creatinine crosses the 8 mg/dl mark or symptoms of kidney failure are so advanced irrespective of the level of S. Creatinine, i.e, difficulty in maintaining the water balance, uncontrolled high blood pressure and deteriorating intellectual performance.
If the patient had fluid or swelling in the heart membrane (pericarditis), water in the lungs (pleural effusion), weakness in the legs due to neuropathy or when the dialysis or transplant has been delayed too long, the patient should immediately consult a transplant team. The surgeon should make A.V. Fistula on these patients much in advance of the dialysis they require because this is the lifeline of such patients which most of them don't understand, and eventually do not follow the instructions of the doctor. Next week: Kidney transplant
Dr Aulakh, MS, MCh, is a renal transplant surgeon and Head of the Transplant Unit at the DMC&Hospital, Ludhiana.
When the bed bugs bite — II
WHEN you wake up in the morning, you’re about an inch taller than when you went to bed the night before. This has nothing however to do with the spurts of growth hormone regulating your appetite and everything to do with the discs in your back. "The weight of the trunk and head pressing down on the discs of the spine compresses them by around 10 per cent throughout the day," says ergonomist Jim Taylour from seating manufacturer Giroflex. "However, a night’s rest allows the discs to re-absorb fluids and nutrients and causes them to swell." The result is that the discs are fatter in the morning than they were the night before, which stretches the spine those extra few centimetres. Unfortunately, the fatter discs are more prone to injury and squishing out of place than compressed ones — making the action of bending forward to put your socks on a perilous activity. Waiting 30 minutes before doing any bending (or vigorous) activity will help prevent injury potential, because by then standing up will have depressed the discs again (and you’ll be back to normal height).
The joints: Arthritis-sufferers find that joint pain is definitely worse at night — exactly when depends on what type they have. Osteoarthritis sufferers usually find things are worse when they first get into bed, as the inflammation that causes the problem is aggravated by an accumulation of daily activity. According to experts on chronotherapy (the science of taking drugs to fit in with the body clock) at the Food and Drug Administration in Washington DC, if you want to be rid of this, you should take your inflammation-fighting drugs around mid-afternoon, so they’re at peak strength when inflammation is likely to be at its worse.
On the other hand, the pain of rheumatoid arthritis is likely to be worse in the early hours. "A hormone called cortisol is the culprit here," says Dr Waterhouse. "Cortisol suppresses the immune system. However, rheumatoid arthritis occurs when the immune system is overactive, so the presence of cortisol reduces its severity and it gets worse about eight hours after cortisol disappears — which happens as we start to sleep." The chronotherapists therefore recommend that rheumatoid arthritis sufferers take their pills at night. This cortisol response is also the reason why allergic reactions are more likely at night — they too are caused by an overactive immune system.
Sex life: While the peak time for couples to make love is 10.34pm, the time ourbodies are most in the mood is around 6am. Levels of testosterone in men and progesterone and oestrogen in women are five times higher then than at any other point in the day, and physically we are primed for action.
What to do when fever strikes?
WHEN infection strikes, the body reacts with an inflammatory response in an effort to contain and overcome it. Fever is a part of this response and protective and useful in nature. It should not, therefore, be interfered with unless there are reasons to do so, for example, the extreme discomfort of the patient, or danger of it entering the zone of hyperpyrexia.
Fever is usually accompanied by headache, malaise, bodyache and general weakness. Other symptoms like nasal discharge, pain in the throat, cough, urinary symptoms or disturbances of consciousness, and others, may vary according to the system involved in the pathological process. Remember that fever is not a disease entity but an outward manifestation of many diverse diseases like those which have been already discussed. It is the doctor who will diagnose the cause and treat accordingly. Your role is to help him by keeping a proper record of temperature and development of symptoms, giving medication as ordered, and keeping a watch on the patient. In case you are confronted with acute fever, you should know what you need to do.
What to do when you are confronted with acute fever?
Do not panic and do not start antibiotics on your own; you will merely complicate things for the doctor and ironically help make the infecting organism resistant and unresponsive to the action of antibiotics.
Some people make the mistake of covering a patient who has high fever, with blankets even in summer in the belief that it will cause sweating and bring down the fever. On the contrary, it will simply elevate the temperature still further and may cause hyperpyrexia. Cover the patient according to the season to make him/her comfortable. In summer, a cotton sheet may be sufficient as a covering, with the fan put on at a comfortable speed.
In the first few days, when the diagnosis may not yet be clear, watch for symptoms. Make a four-hourly temperature chart and, if possible, chart the pulse rate. Look for the appearance of any eruption, especially in the case of children with cough and a running nose. Make a note of any other symptom, if present. Your doctor will expect all this information from you in an effort to arrive at an early clinical diagnosis.
In India, malaria has come back with a vengeance. Unless clear signs of some other disease are present, it may be quite in order to take two or three tablets of the antimalarial combination of pyrimethamine-sulphadoxine. This should be done preferably after blood has been taken for malarial parasite and blood count. In the first few days of fever when the diagnosis is not clear, all that can usually be done is to wait and watch. Some patients may respond to the antimalarial tablets.
(To be concluded)
From ‘Pain & Fever’— Orient Longman
IMAGINE a star-trek like scenario. The patient is wheeled in a remote forward area (which could well be outer space) for a major heart surgery. The super-specialist surgeon (in a party suit) sitting at a console of the size of a PCmanipulates two joysticks and calmly proceeds to perform a complex triple bypass on the patient.
The patient wakes up one hour later with only three 5mm keyhole incisions in the side of his chest. He has a hearty meal and is discharged within two days. Space-age-science-fiction imagination?Not really, for robotic cardiac surgery, blended with virtual reality, is already with us in this millennium. Even Dr Spock would be impressed!!
The advantages of the technique are many. Given below are a few of them:
A pleasing cosmetic result — only three small keyhole incisions instead of a long midline scar. This has obvious advantages for young female patients.
A shorter stay translates into lesser costs to the patient.
With further developments, major surgery may well become an outpatient procedure leading to a greater number of patients being treated for what is basically a potentially fatal condition. While still in its pioneering stage, the system is likely to change the way we would treat heart patients in the coming decades.
Dr Bedi is a visiting Professor at the Minimally Invasive Cardiac Surgery and Robotics Centre, at the Ohio State University, Cleveland, USA and a senior consultant at the Fortis Heart Institute, Mohali (Punjab).
Ritucharya for summer
An interview with Dr R. Vatsyayan on the ayurvedic concept of Ritucharya, with special reference to the summer season.
Q. What is ritucharya?
A. Literally, ritu means season and charya stands for regimen or routine. So, ritucharya denotes the regimen or the healthy daily routine to be followed in different seasons.
Q. How does ayurveda assess the seasonal variations of the year?
A. According to ayurveda, the whole year is divided into two major parts Adaan Kaala and Visarga Kaala, which are also known as uttarayana and dakhshinayana respectively. This division is done according to the positioning of the earth towards the sun. As adaan means taking away, in this period the sun and the wind are powerful and they take away the strength of the people and the cooling qualities of the earth. In other words, it is a debilitating period. The sun releases strength to the people in visarga kaal. It is the time when the moon is very powerful and the earth becomes cool due to clouds, rain and cold wind.
Q. How many ritus are there in a year?
A. One full year consists of six ritus (seasons). Each season is two-months long and three ritus form one of the above mentioned kaala Shishir, vasant and grishma, starting from mid-Januiary to mid-July come under adaan kaala whereas varsha, sharad and hemant further consist of months of mid-July to mid-January to make visarga kaala.
Q. Why does ayurveda put stress on different types of dinacharya (daily routine) for different seasons?
A. A proper daily routine is essential for the maintenance of good health. Biological forces, or vata, pitta and kapha, also known as three doshas, undergo various stages of accumulation, aggravation and decline during different seasons. Keeping in view all these variations, ayurveda advises different types of lifestyle and diet to be adopted right from the moment we rise to the time we go to bed in these six seasons.
Q. How does ayurveda describe the summer season?
A. Practically, the months of Jyeshtha and Ashadha are considered to be the time of the summer season. It is the approximate time from mid-May to mid-July. During this period, the rays of the sun causes the decline of kapha in the body.
Q. What illnesses can heat cause?
A. Charak Samhita defines two distinct types — anshughat jwara, which is heat fever, or heat exhaustion. It is a mild form. The second one or a dangerous form is known as anshughat sannipat or heat stroke.
Q. What are the right diet and proper conduct for this season?
A. Kapha is on the decline in this season. So ayurveda advises us to take sweet, cold and oily food and drinks. One should take plenty of water in general and seasonal fruits with cardamom powder but should avoid food with pungent and acidic taste. Instead of aerated soft drinks, it is better to beat the heat with home-made drinks like buttermilk, lime water, the decoction of dry barley popularly known as sattoo and sharbats of khas and chandan. Regarding lifestyle, one should bathe twice a day with cold water. It is advised that one should stay in cool places and wear light dresses. When out in the heat, take particular care to keep you head and the back of the neck covered.
Q When should one call a person "addicted to alcohol"?
A The following features indicate the state of alcohol addiction or dependence:
When a person feels that he cannot live without alcohol.
Once one tries to leave alcohol, one gets severe withdrawal symptoms and is compelled to take alcohol.
There is a regular need to increase the alcohol intake in order to have the same pleasurable effect. It is called a state of tolerance.
One continues to take alcohol in spite of getting severe physical, social, family and legal complications.
Q What are common alcohol-induced medical complications?
A Chronic alcoholics are more prone to developing alcoholic liver disease, pancreatitis, neuropathies, convulsions and high blood pressure.
Q What are the common psychiatric problems experienced by chronic alcoholics?
A Chronic alcoholics are more vulnerable to depression, suspiciousness, impotence, hallucinatory experiences, behavioural disturbances and violent tendencies.
Q What are the warning signals in an alcoholic?
A Alcohol black-outs Fits of unconsciousness
Q What is "disulfiram therapy"?
A Disulfiram is a drug and when a person taking disulfiram consumes alcohol, he gets severe reaction and develops skin rashes, low blood pressure, reddish skin, restlessness, an increased heart rate, breathlessness, nausea and vomiting.
Q Can disulfiram treatment prove fatal?
A Yes. Once the disulfiram alcohol reaction takes place and if it is not immediately attended to, one can die also.
Q Should disulfiram be given mixed in food without the knowledge of the patient?
A Disulfiram should never be given without the knowledge of the person taking alcohol. It can prove quite risky.
Q What is the role of naltrexone in treating alcoholics?
ANaltrexone is a centrally acting drug and it acts on specific receptors in the brain and decreases the craving for alcohol. Once a person is taking naltrexone and he takes alcohol too, no disulfiram-type reaction is produced.
Q How should one go about the business of leaving alcohol?
A One must approach a trained psychiatrist or go to a deaddiction centre for leaving alcohol.
The author is a Ludhiana-based psychiatrist.