|HEALTH TRIBUNE||Wednesday, November 14, 2001, Chandigarh, India|
Fighting the menace of TB
MENTION A LOT OF MERIT
Diabetes care: new insights
Diabetes mellitus has been synonymous with hyperglycaemia for centuries. The observations that contributed to building up this concept include: (1) high fasting and post-prandial blood sugar as the commonest biochemical abnormality of diabetes, (2) osmotic effects of high blood sugar that cause major symptoms of diabetes e.g (passage of large volumes of urine, and increase in thirst and general weakness) and (3) the control of hyperglycaemia, including symptomatic relief and the prevention of vascular complications of diabetes.
In recent years, the fear of diabetes comes not only from its complications involving the eyes, the kidneys or the peripheral nerves but largely due to coronary artery disease. In fact, diabetes is being recognised as a disease equivalent to acute myocardial infarction, sans the symptoms and signs of a heart attack.
Interestingly, while the onset of the eye, kidney and nerve damage may be seen at the time of the diagnosis of diabetes, coronary artery disease precedes the onset of diabetes.
Fasting blood glucose of 140mg/dl and higher is of a proven risk for the eye, kidney and nerve disease. But the risk for the development of coronary artery disease starts at fasting blood glucose of 100mg/dl or higher. The American Diabetic Association and the World Health Organisation expert panels on diabetes have recently agreed to the diagnosis of diabetes when fasting plasma glucose exceeds 126 mg/dl and consistently blood glucose at this level is considered a good control. It is thus conceivable why the conventional control of hyperglycaemia is not enough to ward off the development of coronary artery disease or the related acute events.
The diagnosis of hypertension is made when the blood pressure exceeds 140/90 at casual recordings. However, in diabetes the blood pressure of 135/85 and higher is sufficient to accelerate the kidney, eye and coronary artery disease. The notion already goes around that lower levels of blood pressure are a sign of good health, with protective effects on the kidneys, the vascular system and the heart. This information should counter the advice of taking extra salt for improving one's blood pressure with a blood pressure record of 90/60 during a medical check-up.
The lipid profile is largely ignored as an investigation in diabetes, although in four out of 10 patients with diabetes (i.e in 40% of them) one or the other lipid parameter is abnormal. Most commonly, the abnormalities are low HDL (good cholesterol), high LDL (bad cholesterol) and high triglyceride (fat). Exercise singularly improves HDL while physical inactivity lowers it. Dietary fat and carbohydrate increase LDL and triglycerides. In Indians, an increase in triglycerides is often attributed to the high consumption of rice and this may account for the high incidence of coronary artery disease.
A recent survey in Chennai has shown that one in every five patients with diabetes suffers from coronary artery disease and peripheral artery disease often involving the legs. For healthy living one needs to have HDL over 45 mg/dl, LDL lower than 100 mg/dl and triglycerides lower than 150 mg/dl through regular exercise, moderate diet and low fat consumption.
The stress of modern living has now been recognised as a factor that doubles the risk of heart attacks in general and more so in diabetes. With an increase in several stress hormones whose actions run opposite to insulin, a rise in blood sugar, lipids and many oxidative tissue products cause more injury to the blood vessels and hypoxic tissue-damage in a cascading manner. Stress, therefore, needs to be controlled by practising the art of living, deep-breathing exercise and greater use of legs.
Diabetes-care today, therefore, includes the improved control of blood sugar, lipids, hypertension and stress, for better health and a longer lifespan.
Fighting the menace of TB
Picture this: A 30-year-old man is down with low-grade fever with dry cough combined with loss in weight and appetite for the past two weeks. He is diagnosed with tuberculosis and advised by his physician to take three or four medicines every day for the next six months. After three weeks of therapy, the patient starts feeling better and experiences a gain in weight with a general feeling of well-being. He stops taking the medicines. Soon after, within the next two or three weeks, he has severe weight loss with recurrent fever. The physician diagnoses him with drug resistant tuberculosis for which very expensive medicines are available.
The patient experiences severe side-effects with liver toxicity due to which the medicines had to be discontinued. This scenario is not fiction any more; it is a very common occurrence with tuberculosis chemotherapy. One useful way to ensure compliance in TB chemotherapy is via a programme instituted by the World Health Organisation (WHO) referred to as Directly Observed Treatment Short Course or DOTS. Under this, a designated healthcare worker watches the patient directly swallow the medicines every day. The DOTS scheme has considerably improved the management of TB, however, it is often impractical in rural areas in developing countries such as ours.
With the advancement of science ad biotechnology, novel ways to improve the delivery of drugs and other biomolecules have been developed. In this regard, in the recent years, a number of novel drug delivery approaches have been developed. A drug delivery system is defined as a carrier or vehicle in which the drug can be entrapped or encapsulated and from where it can be released in a slow and controlled manner to exert its therapeutic effect.
An important class of carriers for anti-tubercular drugs are the vesicle-based systems. These are colloidal carriers composed of substances such as proteins, lipids, carbohydrates or synthetic polymers. Liposomes are the most widely studied among the vesicles. They are closed spherical structures composed of one or more phospholipid bilayers. Our group at the PGI, Chandigarh, reported on the development and formulation of a lung-specific "stealth" Liposomal System (Antimicrobial Agents and Chemotherapy 41, 1211-1214, 1997). This system was target-specific and showed the maximum drug accumulation in the lungs. A lower dose of drugs, when entrapped in them could show the same effect in mice in terms of the clearance of tuberculosis infection as compared to a higher dose of free drugs (drugs without carriers).
But liposomes have certain problems associated with their usage such as decreased stability, shelf-life and an intravenous route for their administration. So, to overcome this, controlled release formulations are being developed. These systems deliver the drugs at pre-determined rates for definite time periods. They are capable of sustained release of the drugs for a long time such as days to years without causing any side-effects. They are also completely biodegradable and biocompatible, and do not cause any adverse reactions in the body after their Injection.
A number of polymer-based systems have been developed as anti-TB drug-carriers. The most widely used ones are those of PLG or Poly (DL-lactide-co-glycolide), which are co-polymers of lactic acid and glycolic acid. PLG polymers in the form of films, fibers and rods containing entrapped anti-tubercular drugs such as Isoniazid and Rifampicin have been used for the treatment of various kinds of experimental tuberculosis infections in the mice model. Though these formulations were capable of sustained release in vivo, they were implantable-type formulations that required surgical procedures for their insertion. We, at PGI, reported on the development of injectable PLG formulations as potential anti-TB drug delivery vehicles (Antimicrobial Agents and Chemotherapy 45 363-365, 2001 and Journal of Antimicrobial Chemotherapy 47, 829-835, 2001). These formulations are capable of prolonged release in vivo up to seven weeks just by a single dose administration of the polymers without causing any toxic effects on the animals. Also, the formulations were capable of effectively clearing bacteria from various organs of mice by a single dose administration of the polymers as compared to a daily dose of free drugs. This implies that the drug dosage could now be reduced to a single dose as compared to multiple doses of the free drugs. A step further in the development of these carriers was the use of PLG polymers or sodium salt of alginic acid (alginate) as oral delivery vehicles.
The formulations could now be administered via a more acceptable and tolerable route i.e. orally, exhibiting a sustained release of drugs. This could go a long way in improving the compliance of the TB patients. These systems thus could offer alternative treatment regimens for tuberculosis control with improved compliance as well as lower probability of development of multidrug-resistant strains of mycobacteria.
Now picture this: A patient is diagnosed with TB and is advised by his physician to take medication daily for a period of six months. With the developed drug-delivery technology, he will be injected with a controlled release formulation that delivers the drug at its required concentration in the body for a stipulated time period without causing any side-effect. He is saved from the discomfort and toxicity associated with the daily toll of taking medicament. Furthermore, patient compliance is notably improved.
This scenario could soon not be fiction with the advancement of science and biotechnology and could go a long way in alleviating the problems associated with the daily intake of drugs.
There is a well-known saying that you should eat your breakfast like a king, lunch like a prince and dinner like a pauper. But in today's world, breakfast is the biggest casualty.
If you wonder why breakfast is important, the answer lies in the world "Breakfast" itself. After dinner, we do not eat the whole night (minimum of 7-8 hours) and this is a long time for the body to go without food. During the day, we keep on eating every 3-4 hours. But the duration between dinner and breakfast is often long, sometimes even 12 hours. So it is equivalent to a fast. Hence, a meal is required to break this fast in the morning i.e breakfast. We should eat a proper and wholesome breakfast.
Breakfast boycotters need to read this carefully. In spite of knowing the importance of breakfast, this decade has seen a steady decline in the proportion of people who regularly eat breakfast, long considered the most important meal of the day. Instead of hitting the snooze alarm to catch a few more winks of morning sleep, it would pay to get up 15 minutes earlier to make time for a nutritious breakfast.
A sweet roll and coffee is not an adequate breakfast. Nor is the so-called breakfast bar or that bag of chips munched on the way to school. These may temporarily suppress hunger pangs, but they will do little to enhance brain function and mood, not to mention nutritional status and overall health. So if you don't eat proper breakfast or skip breakfast your body shuts down your metabolism in an attempt to preserve what fuel reserves it contains. Breakfast breaks the fast initiated by sleep and increases your metabolism dramatically. Since metabolism accounts for approx about 70% of your energy expenditure, it is clearly the largest form of energy expenditure and should be encouraged. By skipping breakfast you are sending the wrong signal to your body and actually conserving energy. By conserving energy you are preserving your weight.
Eating breakfast has been proven to improve concentration, problem solving abilities, mental performance, memory and mood. You will certainly be at a disadvantage if your classmates or colleagues have eaten breakfast and you've gone without. On an average, they will think faster and clearer, and will have better recall than you. School or work can be tough enough without this extra-added pressure.
Some people believe that skipping breakfast may help them lose weight. But its not so. Skipping meal's often lead to overeating in the day. Becoming over hungry often leads to lack of control and distorted satiety signals (Meaning its hard to determine when you're full). This can result in taking in more calories than if one had an appropriate breakfast. As a matter of fact, it's easier to control one's weight by eating smaller meals and snacks more frequently. Courtesy: Value Circle
JALANDHAR: Last week was very fruitful for Aurveda in Punjab. A number of seminars, debates and academic programmes aimed at creating awareness of the ancient system of medicine were organised in Jalandhar, Patiala and Ludhiana.
The role of ayurvedic methods of treatment in the present context was highlighted through a unique inter-college competition, debate and lectures by way of homage to Vaidyaraj Pandit Hari Dutt Sharma of revered memory at Dayanand Ayurvedic College, Jalandhar.
Three-member teams from SLN Ayurvedic College, Amritsar, SSMD Ayurvedic College, Moga, Dayanand Ayurvedic College, Jalandhar, Government Ayurvedic College, Patiala, Desh Bhakta Ayurvedic College, Amloh and Mai Bhago Ayurvedic College, Muktsar, participated.
Mr Kamaleswhar Sinha, Associate Editor of The Tribune, who presided over the proceedings, said that all ayurvedic institutions should work towards creating awareness among the people of the relevance of ayurvedic treatment in the present scenario. Other ways and means of treatment were often risky and very expensive. "We should follow the path shown by the late Vaidyaraja, Pandit Hari Dutt Sharma, who had resurrected several medicines mentioned by Charaka. Sushruta was the Vaidyaraja's role model.
Dr Ravindra Vatsyayan, a famous Ayurvedacharya, explained the human values on which the great system was based.
Dayanand Ayurvedic College, Lahore, was the first institute in pre-partition India to have started degree courses in ayurvedic medicine in 1898, said Dr Raj Kumar Sharma, the Principal of the Jalandhar College.
Dr R. Vatsyayan, Ayurvedacharya
The idea behind the ayurvedic concept of revering the five primordial elements is purely environmental. Ancient Indians in their daily prayers were reminded to maintain the sanctity and purity of earth, air, water, fire and space — so much so that our seers pleaded for peace and harmony with every object right from earth to space.
The majority of our festivals were also based on our relationship with various seasons and cultural values. Out of them, Divali is celebrated at the end of the monsoon season in Sharad Ritu when winter is just at the doorstep. Legends apart, this festival puts more stress on the cleansing of our environment and on bringing the spirit of happiness and gaiety in our daily life than on anything else.
With the changing times, the spiritual, social and the cultural tenets are being replaced by deviated tendencies. Divali has been metamorphosed — from being a festival of lights to an ugly nightmare of noise and noxious smoke. Most Indian cities are not healthy places to be in around this great festival. Due to the thick smog in the evening, a large number of people report sick having simple to severe health problems.
The air pollution of Divali days results solely due to the mindless bursting of huge amounts of explosive material used in fire-crackers. A comparative study of the pollution level before, during and after Divali has indicated that the nitrous oxide and sulphur dioxide levels rise considerably during the festive season. Noise pollution also hits an all-time high and goes much beyond what is considered to be the normal limit.
It may be noted that harmful gases and chemicals emitted through smoke can pose health risks not only to the persons who are allergic to them but also to those who are healthy. Patients of asthma, bronchitis and naso-bronchial allergies find it very difficult to withstand this ordeal and there is a sudden rise in the number of such persons visiting doctors' clinics during these days. The blast of crackers is known to have an adverse effect on many people, including heart patients, infants, senior citizens and pregnant women. As if that is not enough, the incidence of burn injuries becomes more or less the hallmark of Divali.
However, minor respiratory problems arising in such situations can be managed with home remedies. Taking one gram of mulethi powder and half a gram of long pepper with honey helps to remove phlegm and spasm. The famous Sitopladi Churna and Lakshmivilas Rasa is another medicine which, if taken with honey, is good for allergic bronchitis. Similarly Haridrakhand in a dose of two grams at bed time with warm water or milk can be used in all naso-bronchial allergies. Though coconut oil, if applied to minor burns is beneficial, more severe of all these problems may require immediate specialised medical help.
Divali is a festival when friends, relatives and families meet and it is time for blessings and thanksgiving. Ayurveda sees environment as a vital part of our family and we should celebrate festivals without spoiling it. Pollution breeds disease and it is better to be safe than sorry. Happy Divali!
Dr R. Vatsyayan is an ayurvedic consultant based at the Sanjivani Ayurvedic Centre, Ludhiana. (Phones: 423500 and 431500; e-mail - [email protected])
Clinical Surgery: A Comprehensive Update by Dr J.D. Wig, MS, FRCS, FAMS etc; pages 563 (large), price Rs 800 (subsidy in deserving cases ); available through the author in the Department of Surgery, PGI, Chandigarh ( phone 747369 ).
Dr J.D. Wig is a major signature in the field of general surgery in North India. He has not abandoned the tried and tested old methods while taking into the operation theatre and postgraduate classrooms the latest advancement in the vast field of surgery.
The Tribune's readers have benefited immensely from his topical, typical and critical articles on growing problems from a bursting appendix to cancer spreading fast from a small part of the body to the many vital portions.
Clinical surgery has, however, remained his obsession as a teacher and a surgeon.
The book under review is unique in many ways. It is an update on various aspects: critical care, damage control, occupational hazards, actual surgical methods, vascular challenges, debates on gastrointestinal operations, pancreatic resection, liver trauma, thyroid problems, cancer and AIDS.
The book bears the seal of authenticity because of the participation of experts from all over the country and consequently its nature is comparative, analytical and diverse.
It is the first book of its kind in the 21st century, which calls for constant update. The price is surprisingly low. It will be of help to surgeons , students in medical colleges and libraries because of its contents and reference value.
MENTION A LOT OF MERIT
We are glad to report that our indulgent contributor, Dr S.K.Jindal, Professor and Head of the Department of Pulmonary Medicine, at the PGI, Chandigarh, has been honoured with international awards of the Chest Foundation of the USA and the American College of Chest Physicians. He received these awards two weeks ago at the World Congress of Chest Diseases at Philadelphia.
(1) The Community Service Award for Health Education and Awareness and (2) Commendation for End of Life Care; Making a Difference in International Programmes are the new prestigious feathers in his cap.
The awards, Professor Jindal says, had much to do with his "health articles" published in The Tribune. He mentioned this newspaper's health concerns in the USA.