HEALTH TRIBUNE Wednesday, December 26, 2001, Chandigarh, India
 


BIOCHEMSPEAK

The disease detective
Dr Gopal K. Khuller
M
EDICINE is like a table having four legs-biochemistry, microbiology, pathology and pharmacology. If the table has to expand, it can do so provided its legs also grow strong enough to support it. Disease management implies an understanding of the nature and mechanism of disease, its diagnosis and treatment. In this regard, biochemistry plays an important role in disease management.

Goodbye, evil stress!
Dr Rajeev Gupta
S
TRESS is becoming an integral part of our life. Be it a housewife, a working woman, a professional, a government employee, a farmer, a business executive, or a student, all are feeling the impact of the rapidly rising levels of stress in their lives. It is really amazing to find how in a short period stress and its related problems, which were common only in the West and did not touch the Indian horizon, have stricken our lives.

AYURVEDA & TOTAL HEALTH
The science of life
Dr R. Vatsyayan, Ayurvedacharya
M
IND, soul and body are like a tripod. The world is sustained by their combination and they constitute the substratum of everything. This combination is Purusa: this is sentient and also the subject matter of Ayurveda. "It is for this that the science has been brought to light. 

HEALTH EVENTS
Elders’ hearts
Dr Harinder Singh Bedi
A
S a result of increasing longevity and a trend towards a reducing birth rate in the middle class and above the segment, the elderly population is expected to account for a rising proportion of the population during the next two decades in most industrialised countries.

And now EyeSoft!
T
HE healthcare portal at http://indmedica.com has been online for close to four years now. It caters to the need of medical professionals, corporates and individuals. It already has more than 10,000 doctors registered with it and it provides a platform for free and healthy interaction with doctors of all specialties of medicine.


 
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BIOCHEMSPEAK
The disease detective
Dr Gopal K. Khuller

MEDICINE is like a table having four legs-biochemistry, microbiology, pathology and pharmacology. If the table has to expand, it can do so provided its legs also grow strong enough to support it. Disease management implies an understanding of the nature and mechanism of disease, its diagnosis and treatment. In this regard, biochemistry plays an important role in disease management.

Identification of risk factors: For any disease to occur, there are certain predisposing factors which could be genetic and or environmental. High blood cholesterol is a known risk factor for premature coronary artery disease. Simply by taking the history and performing a physical examination, one cannot say whether a cardiac patient has a high blood cholesterol level. The information, however, is critical because the lowering of blood cholesterol by hypolipidemic drugs can significantly alter the progression of disease. On the other hand, normal blood cholesterol in a cardiac patient is equally important because it guides the physician to seek for other possible risk factors, eg, elevated blood homocysteine (a sulphur-containing aminoacid) levels. The latter is as atherogenic (if not more) as cholesterol because of which it is now called "new cholesterol". Many other disease-linked risk factors are known, such as alcohol (in the case of hepatitis), high plasma gastrin (for peptic ulcer), high plasma uric acid (for gout), low plasma vitamin C (for scurvy) etc. It is only the clinical laboratory that can tell the physician precisely whether his suspicion of biochemical malfunctioning is correct or not and to take appropriate treatment decisions. Thus, a patient having hyperacidity because of long gaps between his meals, would be managed by increasing his diet frequency and, if necessary, by antacids. But if the reason behind the hyperacidity is excessive gastrin secretion from a pancreatic tumour (gastrinoma), the surgical removal of the tumour is the only cure.

Confirmation of the clinical diagnosis: Very commonly, a patient is admitted to the emergency ward with a complaint of chest pain. There could be several reasons for the pain but the most important question to be answered at the earliest is: could it be an acute myocardial infarction (AMI, heart attack)? In this condition, a small portion of the heart muscle stops working due to a lack of blood supply, releasing several intracellular components into the blood stream. Elevated levels of one such component, creatine phosphokinase MB(CPK-MB), is virtually diagnostic of AMI. The test is performed in the emergency biochemistry lab using commercially available rapid diagnostic kits. This also enables a prompt commencement of life-saving therapy.

Another common emergency condition is that of a diabetic patient on insulin therapy who suddenly becomes unconscious. Two possibilities exist. Either there has been a "relative insulin overdose", i.e. the patient took his insulin injection but accidentally missed his meal which resulted in a precipitous fall in the blood glucose levels (hypoglycemia); or diabetes was poorly controlled so that he or she has entered the stage of diabetic ketoacidosis (DKA) characterised by severe hyperglycemia, acidosis in the blood and elevated levels of certain breakdown products of fatty acids called ketone bodies. Only biochemical investigations can help to clinch the diagnosis, which is all the more important because the two conditions require opposite treatment strategies.

Whereas hypoglycamia is dealt with simply by dextrose infusions, tackling DKA is tedious and requires insulin administration titrated against serial blood glucose estimations, controlled bicarbonate infusion (to counter acidosis) and potassium supplementation with monitoring of serum potassium levels (insulin concomitantly lowers serum potassium levels). A host of other conditions, such as gastroenteritis, jaundice, renal impairment, gout, etc, also necessitate a strong biochemical back up for efficient management.

Faced with the dual problem of handling the ever-increasing number of samples on the one hand and the necessity of pinpointing the diagnosis on the other, more and more labs are making use of modern diagnostic gadgets. Procedures like radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA), electrophoresis, etc, are well established. ELISA/RIA are best suited for diagnostic endocrinology to detect hormonal imbalance, e.g. decreased levels of thyroid hormones in hypothyroidism.

Electrophoresis often serves to solve a diagnostic dilemma, for instance, in an apparently healthy patient showing increased plasma alkaline phosphatase (ALP), an enzyme found in several organs, e.g. liver, bone, kidney or intestine? Under defined experimental conditions, the enzyme from each of the tissues has a unique mobility when moving in an electric field and that forms the basis of the biochemical diagnosis by using the electrophoresis technique.

Another novel innovation is the Polymerase Chain Reaction (PCR), which can detect changes in the DNA and has helped in our understanding of the genetic basis of important cancers like blood cancer and colon cancer. Further, PCR also enables a rapid prenatal (before birth) diagnosis of genetic disorders.

Monitoring disease progression: Viral hepatitis leading to jaundice is a common condition in our country. It is associated with a rise in serum bilirubin and SGPT (an enzyme), which, however, decline as the patient improves. In some cases, there is a secondary rise in these analytes indicating a relapse. This may have an unfavourable outcome because it usually implies that the individual is progressing towards a chronic/carrier state. Though the patients do not relish it, a repeated testing of blood for bilirubin/SGPT is imperative for adequate disease management. Likewise, a resurgence of plasma prostate specific antigen (PSA; a tumour marker), years after the removal of the prostatic cancer is suggestive of a recurrence of the primary tumour. The biochemist's report is a "red alert" for the surgeon.

Basic research: Basic research in biochemistry is directed at achieving a better tomorrow from the health point of view. The successful use of gallstone-dissolving agents has been a result of painstaking understanding of the basic mechanism of stone formation and growth. Today, small stones are curable without taking recourse to the removal of the gall bladder. Similarly, extensive research in vascular biology has revealed that the substance responsible for relaxation of arteries is actually a gas as simple as nitric oxide (NO). In fact, the commonly used drugs, such as nitroglycerin for anginal pain, are nothing but NO-donors.

However, it is genetics, which has become the most popular area of biochemical research today. Scientists are focusing on those parts of DNA which are crucial for development during embryonic life. Partial success has been attained in identifying the developmental genes in some species. Workers in Japan have been able to develop tadpoles some of which are headless and some trunkless! But these are alive and merrily swimming in the lab aquaria. It is exciting to visualise that some day the role of "bad genes" in organ development would be identified and eliminated so that the word "handicapped" would be history.

On the other hand, the bad genes responsible for some diseases such as cystic fibrosis (abnormal physicochemical properties of glandular secretions) have already been identified and the treatment devised is no less than gene therapy itself. Extensive gene therapy trials are being undertaken for many clinical conditions and this is likely to become an important treatment alternative in future.

Biochemistry has become an inter-disciplinary subject and it is an indispensable tool in the diagnosis and management of human healthcare. It has revolutionised the approach towards molecular genetics, cancer, ageing, AIDS, tuberculosis, atherosclerosis, obesity and endocrine disorders, to name a few. It is likely that in the new millennium, at some point, the demarcation between "curable" and "non-curable" diseases would become extinct.

Dr Gopal K.Khullar is Professor and Head of the Department of Biochemistry at the PGI, Chandigarh (Ph: 715170).

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Goodbye, evil stress!
Dr Rajeev Gupta

STRESS is becoming an integral part of our life. Be it a housewife, a working woman, a professional, a government employee, a farmer, a business executive, or a student, all are feeling the impact of the rapidly rising levels of stress in their lives. It is really amazing to find how in a short period stress and its related problems, which were common only in the West and did not touch the Indian horizon, have stricken our lives. Today, in every walk of life, we undergo tremendous amount of stress. Why?

In Indian society, the family pattern is undergoing a sea change. Families and social ethos that provided the individual psychological and emotional anchor are fast disappearing. Their absence has led to a crisis in the human situation which is more apparent in urban areas. The spectre of stress has begun to haunt the human person leading to physical and psychic inequilibrium — the basis of many psycho-physical ailments.

It is the need of the day to have an insight into the mechanisms of development of stress and its clinical manifestations. In my clinical practice, I have often observed that many people feel shy to accept the fact that they are under some form of stress. They think that this confession would lead others to believe that they are weak and not strong enough to face the harsh realities of life. This fact has also been observed by my colleagues during their contact with patients. In our day-to-day life and in medical practice, it is very important to identify people who suffer from stress. If we fail to identify stress, patients will keep on suffering and complaining to doctors of nonspecific "physical ailments" which don't have any physical basis. Doctors will keep on investigating them and prescribing all kinds of medicines for physical problems which are in fact the result of the lack of emotional security and familial solidarity.

The optimum level of stress: In our country, stress is still a kind of taboo, a negative emotional problem that people are averse to talking about and sharing with friends or family doctors. We must realise that an optimal level of stress is a must for all of us. A sitarist fully knows that a certain amount of tension is necessary in the strings of the sitar. It is true for many other musical instruments. Too much tension may snap the strings. Some degree of healthy tension is essential for students to prepare for examinations. Similarly, the required quantum of tension is needed for a pilot to fly an aeroplane or for a surgeon in the operation theatre. At the same time, it is important to remember that if the stress levels cross the optimal level, these will paralyse the entire system.

(To be concluded)

The author is a consultant psychiatrist and de-addiction specialist at MANAS Psychology and De-addiction Centre, Tagore Nagar, Ludhiana (Phones: 472822 and 472899)

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AYURVEDA & TOTAL HEALTH
The science of life
Dr R. Vatsyayan, Ayurvedacharya

MIND, soul and body are like a tripod. The world is sustained by their combination and they constitute the substratum of everything. This combination is Purusa: this is sentient and also the subject matter of Ayurveda. "It is for this that the science has been brought to light. More than two thousand years ago Mahirishi Charaka penned these lines while writing his major work which later came to be known as Charaka Samhita, the most respected treatise on Ayurveda.

Ayurveda, if literally translated, means the science or knowledge of life. It is the traditional medical system of India. Its knowledge has its written origins in the Vedas, known as the oldest corpus of writings in the world. But still its antiquity goes back to the time when history fades into legends. It is believed that the gods themselves revealed the principles and prescriptions of health and longevity to the enlightened. The inquisitive seers played their own part in the dissemination of knowledge.

Over the hoary past its knowledge continued to pass through the guru-shishya tradition with the sole aim of maintaining the health of a healthy person and curing the disease of a patient. In fact, according to Ayurveda, the concept of perfect health is so vast that it includes not only physical health but also mental and the spiritual wellbeing. In other words, Ayurveda is an integral spiritual science devised to give a comprehensive understanding of the entire universe which it sees as the epitome of the five primordial elements of earth, water, fire, space and air.

In the course of its development, through several centuries, Ayurveda was nurtured and enriched by the works and observations of many sages and scholars who specified its eight different branches as general medicine, eye and ENT, surgery, paediatrics, toxicology, psychiatry, gynaecology and obstetrics and the science of rejuvenation (and aphrodisiacs). Though everything in it is addressed according to the theory of the five elements, the basis of the diagnosis and the treatment revolves round the three subtle energies called tridosha (three body energies) as vata, the force of movement; pitta, the energy of transformation; and kapha, the force of cohesion.

Apart from being a medical system, Ayurveda is more a way of life, means of cooperating with Mother Nature and living in perfect harmony with her. It helps us to understand the importance of the right diet, the disciplined daily routine and a balanced lifestyle, which results from taming the body and the mind. As long as we maintain balance and harmony with Nature we are healthy. When we deviate from this path, there is disease, unhappiness and misery.

The concept of Ayurveda is best summed up in this shloka of the Gita: "Yuktaharaviharasya yuktacestasya karmasu: Yuktasvapnavabodhasya yoga bhavati dukkhaha". This means: One who is regulated in eating and recreation, one who is regulated in actions, in sleeping and waking, to him yoga (the union with the inner self) becomes the destroyer of sorrow.

It is this holistic approach towards life, not just health, that makes Ayurveda shine most luminously among other medical sciences.

Today, not only in India but in the most developed countries of Europe and America, Ayurveda is being looked upon with increasing interest. Observations made by our ancient seers have been revalidated on the basis of modern scientific parameters. The time cycle of the millenia may change the world, but man's quest for total health will remain changeless.

So the message of Ayurveda is: we can make our fullest contribution to life only if we are healthy, and in turn total health (alone) enables us to enjoy life to the fullest extent. Next week: the theory of five primordial elements.

Dr R. Vatsyayan is an ayurvedic consultant based at the Sanjivani Ayurvedic Centre, Ludhiana. (Phones: 423500 and 431500; E-mail- sanjivni@satyam.net.in). The Tribune congratulates Dr Vatsyayan on his decoration with the Vaidya Shiromani Award last week.

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HEALTH EVENTS
Elders’ hearts
Dr Harinder Singh Bedi

AS a result of increasing longevity and a trend towards a reducing birth rate in the middle class and above the segment, the elderly population is expected to account for a rising proportion of the population during the next two decades in most industrialised countries. As many as 40 per cent of all octogenarians have symptomatic cardiovascular disease and a significant number of these may benefit from surgery. Age being an independent risk factor for the development of the coronary artery disease, the incidence of symptomatic coronary artery disease (CAD) requiring coronary artery bypass grafting (CABG) in the elderly is bound to increase.

Earlier, referral for surgery especially in those already hospitalised, should be encouraged both for patient benefits and for reducing costs. A more aggressive approach to correct the disease process during a period of stability might result in a higher overall rate of success in octogenarians. Continuous refinements and advances in cardio-pulmonary bypass techniques, myocardial protection, improved anaesthesia, improved perioperative and postoperative care, a better understanding of the pathophysiology of disease and, probably most importantly, the use of off-pump (beating heart) techniques have led to a markedly improved safety of surgery in elderly patients.

On the basis of the author’s large experience of a good completeness of recovery and excellent functional results in the elderly patients, these patients should be offered CABG without regard to age alone and with good expectations of excellent post-op recovery and improved longevity.

We advocate an aggressive proactive approach in managing cardiac disease in this age group, thus avoiding emergency interventions in poor surgical candidates. (Details next week).

Dr Bedi is a senior consultant cardio-vascular surgeon at the Fortis Heart Institute, Mohali, Punjab.

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And now EyeSoft!

THE healthcare portal at http://indmedica.com has been online for close to four years now. It caters to the need of medical professionals, corporates and individuals. It already has more than 10,000 doctors registered with it and it provides a platform for free and healthy interaction with doctors of all specialties of medicine.

A doctors’ directory, a mailing list, cyber lectures, an image library, conferences, case discussions, an equipment suppliers' list, medical associations, hospitals, blood banks, and STD clinics are some of its unique features. Ind Medica has now announced the release of ‘‘EyeSoft’’— software for eye specialists.

‘‘EyeSoft’’ is a user-friendly MS Windows-based patient- record system developed for ophthalmologists to automate clinical activities right from booking a patient, history taking, ocular examination, systemic examination, investigation test orders, admission records, operation details and postoperative and follow-up notes.

It enables the eye specialists to make and record diagnoses as per international coding of diseases. It also enables them to make masters of prescriptions, instructions, etc, and gives a printout just on the click of a button.

Besides maintaining computerised clinical records, ‘‘EyeSoft’’ helps in keeping entire accounts along with the payment status for each patient. One can have records of the cash-book, bank accounts, ledgers and trial balance at any given moment.

‘‘EyeSoft’’ also manages correspondence through mail merge. The appointment Scheduler provided with ‘‘EyeSoft’’ can keep track of the specialist’s appointments for consultations, follow-ups, meetings, surgery lists, etc.

The software has been highly acclaimed by the medical profession. Ind Medica is also bringing out softwares for all specialties of medicine and for hospitals, nursing homes, clinical laboratories and diagnostic centres.— KPS

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