|HEALTH TRIBUNE||Wednesday, January 23, 2002, Chandigarh, India|
ISSUES AND THEMES
Pain of cancer in bones
AYURVEDA & TOTAL HEALTH
You can prevent illness
"Prevention is better than cure" is a simple dictum known to even the most uninformed individual. To prevent a disease is a matter of common sense. After all, who does not understand the need to be free from disease and disability ?
In spite of the utmost significance of disease- prevention, it is the most inadequately and inefficiently adopted practice. Quite a few might know about the principles of good health but only a few would adopt healthy practices. Although the phenomenon is global to some extent, it is worse in this country. Some of the statistics compiled by the World Health Organisation are rather revealing and possibly shocking.
India, along with many other developing countries, has always faired badly and has a large burden of infectious diseases. But the news in case of non-infectious or non-communicable diseases (NCDs) is equally bad. Our burden of diseases such as cancers, chronic heart and lung diseases, diabetes and mental health problems is enormous and rising rather steeply. It is estimated that the total burden of these problems is going to surpass the burden of infectious diseases in less than 20 years from now.
It is because of the rising trends of these life-style disorders that the WHO passed a resolution on the "Prevention and Control of Non-communicable Disease" in 2000 at the 53rd World Health Assembly. It had resolved to help the Member-States to initiate surveillance of risk-factors responsible for these diseases and strengthen healthcare activities. A regular and continued monitoring and assessment of different risk- factors is considered essential to keep a check on the rising incidence of different diseases.
Several factors have been identified from a wealth of data obtained from numerous scientific studies and statistics. We leave aside the mental and psychiatric problems for this discussion, although their burden is estimated to rise disproportionately more than most other problems. Tobacco-smoking tops the list. Physical inactivity, nutrition, obesity, alcohol consumption, raised blood sugar and blood pressure levels are some other factors important in disease-causation and progression. It is obvious that the causes are not related to poverty or poor economic standards on which we harp everytime we talk of infections. Insanitary and unhygienic conditions, including the lack of safe supply of water, which are important causes of infectious diseases, require major economic inputs for control. On the other hand, the avoidance of most risk-factors listed earlier, will only save money, at least at the level of the individual concerned.
Tobacco-smoking, undoubtedly, is the enemy number one in causing diseases such as cancers, heart attacks, chronic respiratory disability and strokes. The charisma, glamour or satisfaction and pleasure of smoking must be weighed by each individual against the problems and risks which he or she is likely to confront in the future if smoking is continued. This is a habit imported from the West in the past and cultivated by economics in the present. The earlier one can get rid of the habit, the better it is. It is always good to know and repeat that smoking in the Western men, including the celebrities and trend-setters, has remarkably declined.
Alcohol is another risk-factor which significantly contributes to the problem. There is every reason to save money by avoiding the purchase of alcohol and cigarettes and spend it on nutrition, which is another important health issue. Fruits and green-leafy vegetables are definitely superior foods, now proven to help the prevention of cancers and other diseases. A good intake of four to five servings is, however, required every day. Rich and high-calorie foods are likely to promote obesity and atherosclerosis — narrowing of arteries — responsible for high blood pressure, heart attacks, strokes and other vascular diseases.
What I wish to stress the most is the issue of physical inactivity. I used the word ‘‘shocking ’’ in the beginning of this article keeping this particular factor in mind. The major risk factors for NCDs were compared for three mega-countries — India, Bangladesh and Indonesia. While the magnitude of most factors was similar in the three countries, physical inactivity was most pronounced in India. When physical activity was graded as per severity, only 11 per cent people had vigorous or moderate activity while 89 per cent were found to possess sedentary habits. The scenario is much better in other above-mentioned countries. In most of the developed countries of the world, sedentary habits are found in less than 10 per cent individuals.
It is surprising to find high levels of physical inactivity in these countries where the economically weaker people have to strive hard to earn. It only reflects the laziness and ignorance of relatively well-to-do people who have adopted easy styles forgetting the principles of healthy and happy life. Forgive me for being blunt but it hurts to see good people suffering from diseases which are otherwise preventable. It was nicely said by Sydenham over 300 years ago: ‘‘.... of chronic disease, the patient himself is the author".
ISSUES AND THEMES
THE role of ethics in the development of Clinical Practice Guidelines (CPGs) and recommendations to health care providers is to ensure that values, which may not be adequately incorporated into the law, are given reasonable consideration. The framers and users of the guidelines must be aware of the potential ethical conflicts inherent in many medical decisions, and the guidelines must reflect a thoughtful consideration and balancing of the issues.
Like the legal issues, the ethical issues related to blood transfusions are fundamentally no different than those relating to most forms of medical treatment. One feature that may be somewhat different is that in response to the fear of HIV, consent to blood transfusions has taken on an increased significance, such that the amount of information and level of consent required are closer to that usually required for more complex and risky procedures.
In this section, several ethical issues related to blood transfusion are discussed in practical terms. This is not an exhaustive discussion; it is intended to provide the reader with a general understanding of the issues.
Risk: A major ethical concern surrounding the use of blood products is that the public perception of the risk is, in most cases, far greater than the objectively measurable risk. This raises questions related to the true need for increased access to alternatives to anonymous donor blood products and the requirement for fully informed consent. However, the perception of risk must be recognised. The physician should understand the patient’s point of view and the patient’s fears and suffering.
Access to the anonymous donor-based blood system and alternatives: In Canada, blood is currently available, free of charge, to all Canadians requiring it or its components. The system is a voluntary one, in which anonymous donors are not paid for their donations. One of the questions being asked is whether alternatives to the anonymous donor system should be made available to all or some recipients of blood. Alternatives, such as directed donations and the use of autologous blood, may reduce the already low risk of contamination while introducing substantially higher costs into the system.
Currently, there is a significant additional cost involved in the collection, storage and delivery of non-anonymous blood. Therefore, in the short term it is economically more efficient to rely on the traditional system. However, over the long term, the financial premium may not be as great as it appears. Like any preventive programme, there is a cost saving associated with the harm prevented. Although it may not be possible to determine this yet, it must be considered in a cost-benefit analysis. The larger issue is whether the financial cost of alternatives to anonymous blood transfusions are justified.
In addition to financial costs, ethics requires consideration of the costs and benefits at other levels: societal and psychological. In the end, a multifactorial consideration may favour the allocation of resources to research on new medical interventions that obviate the need for transfusion or on improving current alternatives.
Decisions about access to alternatives may require a discussion about the broader societal good versus the individual good. The greater good of society may dictate the minimal use of directed and autologous donations as they may be an unnecessary drain on the health care budget. However, the individual good may require allowing such procedures as they provide psychologic benefits to the patient, for example, parents donating blood for their child.
Depression and voluntariness: It is legally clear that a mentally competent adult is entitled to refuse any medical treatment, including a blood transfusion. However, if screening indicates that a patient may be incapable, further expert opinion is generally recommended to ensure that the refusal is truly informed and voluntary, particularly in cases where the patient’s life is at risk. One particular area of concern is patients with underlying depression that may influence the decision of a seemingly competent person.
Cultural issues: In some cultures medical decision-making is the responsibility of men; in other cultures the physician is regarded as an authority figure who is not to be questioned. Ethically, it is necessary for the physician to respect the cultural practices of the patient while meeting legal and professional obligations. To accomplish this, the physician may explain to the patient and the patient’s family members, either directly or via a trusted member of the patient’s cultural community, the need to provide information and obtain consent.
Conclusion: It is difficult to reduce the legal and ethical obligations of physicians to a set of guidelines. Although the legal principle of informed consent can be stated in a few words, it does not convey the scope of responsibility and how it may vary depending on the circumstances, the patient and the procedure. It certainly fails to convey the ethical complexity involved in a physician-patient interaction and the potential clash of values and beliefs that can occur in our multicultural society. The various issues demonstrate that many judgement calls arise in the day-to-day practice of all physicians. These judgements require awareness and respect for legal and ethical considerations, but above all, they require an empathetic understanding of the patient and his or her situation.
Pain of cancer in bones
THE bony skeleton is one of the most common sites of the spread of cancer. It has been estimated that 15 to 20 per cent of the patients with cancer develop secondary bone disease. In many cases it is this spread to bones that causes the symptoms leading to the diagnosis of cancer.
Cancer affects the physical, psychological and social aspects of life. And the secondary spread to bones can compound this by causing more problems.
Certain cancers spread to bones more easily and frequently. Cancers that spread to bones are those of the breast, the prostate, the kidney, the thyroid and the lung. Tumours originating from these areas have a unique affinity to bones. Cells from the primary tumour travel via the blood stream and precipitate in the bone marrow. The bone marrow provides a rich source of nutrition and a suitable growing environment for cell deposits. Cancer cells in bones do not destroy bones directly; they do so by the stimulation of cells responsible for bone resorption and releasing enzymes. The enzyme digests the protein portion of the bone and splits the salts deposited in the bone matrix.
The spread to bones is the cause of significant morbidity due to pain, fractures, increased calcium in the blood (hypercalcaemia) and bone marrow replacement. Cancer cells cause bone destruction and hypercalcaemia.
Pain is a frequent symptom of secondary bone disease. The pain that resists usual pain medication, the pain persisting for a relatively long period and the progressively increasing pain are suggestive of the spread of cancer to the bones. Referred or radiating pain caused by nerve-root irritation may be overlooked for a long period.
Increased calcium concentration in the blood appears to precipitate or exacerbate pain by modifying the pain threshold. Increased calcium in blood can cause a variety of symptoms such as confusion, drowsiness, thirst and vomiting which can have serious implications for cancer patients.
"Bone spread" can inhibit the mobilisation of iron from body stores and can cause chronic anaemia. This results in increased lethargy and reduced mobility.
Patients may develop spinal cord compression due to the spread to the vertebrae. This compression can have catastrophic implications — bladder and bowel involvement, sensory loss and even paraplegia.
Bone fragility can lead to fractures of the bones of the arms and the legs, which may result in pain, debilitation and decreased mobility.
There is no ideal method for detecting the spread of cancer to the bones. Bone-scanning is the most sensitive method of choice. It is more sensitive than the skeletal survey. X-rays of bones determine the amount of bone destruction and to assess whether that particular lesion requires surgical stabilisation.
Current treatments aim at controlling pain, and improving the quality of life. Treatment options include surgery, local radiotherapy, chemotherapy, endocrine therapy, radiostopes and agents that inhibit bone resorption. Response to treatment should be assessed objectively, and as early as possible. If a patient fails to respond, treatment can be altered.
The life expectancy of some months is an essential condition to justify surgical treatment. A single bone metastasis is best treated by wide resection and prosthetic replacement. Spinal instability is treated successfully by surgical stabilisation procedures.
A painful metastasis in a patient with widespread cancer is best treated by radiotherapy.
The spread of cancer to bones thus poses significant problems for patients and their families. The spread is associated with distressing symptoms and compromises the quality of life. There is need to be aware of the consequences of this problem and efforts must be made to minimise the possible physical complications. The development of a method for predicting which bones involved with cancer are likely to break has been a difficult clinical problem. Effective rehabilitation can help prevent a patient from becoming prematurely bed-bound and dependent in activities of daily living.
Dr Wig is The Tribune readers' great source of surgical advice. He, an FRCS, is based at the PGI, Chandigarh.
& TOTAL HEALTH
APAMARGA (Achyranthes aspera) has been described as a divine medicine in the Vedas. Acharya Charaka was so much convinced of its efficacy that in his famous work Charak Samhita, he specially gave the name of one of its chapters after the great herb. Apamarga grows in plenty in wasteland and by the roadsides throughout the Indian subcontinent. It is more commonly known as puthkanda.
Apamarga is pungent and bitter in taste and light, dry, sharp and hot in effect. It not only alleviates kapha and vata but purifies pitta also. The whole plant, which is medicinal, contains an alkaline substance — specially "potash". Depending upon the colour of its flowers apamarga is of two types —red and white. But the medicinal properties of these two are the same.
All ancient ayurvedic texts have attributed a wide range of actions of apamarga on the human body. It is famous as a herbal lithotriptic agent (that breaks the urinary stones) and is a diuretic. It is also carminative, digestive, expectorant, anti-inflammatory and a killer of intestinal worms. Having blood-purifying and anti-endotoxin properties, it is also a bitter tonic.
Apamarga is used both internally and externally for many ailments. Because of its diuretic and alkaliser properties, it is a drug of choice for urinary afflictions like calculus and irritation in the bladder and the urethra. It is also used in various other diseases like anorexia, colic, ear infection, bronchitis and skin diseases. In rural India, apamarga is the first medicine to be used to counter pain and swelling associated with a scorpion bite.
Ayurvedic texts describe the use of apamarga kshara to gain the maximum medicinal benefits. To make it, the whole dried plant is burnt and its ashes are washed in water. This kshara is used in a number of diseases. If taken in the dose of 250 mg mixed in a teaspoonful of honey two or three times a day, it acts as a good expectorant. Given with warm water and half a teaspoonful of ajwain churna the kshara also works well in acute abdominal colic.
To treat small urinary stones, apamarga kshara is considered the foremost ayurvedic medicine. For this purpose one gram of the kshara can be given two or three times a day with the decoction of gokhru (Tribulus terrestris) which, in addition, is itself a very good diuretic and stone-breaker. To treat chronic sinusitis and the related heaviness of the head, giving snuff made of apamarga seeds is used.
Apamarga is the chief ingredient of the famous apamarga kshara tailam which is a classic medicine for the treatment of chronic ear diseases. The juice of fresh powder of apamarga is also used to treat chronic febrile conditions, bleeding piles, intestinal worms and post-delivery uterine problems. The average daily dose of its kshara and juice is up to 2 gm and 20 mg daily respectively.
(Next week: Hing, the gas-cure.)
EVERY woman has a different experience of menopause. Most of the women experience certain symptoms. Some hardly notice any change while others experience moderate hot flushes and depression. A few have more intense symptoms. The common menopausal symptoms are: hot flushes, sleep disturbances, depression, anxiety, loss of libido (sexual desire), headaches, backaches, fuzzy thinking, vaginal dryness, mood swings and irritability.
Although there are many homoeopathic remedies to consider, Sepia tops them all with distinct indications that are so commonly associated with menopause. For women requiring Sepia, a change in the temperament requires a special mention. From being calm and gentle before menopause, she becomes very irritable and is not able to show affection towards family members. The feeling of sadness, with no desire to meet friends and no interest in daily activities, makes her feel worse.
She feels easily tired. Flushes of heat (sensation of heat) in various parts of the body, which may be also associated with excessive perspiration, are common. She has an aversion to sex, and may experience a dragging or bearing down sensation in the uterus, feeling as if she has to cross her legs to hold it in. Menstrual flooding is possible, as is scant and irregular bleeding. Hot flushes and sweating are usual.
Backaches are often part of the symptom pattern. Sepia can work wonders. Sepia 200 c, two doses every week for a period of one month, makes this transition through menopause a comfortable one and brings back the vivacious woman in her.
Dr Vikas Sharma is based at 1290,
Sector 21-B, Chandigarh. (Phone : 721501.)