Prescription CASCADE

Have you noticed that medical prescriptions hardly ever consist of a single drug but most often comprise a long list of them, even when the symptom that took you to the doctor was just a single one? It is due to a recently recognized phenomenon called Prescription Cascade.

As most drugs have side effects, what the doctor tries to do is to add balancing drugs that would counter them should they occur.

The most common example of this phenomenon is to co prescribe drugs that lower the stomach’s acidity when prescribing pain killers. Most pain killers such as aspirin, ibuprofen, diclofenac, indomethacin or naproxen are plagued by the side effect of causing gastric injury, called gastritis or gastric erosions. Indeed long term use of these agents are associated with the development of ulcers in the stomach or duodenum, that apart from causing stomach ache, can sometimes bleed or perforate  posing a threat to life. Doctors, therefore, often find it more covenient, and perhaps safer to add a drug from the group of PPI (proton pump inhibitor), such as omeprazole, pantoprazole or rabeprazole that would suppress the stomach’s acidity and reduce the chances of gastric erosions or ulcers.

While most of these PPIs are generally innocuous themselves, do add significantly to the cost of therapy. While aspirin for a prologed backache, for example, would cost a mere Rs 2 per day, a PPI would cost around Rs 5. At the end of a month, you would therefore have spent Rs 60/- for your backache, but Rs 300/- to prevent a potential adverse consequence of your primary treatment.

Another example is that of an antibiotic and a probiotic. Antibiotics, prescribed for infections, often cause extensive damage to the numerous “good” healthy bacteria that colonize our intestines and ensure our well being. Hence use of antibiotics is often associated with loose motions, called “antibiotic associated diarrhea”. It has therefore become common place to add a concoction of healthy bacteria, called probiotics, when prescribing antibiotics. These probiotics often cost Rs 30 to Rs 60/- a day, sometime s more than the antibiotics themselves, and often need to be taken for periods longer than the 5 day course of the primary drug, making a big hole in the patient’s pocket.

Several medications  that cause nausea or vomiting, such as anti-amoebic drugs  or anti-cancer drugs are routinely co-prescibed with anti-emetics drugs that counter these effects. The situation often gets complex as these secondary drugs sometimes cause side effects themselves such as abnormal muscular movements (dyskinesia), drowsiness or secretion from the breast, causing more concern than the anticipated problem with the primary drug itself.

 The numerous such examples of the  long prescriptions that we  get from  doctors  has raised a debate as to how much is really too much. While undoubtedly prescription cascades may sometimes help make the primary therapy more tolerable, the additional side effects and the cost multiplier effect needs careful consideration.

Short is usually not bad then, especially when it comes to prescriptions.

As published in HT City( Hindustan Times) dated 19 december, 2010. 

Dyslexia: Are We Being Cruel To Bright Kids?

One of the cruelest acts that we as parents, teachers or colleagues might be inadvertently indulging in is failing to recognize dyslexia, and labelling it as mental weakness.

Dyslexics, comprising 5% of the population, can be spotted from pre-school age. Typically, these kids have bright intelligent eyes, seem to follow what you tell them, react intelligently to situations, are emotionally normal, but seem to get into problems when asked to read or write. They may sit with the book open for long hours without progressing down the page, write poorly with lots of spelling mistakes, confuse “b” with “d” (mirror images) and hence get poor marks in the way tests are “normally” conducted.

They are certainly not mentally weak. In fact studies show that some of the brightest and most successful have had the trait. Albert Einstein the great scientist, John Lennon of Beatles fame, Richard Branson the owner of Virgin Airlines, Tom Cruise the Hollywood star, Thomas Edison who gave us the electric bulb, Winston Churchill the British PM are some examples of immensely successful people with dyslexia.

The problem in dyslexia is not with intelligence but with the wiring in the brain that deals with the way we learn or reproduce the symbols of language, such as alphabets or words, especially the written ones. Language, especially alphabets and words, have been made by man as an instrument for communication, and is therefore not something truely “natural”. Dyslexics have a problem learning symbols of this man-made language and hence struggle in assesments that test the ability to learn and reproduce them.

What complicates the lives of dyslexic children is that parents as well as school teachers are often not aware or trained to pick up dyslexia. The trauma of a lovable bright child starts when he underfperforms in his first written test, gets poor grades and is told that he is dull or inattentive. Parents are then informed in PTMs that their child is mentally weak. Imagine how we would feel if we were told that we are dull just because we could not reproduce or write words or sentences well, but we had wonderfull skills in painting, music or designing that our teachers never tested us at!

That then is the tragedy. Dyslexics are often very creative and artistic and can leave their “scholar”colleagues way behind if only they were tested at what they were gifted with – art, designing, music, creativity etc. They would grow up and make the list of geniuses longer and brighter.

Amir Khan’s “Taare Zameen par” helped bring dyslexia to society’s notice. Now special training modules are available that can help dyslexic children learn language well and rub shoulders with the toppers of his class. Picking these kids with special traits up at an early age, perhaps in preschool, is what we need to strive for. Our dyslexic geniuses will then realize their true potential and lead us forward with their creativity. 

As published in HT City ( Hindustan Times) dated 12 december, 2010.

Music and Health

Are you getting enough of good music to benefit your body and mind?

Research has shown that music has a profound effect on your body and psyche. In fact, there is a growing field of health care known as music therapy, which uses music to heal. Those who practice music therapy are finding benefit in using music to help cancer patients, children with ADD (attention deficit disorder), and even hospitals are beginning to use music to manage pain, fight depression, calm patients and ease muscle tension,

 Airlines and hotel industries were quick to spot the benefit of soft soothing music on customers and started using it in flights and hotel lobbies. Their customers started feeling cheerful and stress-free with patient satisfaction surveys and business turnover showing mprovement.

 Studies have shown that patients waiting for endoscopic or surgical procedures are less stressed and have fewer complications if soothed and prepared with soft music. Further, surgeons undertaking high-risk challenging life-saving surgeries such as liver transplnation, heart or brain surgeries seem to perform better when soft music is played in the operation theatre.

 How does listening to music bring about these changes?

 Music with a strong beat can stimulate brain waves to resonate in sync with the beat, with faster beats bringing sharper concentration and more alert thinking, and a slower tempo promoting a calm meditative state. Young people therefore prefer fast loud “rock” music that provides the pep. The march tunes, such as Colonel Bogey, provide the much needed beat, pride and “valour” sentiments during march pasts.

 Further, with alterations in brainwaves come changes in other bodily functions. Those governed by the autonomic nervous system, such as breathing and heart rate can also be altered by the changes music can bring. This can mean slower breathing, slower heart rate, lowering high blood pressure and an activation of the relaxation response. This is why music and music therapy can help counteract or prevent the damaging effects of chronic stress, greatly promoting not only relaxation, but overall health. The chants such as Gregorian, Gayatri or even fusion ones can indeed wipe much of the frustration, anxiety and restlessness from your system.

 Music can also be used to bring a more positive state of mind, helping to keep depression and anxiety at bay. This can help prevent the stress response from wreaking havoc on the body, and can help keep creativity and optimism levels high.

 Which then is the best music for you? The answer can come only from your own heart. Each one should build and listen to his own collection, consisting of some for general listening (perhaps popular movie songs with beats, rhythm and melody, gazals, Rabindra-sangeet), some to bust stress or to support us in bad times (slow chants, bhajans, spiritual invocations), some for background music when stressed, or in office, hospital, aircraft (Kenny G is very popular, try some piano concertos, Strauss, our own rich Indian classical instrumental collection or jazz) , and some peppy ones when we want to lift our spirits and those of our guests as in parties.

 It’s no surprise that so many are seeing music as an important tool to help the body in staying (or becoming) healthy. Music is the medicine of the soul, so let it play on!

              As published in HT City( Hindustan Times) dated 5 december, 2010.

Doc At Party

My well-wishers and grateful ex-patients wonder why I fail to turn up at their parties despite their pleasand insistent invitations. While my wife usually gets fed up with the adulation and importance I usually get from satisfied patients or their relatives at parties, some sour ones are educative enough.

I once found myself squeezed between two defence officers at a party at the MB Club. They seemed jovial, friendly and in “high spirits” and had many interesting stories to tell. Their demeanour however changed  once they learnt that I was a doctor at the SGPGI. The conversation then turned to how terrible places hospitals were, how uncaring the staffs were and how one of them had lost a relative at SGPGI after a heart surgery due to, what they perceived, neglect. 

My feeble protests that I belonged to a different speciality , that patients sometimes do die after heart surgeries in spite of the best treatment, just as jawans do in a war despite all armours, and that the utterance of one rude nurse should not denigarte a whole hospital, fell on deaf ears. When he ordered his 3^rd “Patialla peg”, I realized that it was time to move to a friendlier (or less hostile) table.

The other demand that we face in parties is of medical consultations. When a stranger flashes a smile and moves close with his drink in hand and I reciprocate eagerly hoping to strike a new good friendship, the discover the motive is often quite different. . After the preliminary pleasantries he often dives staright into his irregular bowels, his children’s adenoids or his father’s enlarged prostate, asking for my cell number and that of my colleagues, seeks  an assurance that I will help him circumvent the tedious lines at SGPGI, and a guarantee that all will turn out well when he does!

In another party, I found my industrialist  friend’s wife proudly displaying a painting that she had picked up at Sotheby’s. A beaurocrat guest, not to be left behind, jumped into the fray with his story of buying an art piece at a London auction house (you are not supposed to ask in a party how he acquired such money!). And that is how the converstaion went, till he discovered that I was a doctor at SGPGI, when it turned to hospital bashing, discussion on the terrible state of medical ethics, the lack of facilities at government clinics and so on. When I thought I had had enough, I mustered up the courage to ask him if he had ever been a secretary in the health department. His flushed face indicated that he had. I then let the next obvious question dangle “What, sir, did you do to improve the state of these terrible government hospitals when you were in power?”  That party ended on a sombre note.

It is little surprise then that doctors mingle more amongst themselves and shy away from “mixed parties”

 As published in HT City ( Hindustan Times) dated 28 november , 2010.

Taking The Sting Out Of Bad News

While the news may be bad, the manner in which it is delivered can make it either traumatic or bearable, says Dr Elly Hann, an expert on end-of-life care programme.  And what is interesting is that the technique applies not just to patients detected to have cancers, but to any bad news like loss of a job, failure in an examination, or a failed relationship,

It is being increasingly realized that bad news, no matter how bad, needs to be told rather than concealed, as getting to know it helps the patient or victim to cope better and set realistic goals. Recent research contradicts traditional belief that it takes away hope plunging people in irretrievable despair. That is of course if the news is communicated properly.

The currently accepted technique of delivering bad news that we might all find universally useful in our own lives, has 6 steps.

Step1: Getting started. A little thoughtful preparation needs to go into ascertaining and reconfirming the unpleasant facts before telling them and in creating the right environment, ensuring adequate time and deciding who else needs to be in the room. Breaking bad news, such as the test report showing cancer, cannot be done with frequent interruptions by cell-phone calls, or in a crowded room,  or in haste as while rushing to work on the corridor. You would realize that similar factors would apply while you tell your son about his poor results in an examination or discuss a breakup with your romantic partner.

Step 2: In this step one explores what is already known. The patient may be aware of the diagnosis and may be seeking a validation.

Step 3: is finding out how much the patient wants to know. In Asian cultures, an elderly woman may not want to know the diagnosis, and may delegate the responsibility to her eldest son to find out and decide further. Her wish needs to be respected.

Step 4: is the actual sharing of the information. It should be straight-forward but delivered with sensitivity. It is useful to give a few warning shots such as “The results have come. I am afraid the news is not good” or “I have something serious to discuss with you, unfortunately it is not good news” . Then the news needs to be stated, briefly, clearly and unemotionally. Then WAIT. Let it sink in and let the patient emotionally process the information. Non-verbal communication, such as putting your hand on his shoulder, is of more value at this stage than a long flow of words which the patient may have stopped listening to. Start speaking only when he has responded.

Step 5: is to respond to the feelings that the bad news generates; it can range from depression, anger, and guilt. One needs to be a good listener at this stage, allowing the patients verbal emotions to flow.

Step 6: is to offer follow up and to reassure non-abandonmnent. Break up of a relationship can be hurting, but to decide to part on pleasant terms without animosity or hostility, and remain in touch as friends, will ensure a smoother life ahead for both.

Let us try to take the sting out of bad news in our clinics, homes and offices.

 As published in HT City (Hindustan Times) dated 21 november , 2010.

Test Tube Baby Finally Gets The Nobel Nod!!!

The 85 year old British scientist, Professor Robert Edwards, who helped create the first test tube baby and thus transformed the lives of millions of couples plagued by infertility, was finally awarded the Nobel Prize for medicine, 2010. The person happiest to hear the news was Louise Brown, now 32, who on July 25, 1978, became the first ever child born through in-vitro fertilization (IVF), to her mother Lesley, who was seeking tretament for infertility.

Professor Edwards along with his research partner Dr PatrickSteptoe, had been resarching on taking eggs out of a woman’s body after stimulating the ovary, and fertilizing it with sperms from a donor, in a petri dsh, allowing it to multiply a few times, and then putting it back into the womb of the woman. Their first success came with Lesley Brown who gave birth to Louise by natural delivery.

Dr Steptoe, with whom Dr Edwards had started his infertility research and clinic in Cambridge, died in 1988. As the Nobel Prize is not awarded posthumously, Dr Steptoe could not receive it, leaving many across the world feeling that the recognition for the scientific work should have been much earlier.

The “test tube” often causes confusion. “I was never inside a test tube nor could I get in to one if I tried” says Louise. Only the fertilization of the egg is done in the laborartory, the subsequent growth of the baby in the mother’s womb occurs as in normal pregnancy.

Infertility is a common problem with 10% couples being unable to conceive naturally.  IVF has come as a boon for them. Although still costly and with a 25% chance of success, it has changed many lives across the world. Around four million children have been born by IVF till date and many like Louise, have gone on to get married and have children by the natural way.

India has had its brush with IVF too. A Bengali doctor Subhash Mukhopadhyay was two months late in announcing the birth of Durga or Kanupriya Agarwal - India’s first test tube baby created by him on October 3, 1978. While Edwards, was lauded for his effortsin UK, Mukhopadhyay was fighting a hostile state government that rubbished his findings. Ridiculed and ostracised, Mukhopadhyay was also not allowed to publicise his work in the international arena.He was invited by the Kyoto University in 1979 to present his findings during a seminar in Japan but denied a passport by the Indian government. The depressed physician committed suicide in 1981.

 The Catholic Church has been vehement in its opposition to reproductive research and IVF terming it “duhamizing”.  IVF does pose potential ethical problems as that of a Spanish woman who conceived and delivered at 67 and died 2 years later. Also it is possible for a child now to have 5 parents: the egg donor, the sperm donor, the surrogate mother in whose womb the foetus grows, and parents who rear the child, posing serious issues of parental rights and responsibilities.

 As published in HT City ( Hindustan Times) dated 14 november , 2010.

Smokers now have Help

A new medication, varenicline, promises to help smokers who are keen on quitting the habit, to do so with ease and comfort.

Quitting smoking can be hard for smokers as nicotine, the substance in tobacco that gets you hooked, is one of the most addictive substances known to man.  Stopping suddenly is sometimes associated with intense craving, mood swings, abnormal behaviour and depression making smokers continue with their habit indefinitely till a major health event like heart attack or cancer shakes them out of it.

The addictive effect of smoking is due to nicotine that gets attached to a site in the brain called alpha-4-B-2 receptor and triggers neurochemical pathways that provide the sense of pleasure that go with it. Varenicline works by geting attached to the same site in the brain, thereby blocking nicotine from getting to it. Why Varencline particularly seems to work is because apart from blocking nicotine, it exerts a mild stimulatory effect of its own, just enough to prevent symptoms of craving and withdrawal, but not strong enough to serve as a nicotine replacement.

The beneficial effects of Varenicline have been proven in studies involving more than 4000 smokers who were given either the drug or a placebo (non-active similar looking pill) in a blinded manner, with quitting rates being 3 times higher in those getting the drug.

Manufacturers recommend a slow build-up with 0.5 mg of the drug once and then twice daily for a week, and then to the normal dose of 1.0 mg twice a day for 12 weeks. The “muhurat” or “target quit date” should be around the 7^th to 10^th day. The 11 weeks of therapy that follows provides the transition to a “smoke free” life. The drug is expensive, therapy costing around Rs 7000/-., but one could argue that it is less than the cost of cigarettes and the health bills due to smoking . Never the less it is an additional burden for a well meaning puffer who seems to have recently acquired good sense and intention to transform himself.

Does it work with those addicted to other forms of tobacco such as Gutka? It should, theoretically, but direct hard proof from research studies of its usefulness in Indian Gutka chewers is lacking.

Of equal concern is that all those who take the drug do not succeed in quitting tobacco. The answer here is easy though. Without adeqaute motivation and will power, no drug or strategy ever works. As they say, “You can take a horse to the water but can’t make it drink”. If you seriously wish to quit, you surely can. 

As published in HT City ( Hindustan  Times ) dated 7 november , 2010.

Diwali : Blending Sense with Tradition

Diwali, the festival of joy, lights and cuisines, provides a perfect opportunity to blend tradition with dash of sense and demonstrate to neighbours and friends smart new ways of doing old things.

The Eats: A huge amount of effort and resources are traditionally spent in procuring or preparing sweets for neighbours, relatives, colleagues, partners and bosses. My rough guess is that, diabetes, obesity and heart problems being as common as they presently are, most of these traditional delicacies are hardly touched by those for whom they were intended, and find their way to homes of servants, drivers and junior office staff. 

Should you want your sweets to be savoured and remembered, you need to make them appealing, healthy and different so that guests who have nibbled at the same-old-sweets, are game to try more than a mouthful at your home.  Adding and garnishing your preparation with natural sweeteners such as honey, dates, figs and raisins could add originality and make them stand out.  Milder tastes are in vogue these days; hence cutting down on sugar would be wise. And as most adults are wary of greasy sweets, slashing the ghee and oil content, and baking rather than deep-frying could be recipes for success.

Try cut portions of fruits, either raw or stewed, dipped in honey, and topped with spices such as cinnamon, cardammon and fennel seeds as  mouth fresheners or a simple fruit salad with honey and spices, rather than gulab jamoon, barfi or the artificially coloured khoya sweets.

Lights:  The “made in China” coloured tuny bulbs seem to have become the commonest way we adorn our homes on Diwali. Use diyas for a change. Insects and mosquitoes are repelled or killed by fire and smoke, and not by Chinese-made tuny bulbs. Hence if the present outbreaks of Dengue and malaria are to subside after Diwali, you could play your small role too and appear truely traditionl as well.

Crackers and Fireworks:  If you can’t imagine Diwali without them, wear a touch of class and attitude on your sleeves by using eco-friendly ones. These use recycled paper, have less toxic fumes, shed brighter colored lights and conform to lower decibels of sound.

The spirit of Diwali is to celebrate the victorious home-coming of Purushottam Ram, reverred for his uprightness, devotion to duty and kindness to others; hence using fire-works that might set homes ablaze or creating loud noises that scare infants and cause heart attacks in the elderly are not quite in keeping with the spirit. Cracker fumes are known to precipitate acute attacks in asthmatics. Gambling was also not in vogue in the “Thretha yug” and drinking also not part of the tradition of Ramji’s times. 

Celebrating victory of right over wrong, sharing joy and gifts with less privileged, and caring for others may be more in keeping with the spirit of Ramji.  Make this Deepawali be different.

As published in HT City (  Hindustan Times ) dated 31 october, 2010.

Battling Dengue

The scare of the currently raging Dengue epidemic in Lucknow is neither a false alarm nor media hype. Good many people have fallen prey, and several have already died.

The tragedy is that Dengue is assume its most aggressive form in young healthy adults, who were, till yesterday, up and about their usual lives, attending to business, going to college, partying or planning a grand Diwali bash.

Attempts at mosquito control seem to have gone awary. Many might ask if it had started at all, seeing the heaps of polythene bags by the roads. The striped Aedes mosquitoes are easily seen in homes and offices on their dauntless flights landing on arms, necks and feet for their blood meals and injecting the virus through skin pricks.

High fever with body aches, visit to the doctor, the blood test confirming Dengue, falling platelet count, scurrying to hospitals for platelet transfusions, overcrowded hospitals is the usual circuit.

What can you do to protect your self and your family? Here are some practical suggestions:

1.     Involve your neighbours, make a local team, pool some money and arrange people to clear the heaps of polythene bags from the neighbourhood, burning them if necessary. Arrange a fogging machine and organize Malathion spray if possible. Get some kerosene poured on stagnant pools of water in the locality. Dont wait for the government municipality any more.

2.     Call the carpenter and make sure that your windows and doors are netted to prevent mosquitoes from enetering.

3.     Spray insecticides in and around the home daily

4.     Put away your half sleeved shirts, shorts, and T shirts. Start wearing full sleeves, trousers and socks from today. The Aedes mosquito has a short snout and cant sting through a layer of cloth.

5.     Request the principal to allow your child to wear full sleeves and trousers. Girls should wear pants or long skirts with leggings underneath.

6.     Use mosquito repellents on exposed parts of the body (back of hands, neck, and face) on most times.

7.     If fever occurs and stays for more than 2 days, get the blood tests done as advised by your doctor.

8.     Take only paracetamol for fever. Avoid ibuprofen, acetaminophen, nimesulide (banned in most countries) and othe painkillers. They increase the risk of bleeding and can damage organs. A 39 year old woman who was in otherwise good health, is now battling for life with renal and liver failure in our ICU, precipitated by nimesulide for Dengue.

9.     The main risks from Dengue are shock and bleeding. To prevent shock, drink lots of liquids and make sure you are passing good amounts of urine. If nausea and vomiting are cumbersome, IV fluids infused timely can help.

10.   If platelets fall below 20,000, you may require transfusions. Remember they dont grow on trees and are harvested from blood of donors. Hence there is a risk of transmission of other infections such as Hepatitis B or C and HIV. Procure platelets from reputed blood banks and arrange to have them donated by family members.

11.   Many suddenly take a down turn in the 48 hours after fever has subsided and we feel the worst is over. Take rest for an additional 2 days and drink lots of fluid till your condition is truely stable.

The greatest marvel of human nature is believed to be that seeing others die around him man refuses to believe that he too shall die. With Dengue raging in Lucknow, our complacence suggests that we feel quite that way!

As published in HT City (Hindustan Times) dated 24 october , 2010.

Dengue Fever : Treatment Guidelines

Dengue is having a free run this autumn, thanks to the abundant rains, ramapant water logging and unrestricted breeding of mosquitoes. Almost every household in and around Lucknow has either had a bout of fever in the last month or is likely to in the next one. 

Recognizing Dengue Fever (DF): It is a viral infection transmitted by mosquitoes and presents as a sudden febrile illness of 2-7 days’ duration, with 2 or more of the following:

1.     Headache

2.     Pain behind the eye balls

3.     Severe body aches

4.     Pain in the joints

5.     rash

In children, DF is usually mild. In adults, it can be quite incapacitating, with associated nausea, vomiting, depression and fatigue. Dengue Haemorrhagic Fever (DHF) is a more severe form of the disease associated with bleeding from different parts of the body such as red spots or patches in the skin, bleeding from the nose or gums, passage of black stools or vomiting of blood.

 One of the main concerns in Dengue is the fall in platelet counts from its normal range of above 150,000. Platelets play a vital role in preventing or stopping bleeding from small blood vessels. If their numbers fall to less than 20,000, risk of bleeding becomes significant.

 The other concern is shock. Dengue sometimes causes fall in blood pressure due to leakage of plasma from capillaries with loss of blood volume. The Hemoglobin level paradoxically rises and urination may become less.

 Tests for Fever: It is important to remember that all fevers may not be due to Dengue and Enteric Fever (Typhoid), malaria, and common flu are equally ramapant these days. Further, while Dengue is a viral illness with no specific medicines, typhoid and malaria need specific medications and can be far more dangerous to life than Dengue.

If fever persists for more than 2 days and is severe, tests should include Hemoglobin, white blood cell and platelet estimations, a peripheral smear for malaria, and a serological test for Dengue. The serological test for typhoid often does not show up in the first few days of this infection and hence can be misleading if done too early.

 When to worry: If you have contracted Dengue, lie in bed and take rest for atleast a week, drink lots of liquids (water, juices, soups, nimboo paani or ORS), take paracetamol tablets ( upto 3 a day), avoid aspirin and brufen as they may trigger bleeding,  apply balms on your head and watch TV. Consult your family physician but do not panic. Remember that there is no specific medication for Dengue and yet recovery is the rule.

 Platelets and IV fluids. For platelet counts to come down is not unusual during Dengue but infusions are required only if they drop to below 20,000 or when there is active bleeding. Remember that infusions of platelets have their own risk of transmitting other infections, of allergic reactions, and their effect lasts barely a few hours.

Those with low BP and shock may need intravenous fluids to replace some of the plasma that has leaked out.

 Recovery: Once the fever starts subsiding, one starts feeling better. Nausea, vomiting, weakness and low feeling may linger for a few more days. It is wise to drink lots of fluids and take life easy for a few more days before resuming work.

 As published in HT City ( Hindustan Times) Dated 17 october, 2010.

The Indian Super Bug!

Indian doctors were galvanized last month when the prestigious medical journal, Lancet, published an article describing super bugs that are virtually resistant to all known anti-biotics, and alleging that they originated from the Indian subcontinent.  To add insult to injury, the lead authors, who were British, named this germ after New Delhi (NDM1), consigning the name of our national capital to the immortal pages of medical notoriety.

What most Indians found blasphemous was the fact that although this highly resistant strain was also isolated from other parts of the world, the authors chose to name it after New Delhi, a city from which no sample had actually been tested, and went on to sound a travel advisory cautioning Britishers to travel to India for “medical tourism”.

Development of resistance in bacteria to the latest and strongest antibiotics called Carbepenems, is however alarming news. Alexander Fleming, who had discoverd the first antibiotic, penicillin, in 1941, would have been a very sad man if alive today. While scientists have discovered numerous antibiotics ( I could count 120) over the last 7 decades, germs have discovered ingenuous ways of escaping them with equal promptness.

When Carbapenems (Meropenem and Imipenem) were launched around a decade back, we had thought that the fight against germs was finally over. The last 3 years have shown that despite using high doses of expensive antibiots (they cost around 2 to10, 000 per day!) bacteria are able to survive, multiply and attack, accounting for a growing number of deaths from sepsis.

It is however difficult to deny that antibiotic resistance is common in India. Take the example of the most frequently used ones called quinolones (ciprofloxacin, norfloxacin, ofloxacin etc) that we pop so easily when we have fever, loose stools or any symptom remotely suggestive of an infection. With easy availability, low price, favourable safety profile and widespread use most bugs are now resistant to this group of drugs. Consequently, when treating a serious infection like typhoid fever, one remains worried whether thiese drugs will work or whether we should add another for safety.

Resistance increases with more usage, inadequate doses that allow some germs to remain and fight back, and easy over-the-counter (OTC) availability, as often happens in India. Resistance, once developed, often gets passed from one bug  to another through a portion of DNA called plasmids.

Another common cause is the indiscriminate or excess use of antibiotics in veterinary practice and in growing live stock. Drugs are used in animals that are used as human food, such as cows, pigs, chickens, fish, etc., and these drugs can affect the safety of the meat, milk, and eggs produced from those animals and can be the source of superbugs The chemicals pass into our bodies and evoke resistance in the germs that dwell in our skin or gut.

While scientists continue their search for newer more lethal antibiotics, with the emergence of super bugs, the fight seems far from over and speculation remains rife as to who will have the last laugh - the injudicious man or the ingenous bug.

As published in HT City ( Hindustan Times) dated 10 october, 2010.

Irritable Bowel & Barking Dogs

If “love” is the most misunderstood word in society today, “constipation” cannot be far behind. A recent study revealed that 5-22% of the population across the world are unhappy with the ways their bowels move and they use the same word to describe a variety of symptoms.

“Constipation” means different things to different people, from a feeling of incomplete evacuation (45%), straining at stools (30%), hard stools (10%), bloating and distention (20%) to several others. None of these meet the Western medical definition of “constipation” described as passage of less than 3 stools per week!

How bowel habits differ between peoples and regions, and the urgent need to redifine terms were highlighted during the recent Asia Pacific Digestive Conference in Kuala Lumpur, in which Asian doctors pointed out that the Western definition of constipation was inappropriate for Asians as hardly anyone would actually qualify while many feel they are constipated while passng stools quite liberally.

Bowel habits indeed vary widely not just between peoples and regions, but even between individuals. While many Indians believe that passing atleast one stool per day in the morning is crucial to health, the range could be considerable from 3 times a day, often after food or meals, to once on alternate days. Timing may not be so important after all as modern lifestyle may not often permit us to sit long on the pot before the early rush to school or work while evenings allowing more time to coax stressed bowels to relax and allow the passage.

Food and exercise are once again being thrown into center stage in debates on bowel habits. Our Indian diets of daal-roti-sabji have adequte amounts of fiber that absorb water and toxins, give volume to stools and stimulate the large intestine to move forward with regularity, keeping our constipation as well as our risk of colon cancer at bay. In USA, bowel cancer has become the commonest of cancers, making doctors advocate colonoscopic examination for screening in everyone above 45. If we change our food habits to burgers, sausage, ham and cheese, we will acquire the risks as well, just as Indian immigrants to western countries have started doing.

A few simple tips can be of use: If stools are hard or infrequent, green veggies, and fruits such as papaya, apple, pear or “bel” can help. If your stool tends to be loose and the frequencies high, try bananas and curd, and cut down on milk and cheese. If “gas” and bloating are your main symptoms, excess of gas forming foods such as sprouts, daals, peas, radish or milk could be the culprits; try cutting down on them and see if it makes a difference.

Unsatisfactory bowels movements however do compete with spouses, bosses, children and work place as a significant cause for unhappiness in life. The solution often lies in treating them as barking street dogs: if you heed them they bark more; if you ignore them, they often stop barking. 

As published in HT City ( Hindustan Times) dated 26 september , 2010.

Street Dogs and our CONSCIENCE

In the aftermath of a school child recently bitten by a street dog , attitudes and opinions on how we should deal with these canines have become divided as never before. The hardliners now have a case to justify their demand to kill these unwanted flea-infested animals who seem quite a nuisance on streets and colonies.

Interestingly, no matter how much we humans hate these creatures, they seem to love us; they live near human habitations and refuse to go and live by themselves in jungles, they wag their tails in gratitude for the rest of their lives if you have thrown a slice of bread at them even once, and their loyalty to humans can put ministers to shame!

As the story in Mahabharata goes, when Yudhisthir in his pursuit of truth, withdrew his emotional ties from all his relatives and earthly possessions, and was resolutely marching up the Himalayas towards Heaven, a stray dog started accompanying him on the rough path. By what we can imagine from Yudhisthir’s nature it is unlikely that he cuddled or petted the animal, but may have shared his food at times. After the hectic journey, when he reached the gates of Heaven he was so moved by the dog’s loyalty and companionship that he demanded the canine be admitted too, a proposal that Gods found preposterous.  It was then realized that the dog was God in guise, who was testing Yudhisthir’s capability to reciprocate the canine’s loyalty. I wonder how we would have fared in this test!

At the Sanjay Gandhi Institute residential campus we have had our share of problems too. A dog count showed we had 80 canines, withthe number growing rapidly as new litters of pups were added several times a year. No matter how cute the pups looked they wailed and remained un-cared on the streets. Our children painfully witnessed many die.

While we were wondering how to balance practicality with conscience we met a street-dog lover called Reema Singh who showed us the way. Why not take the female dogs to a good hospital, feed, vaccinate and sterilize them, and leave them where they belonged?

Our collaboration started 8 months ago with Dr Prerna and Mr Om Prakash from SGPGI and Dr Manish Tiwari from Animal Ashram. The initial concern of soulful campus dwellers were soon assuaged when they saw the same familiar dogs returning back after 2 weeks and in healthier forms! Our director, Prof RK Sharma and his kind hearted wife Dr Kumudini, led from the front, and now have seven loyal canine guards apart from their khaki clad security outside their gates.  This was a success story for our campus.

We have much to learn from street dogs. Apart from loyalty and gratitude, they test our tolerance and empathy. They inculcate feelings of compassion and care in us and our children and remind us that unpleasant problems in life cannot be solved by merely removing them from sight. And they help reveal a person’s nature. Watch that boy who throws a stone or kicks a sleeping dog. The chances are that he will get into crime when he grows up.

Tail piece:  Who loves you more – your wife or your dog? Lock them by turn up in a room for an hour and then release them. The dog will come out wagging its tail in gratitude? And wife?

 As published in HT City ( Hindustan Times) dated 19 september 2010.

Mosquitoes may bring India on its Knees

None of our clever politicians and planners could have thought that a burgeoning swarm of mosquitoes could change the course of emerging India and humble us. While children are dying like flies in and around Gorakhpur from the annual post-monsoon wave of mosquito borne encephalitis that year-after-year we promise to stem but never seem to be able to achieve, hospitals of the national capital are being deluged by dengue victims. Our financial capital, Mumbai, especially in its southern part where the rich and mighty live, is also being swamped with malaria, serving as a harsh reminder of our human vulnerability.

Of the several problems threatening the forthcoming Commonwealth games, mosquitoes and threat of diseases caused by them are emerging as key factors to keep international players and fans away.

There are 3 types of mosquitoes spreading diseases: Anopheles, the night biter spreading malaria, Aedes, the striped day time stinger spreading Dengue, and Culex transmitting encephalitis with its twilight stings. While we may not have much of an a la carte option to choose which of them to be stung by, mobilizing steps to protect ourselves from these deadly animals is the call of the hour.

Mosquitoes, as we all know, are breeding in the stagnant waters on the roadside, in water-clogged construction sites, in air-coolers in our windows, in tins and tyres left  in uncleared bins, in choked drains, in waterlogged paddy fields and most importantly, in polythene bags lying around in heaps in our neighbourhood. Students of Jaipuria School have taken an examplary initiative to not only ban and shun use of polythene bags themselves but to reach out to shops and local residents to do so as well. If sustained and encouraged, it can make a major health impact in the Gomti Nagar area for a start.

While most advertisements from mosquito-repellent manufacturers seem to appeal to our fears and focus on individal protection, it is more prudent to tackle the problem at the community level. Mosquitoes can fly for only around 400 metres. Hence keeping our neighbourhoods clean and dry is the crux. And if stagnant water is not possible to remove, pouring kerose kills the mosquito larve waiting there to take wings and strike.

During dengue epidemics, schools and offices have a special role to play as lethal stings occur in the daytime when people are at study or work. Apart from keeping the premises dry and clean, spraying mosquitoe repellents in room corners, under tables and in toilets, it is judicious to encourage children and staff to wear full -sleeved shirts and socks as the quill of Aedes is short and does not traverse a layer of cloth.

Mosquitoes have changed the course of history from time to time; by delaying the construction of Suez and Panama canals, to devastating populations in Indonesia and Kenya. Our CWG organizers should not underestimate the importance of mosquitoes as they may put a spanner in our preparartions next month.

 As published on HT City ( Hindustan Times) dated 13 september , 2010.

Colas have No Class

Cola drinks, once a symbol of American upmarket style, is now to be found perched mainly on the shelves of road-side ‘paan walas’ and local grocers. True, there still are Americans who drink more colas than water, and consume an average of 2 bottles per day of the tangy fizzy dark drink, but it has clearly fallen in stature as offering it to visitors or serving it at parties is no longer elegant.

Premiere schools in Lucknow such as La Martiniere College for girls have shunned colas from their canteen for the last 4 years. The story started with extensive campaigns by HOPE Initiative (Health Oriented Programs and Education) in 2005 creating awareness among the bright students about the long term harms of cola drinks. A heated debate followed in which the rights of an individual student  was pitched against the hazards of allowing gullible youngsters to be enticed by aggressive marketing to gulp colas and fall sick. The intelligent and alert La Marts students dcided on their own, that colas be best removed from their canteen shelves. And a very supportive administration obliged. Several other schools soon followed.

Take one glass of water, add 7 spoons of sugar and a concoction of chemicals, colours, and pesticides and you have a soft drink. There are atleast 4 undesirable health risks that make soft drinks dangerous.

Unbalanced nutrition: A soft drink contains around 160 kilocalories, all of which come from its sugar content. It contains no other nutrients to balance. The content of protien, vitamins and fiber is zero; hence these are referred to as “empty calories”. Making up the daily carorie requirement of around 1600 kcals with these sugars causes imbalanced nutrition and makes the body vulnerable to diseases such as diabetes and fatty liver.

Fluctuations in blood sugar: Simple sugars, as in soft drinks are easily and rapidly absorbed leading to rapid fluctauations in blood sugar and insulin levels. Diabetic are especailly vulnerable to these fluctuations.

Dental caries. Children, or for that matter even adults, who consume soft drinks frequently are more susceptible to dental problems. Try putting a few drops of cola on the tiled floor, leave it for a few hours, and see the stain!

Weak bones: Phosphoric acid, one of the components of cola drinks that provides the tangy taste, leaches calcium from the bones and make them weak and fragile.

Although the calorie problems are offset with the “diet” forms of colas, the other ones still remain.

I drink colas only in way-side dhabas to quench my thirst where clean water is not available. Drinking colas at home or serving them at parties is neither healthy nor chic anymore.It is paradoxical that the very country from which cola drinks originated has recently been in the forefront of campaigning against them on health grounds.

 As published in HT City ( Hindustan Times) dated 5 september, 2010.

Mother Teresa's LESSON OF LOVE

As the world is celebrates the 100^th bitrh anniversay of Mother Teresa, who has become the lasting symbol of caring and loving for the sick and the poor, I wish she had gone around in her younger days inspiring medicos to add empathy to the medical science they practice. What is often forgotten in these arrogant hi-tec days is that modern medicine needs all its 3 legs – science, skills and caring, to stand firmly in society. Ironically, although photographs of Mother Teresa  often adorn the walls of rich homes and institutions, her spirit of humanitarism seems wanting, especially in hospitals and clinics, where it is needed most.

There was a time not long ago, when physicians and nurses didn’t have much else to offer patients other than personal attention, comfort, compassion and concern for their ailments. Medical professionals were revered and respected for that and for what little they could do in regard to symptomatic treatment for incurable conditions.

The Twenty-First Century has thrust health care into an era of modernization, precipitated by advances in medical technology and computerization of everything in sight. We have made fantastic strides in the diagnosis and treatment of many serious illnesses. Patients are living longer and more productive lives as a result of these wonderful advances.

However, concomitant with these changes, we have experienced the indisputable depersonalization of patient care. Patients are often treated as diseases or numbers. We often hear medical personnel referring to a patient as “the gallbladder in room 6” or “the COPD in ward B”. We order test after test instead of taking a history because if we don’t “prove” our diagnosis with a test, we may be subjected to a lawsuit later if something goes wrong. And in spite of all these patients are often dissatisafied and litigations are on a steep rise.

What could make Mother Teresa tick? Her home for the sick and destitutes, called Nirmal Hriday, was crowded and lacked adequate medical facilities. I understand that Mother Teresa had infact, during her life time, come under criticism from some quarters, for running a hospice with substandard facilities. Despite these, patients thronged there, received love and care, lived their last days with dignity and died with a smirk of satisfaction on their faces. And their relatives did not shout at the staff or file litigations in courts.

I remember listening to her Nobel Prize acceptance speech in 1979 that spoke only of love. Her Nirmil Hriday was described as “a place of hope, a house built on courage and faith, a home where love reigns, a home filled with love." I wish our hospitals could say that of themselves!

One of her quotes that I have had pasted on the back of my clinic door and which has reminded me from time to time is “Let no one who comes to you ever leave without feeling happier and better”. Try it on your door and see the difference.

As published in HT City ( Hindustan Times) dated 29 august, 2010.