How to Handle Chronic Diseases

How to Handle Chronic Diseases?

Diagnosis of a chronic disease is the first and almost an inevitable shock which one receives during the adult life. There is a stage of doubt and denial in the beginning. Sooner, however, the reality needs to be faced as a part of life.  An early recognition and acceptance is always good for the long-term management and prevention of later complications.

Chronic diseases often referred to as non-communicable diseases, together pose a major health-care crisis in the 21^st century.  A bane of modern life-style and longevity of life, the crisis has attracted a global call for action for different governments and international agencies including the UN General Assembly thus bringing the NCD agenda to the highest level of attention.  Considered in the past as ‘life-style diseases’ or ‘a punishment of the rich’, they are even more common and burdensome amongst the poor, and in the developing countries. 

Chronic diseases include a host of different diseases of which the four major groups (cancers, diabetes, chronic cardiovascular diseases and chronic respiratory diseases) account for priority action at the international level.  India has included chronic mental disorders and chronic renal disease also in its ambit for its Control Programmes.  It is now estimated that one or the other chronic disease (or diseases) is/are likely to afflict almost every individual beyond the age of 60 years.  What the governments do for their control at the national and the international levels is a subject of policy and planning.  What the individuals can do to safeguard the health and cope with the burden is an issue of interest and understanding for all of us.

Living with NCDs is a fact of life . How to happily live and cope with a disease depends upon an individual’s personal perceptions and understanding of the disease as much as on the medical facilities available for its treatment.  The natural history of chronic diseases is variable from slow for most of the illnesses to rapid progressive for others.  Fortunately, most of them are compatible with a normal life span and style with modifications here and there.  For example, diabetes, hypertension, ischaemic heart disease, asthma and mental disorders can be effectively managed with regulated dietary alterations, regular medication, avoidance of precipitating factors/ triggers, and rehabilitative measures. On the other hand, diseases such as cancers, chronic obstructive lung disease, chronic heart, brain, kidney or liver failures are bound to progress sooner and later culminating into a premature fatal end.  With appropriate managements, the progress of most of these disorders can be delayed and life span prolonged.  More importantly, the ‘quality of life’ can be significantly improved.

It is also an accepted fact that the chronic progressive diseases as above reach an end stage in their natural history when curative treatments have little to offer. Only about 5 percent of us are going to be fortunate to die a sudden death, the rest are destined to be bed ridden from a chronic end-stage disease  for variable periods before the final exit This is the stage for palliative-care i.e. symptomatic management of troublesome complaints ( intractable pain, breathlessness, sleeplessness, severe anorexia, vomiting, gastrointestinal upsets etc.)  Unfortunately, several of the symptom-relief medicines are also likely to be detrimental for other organ functions and survival.  As a classical example, the powerful opioid drugs used for relief of most of the complaints as above, may result in fatal respiratory depression.  This ‘rule of double-effect’ is acceptable in specific situations, of course with a multitude of medical, procedural and legal implications.

Preventive steps are most important for the individuals to undertake.  Four important risk-factors which are common to most of the NCDs (i.e. tobacco smoking, obesity, lack of physical activity and alcohol intake) have been identified the world over.  Unfortunately, the prevalence of these factors is quite high – physical inactivity is almost universal in India.  Obesity is partly contributed by physical inactivity and partly by the intake of unhealthy diet.  High intake of sugars, fats and salt is responsible for several of the ill health effects.  Incidentally, the risk factors have a significant social, economic and cultural background.  The behavioural changes required for their control and avoidance are difficult and slow.  Nonetheless, it is important to minimize their occurrence for a meaningfully, healthy life.

The bottom line of living and coping with chronic disease is to accept its occurrence and win it over with the available armament.

It is worth remembering what was said almost four centuries ago at the dawn of modern medicine – ‘Acute disease is an act of God; of chronic diseases the patient himself is the author” (Thomas Sydenham). 

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000

Patient's Partnership in Disease Management

Patient’s Partnership in Disease Management

Dr. Surinder K. Jindal, M.D., FCCP, FAMS, FNCCP
(Ex-Professor and Head, Department of Pulmonary Medicine,
Postgraduate Institute of Medical Education and Research, Chandigarh. India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D, Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com          Website: jindalchest.com
Email: skjindal@indiachest.org

                There is no better example of mutual trust and belief in a relationship than that between a doctor and a patient.  This is a relationship of a wide spectrum which resembles that between the parents and the children on one hand, and between the seller and the consumer on the other.  It extends from compassion, responsibility and empathy to consumerism, business and (sometimes) confrontation.  Moreover, the relationship is neither permanent nor obligatory.  It is a partnership which succeeds best when both the partners are mutually responsive and responsible.  One cannot just rely on the doctor alone to get the positive results.  Similarly, the doctor must not assume the role of “Mr Know All” and “Mr Do All” whenever managing a sick individual. 

                The issue that a patient needs to participate and cooperate in almost any plan of medical management is undebatable.  A prescription is meaningless unless effectively utilized by the patient.  It is a common knowledge that most people do not follow the treatment instructions in toto.  This is perhaps inherent in human nature.  Yet we often tend to blame the prescription or the physician for any unfavourable outcome of an illness.  Endless examples of such experiences can be counted.

                The issue of treatment compliance is best understood in case of de-addiction programmes.  Compliance can hardly be expected on the mere advice to quit alcohol, a habit forming drug or tobacco consumption.  Every one may want a magic medicine to get rid of a habit causing distress.  But success can be achieved only with a prolonged and arduous programme involving the whole family.

                Certainly, people do understand that a psychiatric disorder or a drug dependence problem is difficult to treat especially because the patient himself/herself is not fully competent and involved.  Let us take more simple examples of an acute infection and a relatively chronic illness such as pulmonary tuberculosis.  As per several assessment studies, more than 80 percent of people will faulter on either the dose or the duration of prescribed drugs.  It was the realization of this very fact that led the World Health Organization and also the Government of India to adopt the strategy of Directly Observed Therapy, Short Course (DOTS) for tuberculosis where each treatment dose is required to be put in the mouth of the patient in front of a drug-provider.

                Patient cooperation is important in not only taking the medicine, but also in following other instructions.  Any number of bottles of cough mixtures and expectorants or strips of antibiotics will do no good to a patient of bronchitis or asthma who continues to smoke, irrespective of medical advice.  Similarly, anti-diabetic and anti-hypertensive drugs will not serve the purpose unless dietary precautions are taken.  Most patients with musculo-skeletal and joint problems cannot fully benefit without recommended exercises and weight reduction.  Unfortunately, many of the ancilliary recommendations are difficult to follow, but do play a crucial role in treatment plans.  Quite often, the non-drug factors may determine the success or failure of a treatment.

                Another important area where patient’s active participation is required is his/her appreciation and understanding of the disease, anticipation of future complications, progress of illness and limitations of treatment.  While most diseases are treated in one or the other way, only a few are cured.  Many of the illnesses require life long treatments and remain controlled while others continue to progress, irrespective of treatments.  It is the last group of diseases which is difficult to understand.  Treatment in these cases is aimed either at palliation or in somehow reducing the pace of progression.  There is a constant dilemma whether to treat or not to treat such patients, especially because treatments are associated with several other problems.  There is no easy way to wriggle out of this dilemma.

                We always like to involve the patient and/or the family in treatment decisions.  This however is not necessarily a successful strategy all the time.  This is even more so in case of relatively unfamiliar illnesses.  People may know the ifs and buts of asthma, tuberculosis, diabetes, hypertension or cancer.  But how many can really appreciate problems such as emphysema, cardiomyopathy, fibrosing alveolitis or motor neurone disease which may relentlessly progress to death, sooner or later?  Patient’s ability to understand depends upon innumerable factors such as age, sex, education, occupation, religion, race and so on.  Further, the explanation given by doctors are interpreted differently by different people.  Generally, people would tend to translate all advice as per their own beliefs and conveniences.  There is almost always a lack of clear understanding.

                Patient’s interpretation of medical advice is quite personal for not only the serious and progressive disorders but also for other common problems such as anxiety, depression, allergies or infertility.  There is never a direct correlation between what is advised and what is understood.

                Lastly, the limitations and problems of treatment as required to be accepted.  Quite often, the treatment effects are unexpected.  There is no treatment which is one hundred percent effective and safe.  Even a highly effective drug in most patients may not show its useful effects in a few.  Similarly, a very safe drug may well prove to be risky in some.  It is a common knowledge that some patients may show allergic or hyper-sensitivity reactions to an otherwise innocuous drug.  Same holds true of a complications following a surgical procedure.  The issue of unexpected effects and reactions is always a sore point with patients.

                On the other hand, many treatments are administered with full knowledge of their side effects and toxicities.  Several kinds of surgical operations are done and medicine (such as corticosteroids and cytotoxic drugs) given in spite of their known problems.  Such a decision is obviously made in being the best (or better) of the available options.  The problems ensue when the opted solution starts causing problems.  Factually, no patient can appreciate the unforeseen problems of a treatment in spite of being told in the beginning.  Yet, the explanations require to be given.

                To summarise, the patient continues to remain as an important and responsible partner in managing his/her disease.  Unfortunately, the disease belongs to him/her alone.  The patient needs all the attention and empathy of a doctor.  But neither the doctor, nor anyone else can own the disease.  Although the treatment is given by the doctor, it belongs to both.  A doctor is more of a counsellor or a facilitator than a proverbial god.  He/She needs to always keep in mind the very ancient saying – I treat, He cures.

               

_____________________________________________

Dr Surinder K. Jindal, MD, FCCP, FAMS, FNCCP

(Ex-Professor & Head, Department of Pulmonary Medicine

Postgrad Instt of Med Edu & Res, Chandigarh, India)

Medical Director, Jindal Clinics, SCO 21, Dakshin Marg, Sector 20 D,

Near Guru Ravi Das Bhawan, Chandigarh, India 160020.

Email: dr.skjindal@gmail.com

Website: jindalchest.com

Ph.  Clincis: +91 172 4911000,  Res.  +91 172 2712030/ 31

Story of a Sesamoid

Story of a Sesamoid

Dr. Aditya Jindal

DM Pulmonary and Critical Care Medicine,

PGI Chandigarh

Consultant Pulmonologist

Jindal Clinics

The year was 2003.I had finished my internship and was trying to psych myself for the dreaded entrance exams to MD courses. Needless to say, I was failing miserably. Then a cousin suggested a skiing trip to the Garwhal Himalyas. It seemed just the thing, so I made my reservation and headed for the hills.

We went to Auli, a hamlet situated 12 km uphill of Joshimath, on the great pilgrim route to Badrinath. The snow clad hills and the fresh air were liberating. After being fitted out with the skiing gear we hit the slopes, all too literally. It was a beginners course and the first thing one was taught was how to fall. One of the instructors even boasted he knew fifty ways to fall!

Soon, one fact emerged – I was the only doctor for miles around. My nascent ability was soon put to the test when I received a message one fine morning – while I was out skiing  – requesting me to attend a young British  lady who had taken a tumble somewhere on the slopes.

The history was that of falling on her right hand. As I went to see her , morbid thoughts of Colles’ fractures and elbow dislocations were hammering inside my head, not to mention the butterflies fluttering in my stomach. Though I had done a lot of hard work during my internship, this was to be my first taste of independent decision making; never had I felt the need of a senior so badly.

Anyway, on examining her, all I found was an area of tenderness localized over the base of the right thumb. I had seen a small clinic in Joshimath when we had arrived, so I sent them there to get an X-ray done and prescribed some painkillers, of which they had an ample stock already!

We met an dinner that day and I was solemnly informed that the X-ray showed a fracture. I asked to see the X-ray; one point I noticed initially was that the doctor who had reported the X-ray was a BHMS. The moment I saw the X-ray I burst out laughing, for the ‘fracture’ was nothing more than a smooth round sesamoid bone lying lateral to the head of the first metacarpal bone! 

I explained this to the couple and told them nothing more needed to be done. I returned home soon after, after refusing payment from the grateful couple, feeling refreshed and with a renewed belief in the medical profession.

Sarcoidosis

Sarcoidosis

Sarcoidosis is a relatively uncommon disease which in India, has been more commonly diagnosed in the last few years.  Unlike diseases such as asthma, tuberculosis, pneumonias and lung cancer, sarcoidosis is rather an unfamiliar term amongst patients.  It is somewhat difficult to understand and appreciate the nuances of sarcoidosis.

A patient with sarcoidosis may present with varied manifestations.  Commonly, there are symptoms of low grade fever, weakness, malaise, joint pains, dry cough and/or breathlessness.  Sometimes, the patient is entirely asymptomatic and the diagnosis is made incidentally on chest x-ray examination.  While lungs are the most frequently involved organs, skin, eyes, liver, spleen and nervous system are the other common sites of disease.  Almost any part of the body can be involved in sarcoidosis.

The exact cause of sarcoidosis is not known.  This is quite enigmatic for both the patient and the doctor to accept a relatively indefinable disease.  It is an immunological disorder but the exact aberrations are not known.  There are a number of clinical, radiological and histopathological similarities with tuberculosis.  But tuberculosis and sarcoidosis are two distinct diseases with entirely different treatments.

Sarcoidosis is generally suspected on clinical and radiological criteria.  The diagnosis is confirmed on histopathological findings of biopsies from the involved organs, for example the lungs, lymph nodes or liver (etc.).  Bronchoscopy, and often endo-bronchial ultrasound (EBUS) guided fine needle aspirations are required to obtain biopsy material from the lungs and the lymph nodes.  It is important to confirm the diagnosis in view of the treatment issues involving the use of corticosteroids, generally for prolonged periods.  It is also important to exclude other diseases such as tuberculosis and lymphomas.

Sarcoidosis is a treatable disease, but recurrences may occur.  Strict monitoring is required for side-effects of drugs such as the corticosteroids, during the treatment.  The response to the treatment is fairly good.  Recurrence of disease requires treatment with alternate drugs which may not be as effective as the corticosteroids.  

Sarcoidosis involving the heart and the nervous system is considered as more serious.  In chronic cases, sarcoidosis may result in diffuse lung fibrosis and respiratory disability.  These cases respond poorly to standard modes of therapy.  Overall prognosis of sarcoidosis is generally good provided the disease is diagnosed before any permanent damage has occurred.

A considered decision is always important before the treatment is instituted. These cases are diagnosed with the help of biopsies from the involved organ/s. Most often, they need fiberoptic bronchoscopy to obtain transbronchial and endo-bronchial lung biopsy.  This is particularly so because the sarcoidosis treatment requires corticosteroid administration, which are avoided in case there is the possibility of an alternate diagnosis, such as tuberculosis (or lymphomas).EBUS guided fine needle aspiration biopsy adds to the accuracy of obtaining tissues especially in case only the thoracic lymph nodes are involved. 

We at our centre, see around 1-2 new cases of sarcoidosis every week, the diagnostic success with bronchoscopic procedures is almost 100 percent. This further emphasizes the frequency of its occurrence and the need for proper diagnosis.

The Use and Abuse of Corticosteroids

The Use and Abuse of Corticosteroids

Corticosteroids sometimes referred to simply as ‘steroids’, form a large groups of drugs with a common chemical structure.  They possess a diverse range of pharmacological and clinical actions.  Steroids with muscle building potential called “anabolic steroids” are sometimes used for wasting diseases, and abused by athletes or other sports persons.  We for the present, are primarily concerned here with corticosteroids used as medicine for different diseases.

Corticosteroids are normally occurring hormones in the body.  There are three types of steroids – mineralo-corticoids, glucocorticoids and the gonadocorticoids (sex hormones).  The gonadocorticoids are produced by the gonads (testes in males and ovaries in females), while the mineralo- and glucocorticoids are produced by adrenal glands located in the abdomen, resting over the two kidneys – therefore they are also called supra-renal glands.  Their production and release is governed by the pituitary gland located in the brain.

Corticosteroids, which are used as medicine, are chemically synthesized.  There is a large number of synthetic corticosteroids manufactured for use as drugs. While individual products have one or the other advantage, the primary actions are common to all the brands.  The mineralo-corticoids influence metabolism of ‘minerals’ i.e. sodium and potassium, while the gluco-corticoids are important in glucose and fat metabolism.

There are extensive indications for the medical use of corticosteroids.  Their use in adrenal deficiency is primarily for replacement therapy.  More commonly, they are used for suppression of immune activity or to control inflammation in a large number of immunological and inflammatory diseases.  In respiratory conditions, they are used in different stages of asthma and other allergies, chronic obstructive lung diseases, sarcoidosis, certain type of interstitial lung diseases, and pulmonary vasculitic disorders.  They are also used in many other medical illnesses – rheumatoid arthritis, polyarteritis nodosa, systemic vasculitides, skin allergies, urticaria, eczema, eye allergies, allergic rhinitis and a number of other common or uncommon diseases.  Steroids are lifesaving in severe anaphylactic shock, acute severe asthma, transplant rejections and diffuse lung haemorrhage (etc.).

There is no other choice when the medical indication for this use is clear and strong.  What is more worrying is their irrational and prolonged use, frequently without the knowledge of the patient.  There is no monitoring of side effects or attempts at their prevention.  It is common in this country for some medical practitioners to use small doses of corticosteroids even when there is no medical indication, to provide ‘magical relief’ to the patient to earn credit.  This is an abuse which must be avoided at all costs.

Corticosteroids, when used for longer periods in an un-regulated fashion, can lead to occurrence of complications such as salt and water accumulation which manifests with swelling of face and feet, hypertension, glucose intolerance or even frank diabetes,.  They also cause osteoporosis and bone- loss predisposing to spontaneous fractures of bones and complications such as collapse of vertebrae or necrosis of hip-joint bones. Fat redistribution results in thinning of limbs (arms and legs), accumulation of fat over the neck and the upper-back. Muscle wasting, abnormal striae over the body (arms and abdomen), acne and petechiae can also occur.  The symptoms of acidity and gastro-esophageal reflux (retrosternal burning, dyspepsia) are common.  There is also an increased frequency of infection, including tuberculosis in such patients.  

It is important to give supplemental calcium and vitamin D to most of the patients receiving corticosteroids.  Regular monitoring is most important which should be done for blood pressure, blood sugar levels, weight gain/ loss, serum calcium and vitamin D levels.

In summary, the corticosteroids use constitutes a double edged sword.  The use, when medically indicated, works like a wonder. Most importantly, the long-term effects need to be carefully assessed. The wisdom lies in the discretion to decide the indication.  This should be done on the basis of available medical evidence, and not on the whims and fancies of an individual practitioner.