School Children need protection from tobacco consumption: CAG & Consumer Voice

Citizens Awareness Group and Delhi-based NGO, Consumer Voice, underlined the need for strict implementation of the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution Act, 2003 (COTPA) in the region to protect children from tobacco consumption.

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Diseases of Breast

BREAST  CANCER :

In India, Breast cancer is the second most commonly found cancer disease in females , although it is spreading very fast, like a wild fire. Cancer of uterine cervix is the commonest cancer seen in Indian females but in metropolitan cities like New Delhi, Mumbai, Chennai, Bangalore , breast cancer has over taken the incidence of cancer of cervix.

Breast cancer has fairly good prognosis but only if detected at an early stage  ( Stage I ) but unfortunately, in India majority of  cases are seen in stage III only when outcome is not very good.

The modern management of breast cancer consists of multimodality treatment – surgery, chemotherapy, radiotherapy, hormone therapy etc, the sequence of application and number of therapies used depend upon the stage of the disease, general condition of the patient and choice of the treating specialist.

Breast cancer can be seen in males also ( 1 out of 100 breast cancer patients) and they have to be treated in the same manner as in females.

Early Breast Cancer :

In this the first line of treatment is surgery followed by other therapies.

In early breast cancer surgery:

  1. One can remove the entire breast known as Total mastectomy and this is combined with Clearance of axilla on the same side to remove all the lymph nodes ; and the combined procedure is known as MRM ( Modified Radical Mastectomy).
  2. One can undertake only removal of the tumour along with rim of normal breast tissue all around the tumour usually combined with axillary clearance. – known as segmental mastectomy ; and the total procedure is known as BCS (Breast Conservation surgery).

It has been established that both BCS and MRM give equally good results , the only significant difference being that there is 5% increased risk of local recurrence after BCS .

In India, BCS is done only by a very few surgeons. I have been undertaking BCS for the last thirty years and I am quite happy with the results. It gives good cosmetic looks and therefore patients are also very satisfied.

BENIGN BREAST DISEASE :

Following diseases are included in this category :

Fibroadenoma of breast :  mobile swelling in the breast, usually seen in young females, it may be a single or multiple in number, it may be small in size or may attin a very big size. Most of these require surgical removal or some of the small ones may respond to medicines.

As fibroadenomas are mostly seen in young females, cosmetic results are very important.

I undertake the operation in such a way that the cosmetic results are very good, the scar is hardly seen and the shape and size of the involved breast remains the same.

 

Tuberculosis of breast : Tuberculosis is a very common problem in India, mostly seen in Lungs, Lymph nodes, Intestines, female genitalia etc but rarely seen in breasts also. It becomes very difficult to diagnose this condition as there are not very many leading symptoms and signs.

I have seen a few young ladies from well to do families who had this problem, could not be diagnosed for a long time, luckily I could detect it , treated them and were cured of the problem.

NON TUBERCULOUS GRANULOMATOUS PROBLEMS OF BREAST :

These are infrequent problems seen in breast , present with progressively increasing swellings or ulcers ( wounds ) in the breast, does not heal with usual treatment with antibiotics,dressings etc. I have seen a few of these cases, managed them with medicines, dressings and subsequently operated upon them and they have been cured of the problem. ( photographs )

BREAST ABSCESS:

Breast abscess is commonly seen in young mothers during their early feeding activities , particularly amongst first time mothers , who are not experienced in breast feeding their kids.

Breast cancer cases are usually surgically treated with incision and drainage, leaving behind an open purulent cavity , which has to be dressed frequently and requires a long time for complete healing and lot  of pain for the patient.

I have been treating these breast cancer patients with drainage by undertaking aspiration, which may be required on a number of occasions.

I have been undertaking this form of treatment for the last fifteen years and have been successful almost in all the patients, even treating patients with 400 to 500 ml of pus on the first aspiration. In three patients , who required repeated aspirations for more than five times, I placed a drainage in the dependent part and all the three patients recovered in due course of time.

 

Versatile Local Anaesthesia

Surgery has become a common procedure for relief of medical problems. Gone are the days when operation was a dreaded procedure with a high mortality (death) and complication rates. I tell my apprehensive patients that there are more accidents and resultant deaths on the roads ofChandigarhthan in all the operation theatres of Tricity and this comparison seems to give lot of confidence and solace  to patients and their worried relations.
Surgical procedures have not only become safer but they are relatively pain free also, particularly if one compares them with the past experience. Major credit for this not only goes to better surgical techniques but also to safe anaesthesia and quick recovery from its after effects.
The type of anesthesia a patient receives depends on the procedure being performed, the physical and emotional status of the patient and also on the preference by the surgeon.

Anaesthesia can be administered mainly by three techniques

  1.  General or total anaesthesia in which the patient as a whole is put to sleep
  2.  Regional anaesthesia in which the region to be operated upon is blocked to sensations – epidural, spinal and caudal anaesthesia are the common examples of this
  3.  Local anaesthesia in which only the operation site is anaesthetised facilitating pain free surgical procedure.

We shall be considering the last, the local anaesthesia, in detail. Number of techniques  are available for giving local anaesthesia.

  1.  by infiltration of a chemical agent in the concerned area, which produces loss of sensations and operation can be undertaken without causing discomfort to the patient. The commonest drug used is Lidocaine in injection form, can be diluted and used in the strength of 0.5 to 2.0 %, the effect lasts for about 30 to 45 minutes. Addition of Adrenaline prolongs its effective time for 60 to 70 minutes; and addition of Hyalurinase extends its area of effectiveness. Newer drugs like Etidocaine in concentration of 8mg \ Kg with Adrenaline can provide satisfactory local anaesthesia for 120 to 180 minutes.
  2. Ring Block – local anaesthetic agent is used in the form of a circumferential ring so that the sensations below the block are blunted. This form of anaesthesia is commonly used for fingers, although previously I have seen it being used for a limb also.
  3. Blockage of  nerve– either for surgical procedure or to relieve excruciating pain in an area where other methods have failed- common examples being blockage  of trigeminal ganglion in the face, coeliac axis block in the abdomen
  4.  Tumescent techniques – in this  larger amounts of anesthetic drug is used in dilute concentrations (0.05-0.1%) with Adrenaline (1:1,000,000). The anesthetic concentration is extremely small, allowing large amounts of solution to be used without reaching toxic levels and therefore it is quite safe.

The patient remains completely alert during local and regional anaesthesia. Addition of sedation either in mild or moderate doses not only potenciates the effect of local anaesthetic agent but also induces sleep \ drowsiness in the patient, the effect is beneficial not only for the patient but for the operating surgeon also.

The usefulness of local anaesthesia has been known for a long time but its versatility has been appreciated recently because of popularity of Day Care surgical procedures, the financial implications, suitability in relatively poor risk and elderly patients where general anaesthesia would be more risky. The non availability of a competent anaesthetist ,  sophisticated  anaesthesia equipment and absence of proper  post operative monitoring of a surgical patient have forced many surgeons to utilise local anaesthesia more frequently. It is good to have a standby anaesthetist but the surgeon himself can learn and administer local anaesthesia easily.

I shall like to share my recent experience with two of my patients who had undergone major operations under local anaesthesia as the anaesthetist did not find them suitable for general or regional anaesthesia and they could not be left without operations.

A lady of 55 years of age was found to have cancer of breast along with encephalitis resulting in marked impaired neurological functions.  Operation was started with an aim to excise the tumour under local anaesthesia, but as the surgical procedure proceeded we could undertake total excision of the breast along with clearance of the axilla, the operation that she really required. She made an uneventful recovery, was given additional appropriate treatment for breast cancer and she rewarded us with complete recovery from her neurological problems and two years have passed and she is disease free.

A lady teacher of 65 years of age, belonging toGuwahati,Assam, had recurrent attacks of severe pain in her abdomen for the last five years because of large number of stones in her gall bladder. She has been suffering from Bronchial Asthma for the last 30 years, incapacitating her for any physical activity. Investigations revealed her lungs functioning only at 20% level and she was denied surgery in her home and neighbouring states also. Her brother, a senior plastic surgeon by profession, wanted some relief from recurrent attacks of excruciating abdominal pain. General or regional anaesthesia were considered to be too risky, surgery was started with local anaesthesia with mild sedation and our efforts were rewarded when we could complete the operation – removing the large sized gall bladder packed with multiple stones. We were pleasantly surprised to find the patient walking to the wash room just six hours after her surgery and she boarded the train 48 hours later for Guwahati, it is more than four months and she is much better than what she was before surgery. Chest physiotherapy and counseling have played an important role in her recovery.

Local anesthetics,  used properly, are safe and have few major side effects but in high doses they can have toxic effects because of their absorbtion. This may have effects on  breathing, heartbeat,blood pressure, and other body functions but are seen quite infrequently.

The take home message – people usually are very reluctant to divert from a well established routine procedure and try a new one but unless one practices it, one will never realise its value or develop expertise in it.

Disappearing Art of Clinical Practice

In November 1966, the practical part of my MS examination was being held inAmritsar. It was very cold but the sight of my examiners – Prof. SSAnand, A.K.Basu, BNBRao, GC Sharma, Eggleston etc. had made it icy cold for the 20 odd examinees who had collected there from all over northIndia.  It was the first of the five sessions spread over 3 days. The examiners arrived for the long case. Just prior to me there was a candidate from my PG Institute, who had failed twice before. He presented a case of lump inRIF, 5 cms in diameter, firm in consistency, dull on percussion, slightly tender and mobile. The examiners asked for the diagnosis and he said appendicular mass; of course he did mention two or three other possibilities in his differential diagnosis. Prof. Anand, the internal examiner for the candidate roared- “you said the mass is mobile ?”, “ yes sir” – the candidate mumbled; Prof. Anand- “you idiot, in my 40 years of surgical career, I have never seen an appendicular mass to be mobile, I am ashamed of you, get out and come after 6 months”; and there the poor chap’s entire examination came to an end. The importance of clinical examination, elucidation of physical findings and their proper interpretations could not have been hammered more appropriately. 30 years later while examining a DNB candidate at Pune, when I found that the candidate could not evaluate the fixity of a breast lump or tell me whether the thyroid nodule had mediastinal extension or not, I became very annoyed and also very depressed. Like Prof. Anand, I could not debar the candidate from the rest of the examination, but I definitely made sure that he would not pass this time however good his remaining sessions may be. Fixity of breast tumour and mediastinal extension of a goiter are important findings and the management depends upon this.
In this era of CT scan and MRI, Ultrasound and Mammography, it is not unusual to see a large no. of clinicians, and I dare say particularly the younger ones, do not even bother to get up from their cushioned chairs to examine the patient, they coolly write down sophisticated and expensive investigations and depend entirely on their results.  Anyone complaining of abdominal malady is subjected to US or CT or MRI scan upper GI endoscopy or colonoscopy or may be both. Modern day clinicians are completely dependent upon the imaging results, little realizing that the imaging expert may be a novice and the observation and interpretation may be far from being reliable or correct one. It has been proved beyond doubt that at times the investigation results may be inaccurate, moreover the results have to pass though human eyes and minds.

A large no. of surgeons will easily testify that the actual operative findings are at a great variance with the imaging results. An imaging result of inoperable case easily turns out to be resectable and vice versa. I feel that 90% of the cases can be easily diagnosed on clinical examination alone and decision taken for the line of treatment.

A few cases managed by me during the last 2-3 years will illustrate and prove my point of view:

A 85 years old NRI has been complaining of recurrent attacks of acute abdominal pain with nausea and mild abdominal distension for almost 50 years. He was extensively investigated inCanada, no cause was found. Every attack brought him to the hospital emergency, where he was treated with analgesics and antispasmodics, IV infusions, antibiotics etc. On examination I noticed mild abdominal distension and increased bowel sounds. On detailed questioning, he gave me the history of abdominal kochs about 50 years back for which he had recd. ATT for 9 months. My diagnosis was sub acute intestinal obstruction and advised him exploratory laparotomy. The patient was surprised that I had advised him surgery without undertaking imaging investigations but he consented for it. Exploration revealed a solitary stricture in the terminal ileum and stricturoplasty cured his long standing problem Recently a former patient of mine brought her old father, who was being treated with chemotherapy for lung cancer on the basis of chest X-ray and CT scan of the chest. I could elicit history of frequency and hesitancy of micturition suggesting BHP. Rectal examination revealed a huge malignant tumour of prostate and the diagnosis was established following FNAC. We have forgotten the dictum- if you do not put your finger in the rectum then you put your foot in it. Doing a PV or PR examination should become a routine with every abdominal examination.

I can easily recollect at least three patients during the last 1 year, who were referred to me for urgent appendicectomy following US scan in two and  CECT in one patient. I was not impressed on clinical examination and rectal examination revealed hard faecal matter in all the three cases and manual evacuation and enemata cured the so called appendix patients.

A patient of intestinal obstruction was being treated as a case of acute pancreatitis with paralytic ileus. Exaggerated bowel sounds with metallic tingling clearly gave the diagnosis of mechanical obstruction but no one had put his stethoscope on the tummy. All of us have been taught these basic steps right from third year of our undergraduate days but we easily forget the golden teaching. Present day surgeons of course do not carry a stethoscope anymore so the auscultation is already a forgotten step.

A young man of 30% electric burn complained of abdominal pain and I was called to see the case. The plastic surgeon in charge  of the case, the GE specialist , dermatologist had  seen the patient and he was being treated with antibiotics, analgesics, purgatives, tranquilizers etc. and then the opinion of a general surgeon was sought. He had superficial burns on the left side of abdomen and left thigh but was complaining of pain on the right side. He had guarding, tenderness in the right lower abdomen and I could elicit psoas spasm also. I lifted the bed sheet below the waist line and I was horrified to see a huge swelling in his right thigh, very tender, raised temperature and his distal pulsations were absent on that side. There was some oozing of blood stained fluid from two three puncture sites in the femoral region. The nurses have been puncturing the femoral vein to obtain blood samples resulting in huge false aneurysm of femoral vessels with secondary infection. He was being dressed on alternate days but no one had bothered to examine him completely.

I was once called by a very senior urologist to examine a senior faculty member who was complaining of pain and swelling in the lower abdomen and was being treated as a case of BHP for the last six months.  There was a large globular mass in the suprapubic region which was thought to be distended urinary bladder. I asked the patient to go and pass urine, he did that but the swelling did not regress at all. Subsequently he was found to be having leomyosarcoma infiltrating into urinary bladder and sigmoid colon.

I can easily recall three female cases of cancer breast seen by me last year, one chief engineer, another one wife of a CEO of a corporate hospital, and third one being Professor in an university , all three of them had  lump in the breast , FNAC were carried out , all were reported as negative and cleared for cancer. But the swellings went on increasing, they came to me for second opinion and  clinical  examination revealed locally advanced stage, FNAC repeated elsewhere were positive. False negative reports are not uncommon for in cytology but if your clinical examination is good then you should ask for repeat FNAC  or may be for excision biopsy but only if you have done the clinical examination and your fingers tell you that the lump looks suspicious.
Detection of cervical lymph node in a breast cancer case or an inguinal lymph node in a patient of anal canal or genital cancer completely alters the stage of malignancy but we still do not bother to do complete examination. Similarly not measuring a breast lump exactly with a scale or caliper can easily alter the staging of the disease and thus the line of the management.

Worst instances of non application of clinical examination are seen in emergency or triage areas. Haemodynamically unstable patients, even of head , abdominal and  chest  injuries are sent to radiology department for CECT, MRI, US scan etc. and they spend 2 to 3 hours over there unattended and uncared for; and scores of instances can be easily found when  the patients have crashed down. We forget that only two or three decades earlier these investigations were non existent and careful, repeated bed side clinical examination could elicit the same information

Absence of clinical examination have converged our vision to a tubular one, we do not see a patient in totality. Take for example a patient of blunt trauma to abdomen, Ultra Sound scan shows laceration leading to haemoperitoneum, he is taken to OT without a detailed clinical examination and the patient collapses after intubation as no one detected the massive haemo-pneumothotax in him.

Failure to undertake proper clinical examination not only leads to incomplete diagnosis but also leads to misguided management.

It seems the present day doctors are treating the images, photos and laboratory reports of the patient and not the human patient. The money spent on useless investigations is the bonus that the patient pays for the careless attitude of the doctor.  Clinical examination can be performed any where and at any time. The best part is that clinical examination can be made repeatedly and this is of immense value not only for diagnosis but also to evaluate the progress of the disease. A patient of acute abdomen may not give the diagnosis of acute appendicitis at the first clinical examination but a repeat examination conducted after 1 to 2 hours later if demonstrates the presence of guarding, rigidity and tenderness   then the diagnosis is obvious. You do not require a CECT to diagnose appendicitis.  It is also important to remember that the clinical examination results can be elicited by different clinicians and compared.

It is also important to remember that in the present era  when patient –doctor relationship is of so much importance, it is the clinical examination that brings the two together as  it involves human touch and some closeness between the two , which is not possible in any technology, however advanced it may be.

BREAST CANCER : RISK FACTORS

Breast Cancer is the most common cancer disease seen in developed countries and it is spreading like a wild fire in western hemisphere. The incidence has been progressively increasing , in  USA  in 1960 it was supposed to affect 1 out of every 20 women ,  and presently it is estimated to affect 1 out of every 8 women . The American Cancer Society predicts that 2, 11,000 new cases of breast cancer will be diagnosed in 2005 and will bring death warrant for about 43300 ladies.

In India, the incidence of breast cancer is not so high but it is definitely higher that what it was about 20 years back. If you take 100 female cancer patients then 16 of them are of breast cancer, and the estimation is that 1 out of 20 women will suffer from this disease during her life time. In contrast to developed countries, cancer cervix is the commonest cancer seen in females but this is fastly changing and lately it has been found that in metropolitan cities of Mumbai, Chennai, Delhi etc. breast cancer has overtaken the incidence of cancer cervix, a sign of modernization?
It is not widely known that breast cancer can also affect males, the incidence is very low; for every 100 female breast cancers, we can see one male patient. It should be also remembered that breast cancer in males have poorer prognosis because of smaller size of breast, which involves the underlying muscles and overlying skin quite early.
It should be remembered that because of its biological behaviour no two patients of breast cancer are the same and hence they do not behave in the same manner.

In spite of extensive research costing millions of dollars, the exact cause of breast cancer has not been established but clinical data have clearly shown a number of risk factors which may be responsible for the development of breast cancer. A brief review of these factors may be helpful in the prevention of the disease.

  1. Age:  The incidence is very low in the age group below 25 years and is seen more commonly after the age of 50 years. The disease is much more aggressive in younger patients.
  2. Sex:  The female sex clearly increases the risk by 99%.
  3. Menstrual Cycle: The disease is supposed to be much more common in the ladies who have a longer menstrual life, i.e. the onset of menstruation  is earlier (prior to the age of 12 years) and cessation of menstruation is later (after the age of 50 years).
  4. Marital and maternal status:  The disease is supposed to be much more common in ladies who have not got married, or if married then have not given birth to children, or if given birth to children then have not breast fed their off springs.
  5. Family History of Breast Cancer: A positive history of breast cancer in the immediate relations (mother, sisters, and daughters) increases the risk. The timing of development of breast cancer in the relative has some bearing on the risk factor, if the family member was post-menopausal (older lady) at the time she was diagnosed to have breast cancer then the lifetime risk is increased by 5%, if she was in premenopausal stage (younger person) the lifetime risk is increased by 18% and if the relation was in premenopausal stage with cancer in both the breasts then the lifetime risk jumps to an increase by 50%.
  6. One should clearly understand that the above figures do not show the absolute incidence of developing breast cancer but only indicate the lifetime   risk vis a vis other women who do not have positive family history.
  7. Smoking and alcohol intake:  Both these factors are supposed to increase the risk.
  8. Prior history of breast cancer:   Ladies with past history of having breast cancer on one side are at greater risk to develop cancer on the opposite side also, about 1 % per year and the lifetime risk is 10%.
  9. Obesity and higher intake of saturated fatty acids:  These have been also linked.
  10. Lethargy:  It has been said that a woman who exercises four hours per week reduces her risk of breast cancer. Exercise pumps up the immune system and cuts the estrogen (female hormone) level.
  11. Radiation to chest:  Exposure of breast to radiation as that may happen during radiotherapy for any cancer disease located either inside the chest or on the chest wall may make the person more vulnerable for the development of breast cancer. This may happen 10 to 12 years after the exposure.
  12. Oral Contraceptives: Ladies below the age of 35 years, who have been using oral contraceptive pills for more than 10 years, are at increased risk for development of breast cancer.
  13. Hormone Replacement Therapy :  Combined oestrogen plus progestin hormone therapy ( CHT ) after the cessation of menstruation used to be a common practice, and was supposed to be good for reducing the risk of osteoporosis, heart disease, colon cancer and Alzheimer’s disease.  But it has been shown that both, continuous and sequential uses of combined hormone therapy are linked with increased risk for development of breast cancer. Not only this, but it has been also found to be associated with diagnosis at a more advanced stage of breast cancer and a much higher rate of mammography abnormalities leading to anxiety and subsequent costly workup like stereo tactic or mammotome biopsy.

The researchers also found that the women who have been using only Oestrogen therapy as hormone replacement therapy   (i.e., not combining with progestin) for 25 years or longer had no significant increase in risk of breast cancer.

Risk factors for male breast cancer:

As mentioned earlier, males can also develop cancer in their breasts although the incidence is very low. The risk factors in males include hormonal abnormality, presence of gynaecomastia ( presence of exceeesive breast tissue in males ) , intake of hormone containing drugs like oestrogen, history of trauma or infection to  the testis etc.
I shall like to caution the readers that the above mentioned facts have been derived from the statistical analysis of the factors seen in the cancer breast patients; they should not be taken as causative or predisposing factors. In the present era when cancer breast has become such a common disease, it is advisable to follow the guide lines.

CANCER : FEW BASIC QUERIES ANSWERED

Dr.S.M.Bose. , MS , FRCS, FAMS, FACS, FICS, FACG,

Q. 1 What is cancer and how does it spread?

Ans. Cancer is a serious disease and can affect any part of the body. It is caused by very rapid and irregular multiplication of the cells. The daughter cells are not like their mother cells.
The cancer cells have the characteristic of getting separated from the main tumour mass. The separated cell can travel to distant parts of the body either through direct extension of through the blood and lymphatic streams. These cells start multiplying over there and produce what is known as secondary deposits or metastasis.

Q2. What is the cause of cancer?

Ans. The exact cause of cancer is not known although world wise research has been going on in this direction. Cancer is caused by constant irritation by some factors and some of the known factors being:

  1. Tobacco in any form
  2. Radiation
  3. Chemical agents
  4. Hereditary
  5. Faulty diet
  6. Few chronic diseases

Q3. What are the danger signals of cancer ?

Ans. There are seven danger signals of cancer as described by WHO. These signals do not mean that the person has cancer but they only caution the person that in cast the person continues to have these inspite of normal treatment then one should visit a specialist to rule out the possibility of cancer being responsible for these.

The danger signals are :

  1. Change in bowel or bladder habits
  2. A wound that refuses to heal
  3. Unusual bleeding or discharge from any source
  4. Thickening or swelling anywhere in the body
  5. Indigestion or difficulty in swallowing
  6. Obvious change in mole or wart
  7. Nagging cough or hoarseness of voice

Q4. How do you diagnose cancer?

Ans. Cancer can be suspected by examination by a doctor but it requires several investigations to find out the type and stage of the disease.

Biopsy can only confirm the presence of cancer and hence it must be undertaken whenever there is doubt of cancer.

Q5. How is cancer treated?

Ans. Cancer is treated by multimodality treatment schedule and this comprises of

  1. Surgery
  2. Chemotherapy
  3. Radiotherapy
  4. Hormone therapy
  5. Immunotherapy

The patient may require all the modalities of treatment or only a few of these.

Q 6 . How can a woman suspect cancer of breast in herself.

Ans. Cancer of breast can be suspected by the presence of any of the following:

  1. Swelling in the breast or in the armpit
  2. Bleeding from the nipple
  3. Ulceration or wound of the breast skin
  4. Thickening of the breast skin so that it looks like orange peel

MALE MENOPAUSE : THE ANDROPAUSE

Dr.S.M.Bose

It may come as a surprise and may be as a rude shock to the male chauvinists that like their female counterparts, males also attain menopause. In males it is actually not Menopause, which literally means pause or cessation of menstruation; it is known as Andropause or Viropause or Male Climacteric and this physiological state is similar to menopause in females.

Andropause was conceptually described in medical literature about seventy years earlier but realization seems to be coming now. Longevity of life has increased, life style is changing fast and the desire to live better and happier in all aspects have drawn the attention of medical personnel to look into this aspect of aging male population.
By the age of 50 to 55 years, a male person may start feeling the first sign to suggest the onset of Andropause; of course, neither all get it nor all start at the same age and obviously the severity and perception also varies in individuals. In contrast to females where cessation of menstruation is the obvious signal for this physiological change, in males there is no definite signpost and that defies easy recognition.

The physiological ( natural ) reason for this transformation is the decreased levels of sex hormone, oestrogen in females and testosterone ( He – hormone ) in males. The decrease in sex hormones can be also due to diseases – pathological causes, but here we shall restrict ourselves to normal aging process. As the man reaches the age of 50 years ( it can vary a lot, can be less or more ) , his testosterone level starts declining ; again the degree of decline is not the same in all men population. This decline is gradual and may take years together to manifest its full effect. This decrease in testosterone level and its manifestation resulting in Andropause varies with the physiological and psychological state of the person, presence of any disease or infection, intake of alcohol or medicines, physical stress due to injury or any major operation.

Andropause may cause a number of problems, the main ones being:

  1. Decreased libido resulting in lack of interest in sexual activities.
  2. Loss of muscle mass leading to decreased muscle power. You must have heard of athletes , weight lifters taking drugs ( testosterone being one of them ) to strengthen their muscle power and decreased testosterone level weakens the muscle power.
  3. Obesity , commonly resulting in paunch , is seen after the middle age and it is not only due to lack of activity but also because of deficient hormone also.
  4. Psychological and behavioural changes so that the interpersonal and social relations change. Loss of memory and concentration, delayed reflexes, lack of alertness ; nervousness and irritability, sleep disturbances, indecisiveness , loss of interest and self-confidence all are supposed to be aging problems and these to some extent are due to decreased levels of hormone. In short it may be said that an active person goes into a shell.
  5. Low testosterone level results in decreased bone density , 15 to 20% , and this gives rise to Osteoporosis or Weakness of bones. This results in low back pain, fractures after trivial injuries – like hip fracture after a fall.
  6. Circulation problems – Preliminary research has shown that like women, men are also prone to develop atherosclerosis due to diminished testosterone levels, but it requires to be clearly documented.

Ignorance and lack of awareness about andropause results in nondiagnosis of the condition in a significant number of cases. The awareness for andropause is very poor both amongst common men and also amongst physicians ; resulting in poor and delayed diagnosis. The symptoms are very vague. Moreover the man gets this at such a stage when retirement, psychological stress, aging problems etc. are present and the symptoms of andropause are taken as results of changed life style. Neither the patient nor his relations or his family physician take him seriously and he is just prescribed a few medicines – vitamins, antidepressants , mood elevators etc. and advised to devote his time in meditation and prayers. On many occasions the patient may be labeled a psychological problem and referred to a psychiatrist., the patient hardly ever follows the advice and the problem persists .

How is Male Menopause produced?

Testosterone is the male sex hormone , produced by testis and the adrenal glands. Testosterone level keeps on increasing from puberty and starts declining from the age of 30 years , almost 10% per decade. This decline may be very fast and steep in some resulting in marked andropausal symptoms whereas in some it may not be that bad. It is estimated that approximately 30% of the men folks in their fifties develop low levels of testosterone resulting in marked manifestations of andropause.

Testosterone acts on many organs of the body, male sex organs , liver, bone, muscles, brain, kidney etc. It has varied functions, some of the important ones being – growth of secondary sexual organs and characters, sexual behaviour including libido, protein and carbohydrate metabolism, bone formation, and production of blood cells from the bone marrow.

Low level of testosterone brings about a few changes in the person _ diminished muscle power, decreased libido and sexual activity, behavioural changes, weakening of bones ( Osteoporosis ) resulting in backache and fractures, indecisiveness , loss of hair, obesity particularly in the mid part of the body. Decrease in testosterone level is also supposed to increase the risk of heart problems, the most important being atherosclerosis – the narrowing and hardening of the blood vessels.

All these features are commonly seen in old age and are linked to aging. It is not widely recognized that in a large percentage of cases this is due to decreased levels of testosterone and this can be kept under control by rationale replacement treatment.

Diagnosis :

As already mentioned earlier, andropause is not a newly discovered problem but its impact has been recognized recently. New and more sensitive blood testing methods are available now for the estimation of bioavailable testosterone resulting in accurate diagnosis of the condition.

Treatment :

The treatment is HRT – hormone replacement treatment , and this is done by prescribing testosterone , usually in the dose of 40 mgs per day. The drug is available in the form of oral capsules, injections or skin patches. The effect is usually noticed after 3 to 6 weeks and the replacement therapy should be continued for very long time.
The medicine should be started only after a careful medical check up to rule out the presence of any other medical problem. Blood testosterone level should be also determined and the medicine is only given if the level is on the lower side.

Testosterone should not be used by the persons who have or had breast cancer or prostatic cancer. It is also not prescribed to the persons who want to father a child as testosterone may cause infertility. Similarly the presence of any of the following conditions should caution a person and the medical specialist would take decision after evaluating the details of the ailment with the help of investigations :

  • Heart or circulation problem
  • Enlarged prostate
  • Kidney disease
  • Diabetes Mellitus
  • Liver disease
  • Edema or retention of fluid in the extremities
  • History of allergy following intake of testosterone or androgens
  • A bed ridden person
  • A person who is on anticoagulants – blood thinning medicine

Science is progressing very fast and so also the medical science. Present day medical practice is committed to help a person, not necessarily to treat the diseases only but to make the life more comfortable and enjoyable. Treatment of male menopause or andropause is an effort in this direction, it has been realized late as compared to female menopause. But now effort is needed on the part of the affected persons to do away with shyness and consult their doctors and the medical doctors should take initiative not only to counsel their patients but to treat the person who may not be harbouring a disease in the true sense but who desires and deserves a happier and comfortable life.

  1. Effects of Andropause:
  2. Loss of muscle mass and muscle power
  3. Psycho-social behavioural changes
  4. Decreased bone density resulting in backache and fractures Treatment

Effects of andropause can be kept under control by judicious use of Testosterone –the male hormones; under the supervision of a doctor.

Day Care surgery Quick, cheap, effective

here is a perpetual shortage of beds in hospitals, particularly in government hospitals, where the majority of the patients seek admission. Although new hospitals are being started and more beds are being added in the existing hospitals, there are long waiting lists in every government or charity centre. It is not uncommon to see a patient making multiple trips to a hospital to seek admission. He fails to do so, gets frustrated and ultimately gives up the idea of getting admitted only to land up in the hospital as an emergency case. He may start visiting the hospital again when the condition becomes worse as in cancer.

This is not a problem unique to India. It is being faced by almost all the developing countries. The developed countries have already faced it and come up with the idea of day-care surgery, also known as outpatient surgery or short-stay surgery.
Day-care surgery has been known for a long time. This means that the patients spend only a few hours in the hospital after the operation and are subsequently sent home. But the concept has been implemented on a larger scale over the past 10 years only.

Dr Sujit Pandit, Professor of Anesthesia from Ann Arbor, University of Michigan, delivered an informative lecture at the PGI recently and I would like to share the interesting points in it and the crux of the lively deliberations that it generated.

About a decade back, only 10 per cent of surgical operations were done as day-care procedures, but over the years it has become such a successful venture that almost 50 per cent of 37 million operations performed in the USA every year are now being carried out as day-care procedures. More and more major operations are being included in this programme.

The advantages or day-care surgery are many. Some of these are mentioned below:

  1. Prevention of cross infection to the patient from the hospital’s atmosphere and other patients.
  2. Sparing the much-needed hospital beds for seriously ill patients who require hospitalisation and close monitoring.
  3. Sparing the doctors and the nurses the burden of monitoring very sick patients.
  4. Cutting down the expenses. Health-care has become a very costly affair. In the USA an average hospital bed costs $600 per day and in India it may cost Rs 500 to Rs 5000 a day in a good nursing home. Even the PGI charges about Rs 1000 for a bed only. Other charges are inescapable.
  5.  Psychologically, the patient and his relations feel happy to go back home and recover in their known environment.
  6.  The inconvenience to the patients and their relations are minimised.

But all said and done, the implementation of any new system requires planning, infrastructure and proper execution; success is achieved only if periodic evaluation is carried out, followed by the required restructuring and modification.
Here are some of the basic requirements for day-care surgery.

  • The patient should be thoroughly examined in the outpatient department, not only about his present illness but also to evaluate his suitability for undergoing anesthesia and the operation.
  • All the relevant investigations must be carried out as outpatient tests.
  •  Facilities must exist to receive the patient in the operation theatre complex at least three hours before the operation.
  •  Pre-operative steps liked the change of clothes, the preparation of the part to be operated upon, the administration of premedication, the attestation of the consent form and other formalities have to be gone through before the operation.
  •  Facilities must exist to keep the patient in the post-operative ward till he comes out completely of anaesthesia and is able to travel to his residence.
  •  The hospital facilities should be available round the clock so that the operated patient can be cared for promptly if he develops any problem.
  •  Communication facilities are most necessary.
  •  Arrangement should be made for a doctor or a nurse to visit the patient at home at night for evaluation and advice — particularly for pain relief, the administration of antibiotics, etc.
  •  It is desirable that the patient should stay within a radius of 20 to 25 km from the hospital.
  •  The patient should be given complete instructions at the time of discharge.

I am of the opinion that the most important factor is the establishment of mutual trust between the patient and the operating team.

The PGI has been undertaking day-care surgery in a small way and it is likely to get a big boost with the opening of the new OPD complex where day-care surgery has been planned with six operation theatres and various facilities. But we shall have to move cautiously and progress slowly but steadily to make this a successful venture. A multidisciplinary approach and proper organisation are the key to success in this field.

More light on breast cancer   BY DR.S.M.BOSE

Breast cancer is the second most common form of cancer affecting women in India. There has been a steady rise in its incidence. It is affecting Indian women at a much younger age as compared to those in the West. Obviously, the disease here is seen at an advanced stage.

The management of breast cancer is controversial. The confusion is multiplied as there is no recommended standard management protocol for the disease in India. To eliminate this lacunae, Prof S.M. Bose of the PGI, who has written the article on day-care surgery, has brought out a book, “Consensus on Breast Cancer” which covers all aspects of the disease, right from classification to follow-up.

The contributors to the book are eminent medical persons interested in the subject.
The volume was released during the inaugural function of the International Breast Cancer Conference held at Nagpur recently.

Dr Bose, the eminent cancer surgeon, received the prestigious Dr B.C. Roy National Award for Eminent Medical Teacher last year. His popular book titled “Cancer”, published by the Government of India and written for the health education of the people, has been translated into many languages. The specialist has also been elected a Fellow of the National Academy of Medical Sciences.

COMMUNICATION SKILLS FOR SURGEONS

n the twenty-first century, the importance of communication can not be over emphasized. Communication is one of the commonest things people do. It is like eating and drinking, breathing and walking. Everyone can do it, has to do it, irrespective of age, sex, educational and financial status.

Good quality communication is supposed to be essential for politicians, leaders of religious sects , advocates, teachers, marketing executives  and for that matter for all those who are involved in public affairs.; but it is equally important for doctors and more so for the surgeons.  A patient offers himself or herself to the surgeon without any reservation. In the present era of awareness and shopping, particularly in the private sector, in addition to the known surgical skill, a surgeon’s communication skill is very important to give confidence to the patient.

We, the professional people, take for granted that our ability to communicate is  very good and we neither try to analyze it nor improve it. Scores of instances may be remembered by each one of us when serious misunderstanding has been brought about because of defective communication, and both the communicator and   communicatee  ( the person at the  receiving end ) blaming each other.

Symbols of Communication :

These are Verbal as well as Non-verbal:

  1. Verbal Symbols:   These are the words we speak or write. What a word or a sentence ( group of words ) really means for an individual depends on several factors including his knowledge, background, personal experience, the mood he is in etc. Most of the sentences can be interpreted in more than one ways. Misunderstanding is inevitable because of the mismatch between the symbols displayed and the symbols received. One can appreciate the little difference in the pronunciation of the words –Bent, Dent, Lent, Rent, Sent, Tent, Went etc and the misunderstanding these can create.Proficiency in the language being used does not guarantee excellence in communication as verbal language is but a minor component for sending and receiving messages. But one should always remember that words are like bullets, once fired they can not be retrieved and damage can be lessened but can not be totally undone.
  2. Non-Verbal Symbols:  These are of wide range and their meanings vary    significantly across cultures. For surgeons the non-verbal symbols are very important as these depict their professionalism, culture, etiquette. Some of the commonly employed non-verbal symbols are:
  1. Clothes and their Accessories:  The clothes you put on , the accessories you use, the perfume you wear can all be a part of non-verbal symbols you display deliberately or unwillingly.
  2. Gestures
  3. Postures
  4. Eye contact
  5. Facial Expression communicates emotions like anger, love, hate, fear, lust, pleasure, anxiety, nervousness etc.
  6. Touch: This is a tricky set of symbols. A  surgeon has to be very careful when examining a patient, more so a female patient; which part he is touching, for how long and how , all these communicate  and interpretation may be different depending upon the cultures.Touch conveys a lot and I usually put a warm hand on the forehead of my patient whenever I feel that the patient is nervous or apprehensive ; and I feel it gives lot of solace and confidence to the patient.

Factors Affecting our Communication:

There are many factors that block our communication and make it slow or    ineffective, the major ones being:

  • Differences in perspective
  • Differences in knowledge levels
  • Lack of common language
  • Tendency to jump to conclusions
  • Strong emotions
  • Self Centeredness
  • Laziness

Factors Facilitating our Communication :

There are many factors which can improve our skills of communication:

  • Selection of proper medium- there are three mediums of communication- spoken, written, non-verbal
  • Selection of proper Channel of communication
  • Create friendly atmosphere , do not try to impose
  • Talk less and listen more
  • Mind your tone and volume of your voice
  • Use language that can be easily understood by the listener
  • Do not use vague and ambiguous words, speak clearly and not in roundabout way
  • Use words that can be understood and grasped by your listener, do not try to  impress him with high flown technical words like Gene, clone, molecular biology, chromosomal abnormalities etc.

A surgeon has to  communicate  with :

  • Patient & his relations
  • Colleagues
  • Senior and Junior coworkers
  • Public
  • Media persons
  • With members of his own Family
  • And he has to keep this constantly in his mind, has to modify his level of communication and all the previously mentioned factors as per requirements of the occasion.

A patient requires :

  • Encouragement
  • Sympathy
  • Understanding
  • Knowledge
  • Love & Affection
  • Solace
  • Comfort- Physical &  Psychological

It should be clearly remembered for all time to come that a patient hands over his or her body to us in spite of the threats of mutilation and disfigurement, pain and agony, monetary loss etc and his decision of selection of a surgeon depends upon his satisfaction gathered during consultation and here communication skill plays a pivotal role.