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Medically Speaking

Accelerate vaccinations to curb Covid spread and variants: Health experts

To prevent any upcoming ‘waves’ of the virus, the government needs to vaccinate more people in a shorter period and allow private hospitals to play a bigger role, suggest top healthcare experts and doctors.

Shalini Bhardwaj

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NEW DELHI: The threat of the spread of mutant variants, its implications and the ‘second wave’ of Covid-19—which The Sunday Guardian’s ‘Medically Speaking’ section was among the first to report—is looming large in the country today. The Sunday Guardian discussed the matter with prominent medical experts Dr Harsh Mahajan, founder of Mahajan Imaging and chief radiologist, Dr Dhiren Gupta, Chairman-elect of the Indian Academy of Paediatrics (Intensive Care Chapter) and doctor at the Sir Ganga Ram Hospital, Dr Avinash Bhondve, former president of IMA Maharashtra, Dr Neeraj Nischal, Associate Professor of Medicine at the All India Institute of Medical Sciences and Dr J.A. Jayalal, National President, Indian Medical Association, to find out how the situation can be managed better.

Dr Neeraj NischalDr Harsh MahajanDr Dhiren GuptaDr Avinash Bhondve

Q: Are we seeing the second wave of Covid-19 or moving towards it?

Dr Nischal: This concept of a wave has been described by epidemiologists. Based on the experience of previous pandemics, it is certain that there will be multiple waves. The moment we lower down our guards, as long as we have vulnerable populations and do not vaccinate most of the population, these waves are going to come. That’s why we have to ensure that we follow the Covid-appropriate behaviours we have been talking about for the last one year. But it is easier said than done. Everyone is saturated and we all want to go out and enjoy the way we did in the past. But the pandemic has not gone away. We will be in big trouble if we lower our guards and that is why, second wave or not, things depend on us. If we allow it to propagate, we will definitely have the second wave, and if we control it right away, we might be safe from the situation which most European countries and the US faced recently.

Q: Maharashtra is going through a bad phase. There was a time when the number of cases was declining but if we see the latest data, the maximum cases have been reported from Maharashtra. What can be the reason behind it? Are people taking it for granted?

Dr Bhondve: Let us talk of some practical and theoretical things. First of all, as Dr Neeraj rightly said, the waves will keep on coming. In early February, new cases were around 2,000 a day, which have gone up to more than 23,000. Before that, in the month of December and January, the number of cases and daily cases and all other parameters came down, but never touched the zero line or went back to the base line. So, this is the rise in the number of cases. There are many reasons. We always blame the common people for not using masks or not observing social distancing, but these things were there even in December and January. The main reason behind the rise in new cases since early February is the government of Maharashtra giving instructions to district officers to increase testing and contact tracing. It was clearly advised that for every patient 280 contacts should be traced. When this number started increasing, it was quite obvious that 90% of the cases, which were asymptomatic or mildly symptomatic, were diagnosed.

Also, the rate at which patients are increasing is very fast. The patients are mostly in the age group of 20 to 45 years, and they are mostly asymptomatic or mildly symptomatic. There was a similar scenario in Britain, where they investigated this and did long sequencing on most of these patients. Like it was a variant in Britain, it could be a variant which has evolved in Maharashtra. These types of sequencing should be done on the patients from Maharashtra like it was done for the patients who came from Britain, South Africa and Brazil.

I think the sum total of all these things is the reason behind the rising cases in Maharashtra.

Q: So, how is Covid-19 striking back?

Dr Mahajan: We know this RNA virus tends to mutate very rapidly. If we see, there are over 100,000 mutations, and over 7,000 have happened in India itself. Out of that, the variants that concern the most have been the three—the UK, South Africa and Brazil variants—as Dr Bhondve also said. In India, about 7,000 patient samples have been genome sequenced, out of which about 200 are from Maharashtra. Out of these 200, in 20% of them they have found two mutations. This is at present. However, as time passes and we do more sequencing, we will know whether it is really the one causing this rapid surge because it is already known that it can be more contagious. The government has now said that 5% of all positive samples across the country will be sequenced. In December, the government also formed institutes for genomic surveillance. So, it’s only when we do more genomic sequencing, that we will know the kind of mutations happening, how they are spreading across the country, if they are similar to the strains found in other parts of the world, and if this is a new Maharashtra strain. But the important point is that if we protect ourselves and we follow Covid-appropriate behaviour, especially the use of masks and practising hygiene and social distancing, we can overcome any mutations and variants. However, we have seen of late, not only in Maharashtra or Punjab, where most of the new cases are happening, but also in Delhi and other parts of the country, that people have reached a level of fatigue. There is a release now, markets are full and weddings are happening, even indoors with hundreds of people. If we continue this, irrespective of what the variant may be, we will get more cases.

But Maharashtra does appear to be at the start of a second wave, as has been said. This may also be due to enhanced testing and very stringent contact tracing where we are picking up more of the asymptomatic variety. This is also the time when the vaccination drive in these pockets needs to be accelerated and the Central Government has to give permission to states to vaccinate those between 20 and 45 years as they are the ones who are getting maximally infected.

Q: What would you like to say about people forgetting to follow Covid-appropriate behaviour?

Dr Gupta: We know this is going to come, which means we cannot stop it. These viruses are going to be here with us. What we need to find out is how we can prevent infections and reduce the number of patients getting infected. Dr Harsh has beautifully defined it. I would like to define it on the levels of the individual, the government and the virus. On the virus level, we know it has marked each and every community. This virus knows much more than what the medical sciences know about this virus.

On the government and individual levels, what I have found is that people are scared of the side effects of the vaccine. So, as Dr Mahajan said, all the population should be vaccinated very quickly. This way we can prevent this virus from circulating quickly, prevent its mutations and suppress such waves, which are otherwise bound to happen. Secondly, there is the problem of ignoring Covid-related behaviours. The kisan andolan is still in full swing, cricket matches have begun, and even politicians are moving here and there without masks. With this type of attitude, whatever we do and whatever programs we start at whatever level, the public is going to behave like this. But what we can do is enhance our vaccination program. There is a lack not only on the government level; it is also the public that is responsible. They are so scared of the vaccine’s side-effects that they forget how bad this virus is. I have worked in the Covid ward and seen people who got infected. Young people think that they cannot get infected or if they do, it would be mild, but they forget that they are the people who are going to spread this virus to the elderly.

But these things are not very simple. I have seen many doctors getting fed up with masks and we have seen that continuously wearing them for 12 hours induces some hypoxia. So, it’s easier to preach. But at the individual level, Covid-appropriate behaviour is very important. We should get vaccinated and, as Dr Mahajan said, open up vaccinations for 20-40-year-olds too and also allow all sorts of vaccines available in the market. We have inoculated more than 2 crore people and no major side effects have happened. We have also got our indigenous vaccine, i.e. Covaxin. This should be promoted as well. We should ask other companies, which have been approved in the US, like Pfizer or Moderna, to export to India. It should be like a flea market: whosoever wants to get it and can pay should get whatever they think is medically suitable. Everyone has to pitch in, including the government, because this is going to rise. I look at the Covid wards, we get a daily warning from our medical director about them being full. So, this is the only way to stop it or slow it down.

Q: The IMA has already urged people and the government to not drop their guard against Covid-19.

Dr Jayalal: Yes, it is quite painful to know that even after very sustainable efforts by the government and healthcare professionals to control the virus, there has been a sudden spike in cases across the country. It is painful to note we have crossed even 36,000 cases in a day, which only denotes we are reaching the second wave. But it is nothing new and it is not in our hands because with any pandemic, multiple waves are inevitable. So, at this moment, we don’t need to panic. We need to sensitize our people. One of the most important things for hospitals and other places where people are accumulated is proper ventilation. Schools have opened and children are coming in, but in many school buildings, the infrastructure and ventilation systems are not adequate. The government should spend much more effort on this because this is not on the children, it is on administrators and management. When we were starting with the pandemic, one of the greatest tasks the Indian Medical Association undertook was to equip hospitals with Covid-appropriate infrastructure with one-way traffic to patients, restrictions on the number of people entering, masking and proper cleaning of the place, etc.

Also, with the elections now, we have seen videos where for every nomination, though there is a control measure, for example, only five to ten persons should go, thousands of people are crowding. The Election Commission has taken a very important step by making sure all officers at the election booths are vaccinated. Now we have also requested the government to make it mandatory for agents coming to the political booths to show vaccination certification. Moreover, as Dr Harsh Mahajan and others said, vaccination should be made more available. There is no point restricting vaccinations when India is able to export more than 5.8 crore vaccines. Vaccination should be provided at the doorstep level. We need to be on a war footing.

Common sense has to prevail among the public too. People believe that Covid is not going to do anything to them and that kind of mindset has settled in because political leaders are not leading by example. That should be punished. We would like to express on behalf of the IMA that in all the countries, the second wave has been more disastrous than the first. Though we have scientific knowledge and know the effects of disasters, we must aggressively fight it. Be assured that the Government of India and the medical fraternity will be on the front lines and we will control and treat people as much as possible. The only thing we want is that the government and our colleagues come together and follow Covid protocol.

Q: Do you think speeding up vaccinations can reduce Covid-19 cases in Maharashtra?

Dr Bhondve: Yes, definitely. As Dr Jayalal rightly said, vaccinations can be increased. I would like to inform all of you that when the two vaccines were allowed to be used on an emergency basis, it was only the IMA under Dr Jayalal that declared that the vaccines are safe. At the same time, neither the Government of India nor any state governments have come out with a statement saying the vaccines are safe and everybody has to take it. With previous vaccines like for polio and other things like the Swacchta Abhiyaan, there were a lot of advertisements. Celebrities were asked to talk about it on TV. But nothing has been done for the Covid vaccinations. This has had a very bad impact on the common people. Right now, even in the first phase, only 40%-50% of doctors and healthcare workers were vaccinated. In the stage where all people over 60 years are being vaccinated, if you observe the statistics, there are people who are not even aware that there is vaccination available and they should get vaccinated. As Dhiren sir rightly said, we have to educate such people. Then there are divyaang people or the handicapped. They are supposed to take the vaccination but none of them are getting it. Meanwhile, for people who are between 45 and 59 years of age, the numbers are not sufficient. 

Secondly, the Government of India said that all vaccination centres should run 24×7. But this is not being seen. All hospitals should be allowed to do vaccinations and take care of any side effects. In Pune, we have around 600 hospitals. So, if we allow even 500 hospitals, at a rate of 100 people, we can vaccinate 50,000 people more. So, the timing and number of hospitals should be increased. And as Dr Dhiren rightly said, more than 3 crore people have been vaccinated and there are no serious side effects. So why not open up the market and vaccines be given by hospitals without all these registrations? During the Covid situation, when the beds in government hospitals were full or restricted, the government allowed beds in all private hospitals, even ones with 5 and 10 beds. So, for accelerating the vaccination drive, all private hospitals should be given a freer hand. Even the VCI head has said this. But it is not being implemented practically. We hope this gets implemented and the vaccine campaign is accelerated so we can control it in 6-8 weeks.

RNA virus tends to mutate very rapidly. If we see, there are over 100,000 mutations, and over 7,000 have happened in India itself. Out of that, the variants that concern the most have been the three—the UK, South Africa and Brazil variants.

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Medically Speaking

A new study suggests early weight loss protects fertility of obese persons

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The reproductive function in obese boys can be improved through weight loss, which in turn could protect their fertility in adulthood, according to new research.

The study presented at the 59th Annual European Society for Paediatric Endocrinology Meeting suggests that even after short-term weight loss, alterations in reproductive function could be partially reversed in young boys with obesity. This indicates that early management of obesity in childhood could help prevent future fertility problems in men. Childhood obesity can have some profound effects on future health in adulthood, including a greater risk of cancer, heart disease and type 2 diabetes. Obesity has also been linked to fertility problems in both men and women. The commonest causes of fertility problems in men are usually sperm abnormalities or a low sperm count.

Leydig cells in the testes become active in puberty to produce the main male hormone, testosterone. Sertoli cells in the testes are critical for the production of healthy sperm and produce several reproductive hormones, essential for sperm maturation.

Previous work has shown early alteration of Sertoli cell function in obese boys from the age of 12, with later alteration in Leydig cell function from the age of 14. However, whether weight loss might reverse the altered function of these cells had not been investigated.

In this study, Dr Solene Rerat and colleagues at Angers University Hospital in France investigated how a 12-week educational weight loss programme in 34 boys, aged 10-18 years, affected markers of Leydig and Sertoli cell function, as well as metabolism.

The boys had a healthy, balanced diet, undertook physical activity for at least one hour per day, according to international recommendations, and had weekly individual sessions with a dietician. Before and after the programme, levels of reproductive hormones, body fat composition and blood glucose were measured for comparison. Over the 12 weeks, the boys significantly lost weight and had improved insulin levels, as well as increased testosterone levels.

No significant changes were found in markers of Sertoli cell function. Since fat cells produce an enzyme that converts testosterone to oestrogen, the actual loss of fat mass may account for some of the increased testosterone levels, in addition to the reversal of Leydig cell altered function.

Dr Rerat states, “These findings underline the need to consider childhood obesity as a factor in future fertility issues. We strongly recommend that early management of childhood obesity is necessary to reverse these impairments, and to help prevent future reproductive problems, as well as lowering the risks of other debilitating diseases.”

The team now plans to measure the reproductive function of the group more long-term and to expand it to include more participants to gather more data to confirm and extend these findings.

Dr Rerat cautions, “Our study only evaluated the effects in a small number of obese boys after a twelve-week therapeutic educational program. Further studies with longer follow up are needed to help us fully study the effect of weight reduction on reproductive function.”

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Medically Speaking

Link between diet and mental health

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Lifestyle components like eating habits, exercise, sleep, and work patterns etc affect our well-being on a regular basis and many health problems both physical and mental, are associated with disbalance in our routine life.

There is no specific diet which treats psychiatric disorders but certain dietary choices and patterns are helpful in improving overall health as well as promote physical and mental stress tolerance which leads to better psychological health.

FOODS TO EAT

Among common diet plans, the Mediterranean diet has the strongest evidence supporting its ability to reduce the symptoms of depression.

Compounds in the Mediterranean diet that have links to lower depression rates include:

• omega-3 fatty acids

• vitamin D

• methylfolate

• s-adenosylmethionine

The Mediterranean diet consists of:

• plenty of fruits and vegetables

• whole grains

• potatoes

• cereals

• beans and pulses

• nuts and seeds

• olive oil

• low-to-moderate amounts of dairy products, fish, and poultry

• very little red meat

• eggs up to four times a week

• low-to-moderate amounts of wine to

FOODS TO AVOID

A 2010 study showed that women who ate unhealthful Western-style diets had more psychological symptoms. The foods that these participants were eating included:

• processed foods

• fried foods

• refined grains such as white bread

• sugary products

• beer

Similar unhealthful dietary patterns that typically lead to obesity, diabetes, and other physical health problems can also contribute to poor mental health.

The balanced Indian meal plans have necessary components for health and well being.

SUMMARY

• Eat a combination of locally grown products like whole grains, fruits and vegetables and limited amounts of unrefined fat like cold pressed mustard oil and desi ghee (clarified butter).

• Fish, nuts and seeds like walnuts, pistachios, almonds, flaxseeds and chia seeds have high amounts of omega3 fatty acids which are good for nerve health.

• Poultry, eggs and dairy products are rich in Vitamin B12 which is associated with nerve health and better stress tolerance.

• Balanced calorie intake with good nutritional components (complex carbohydrates, proteins, vitamins, minerals and healthy fatty acids) is the key to good health and weight management. Over eating and under eating both have negative effect on physical and mental well being.

• Regular eating patterns are helpful in maintaining stable sugar levels and boost energy.

• Water makes 60% of body. Drink plenty of plain water for good health.

• Good gut health is linked to balance of good bacteria in our intestines which are plenty in probiotic foods like curd, chaach, and fermented eatables like idli, dosa, and kimchi.

• Sodium is an essential nutrient that controls blood pressure. It is also needed to make nerves and muscles work properly. For this reason, patients need to consume the right amount. Many medicines reduce sodium levels which can lead to hyponatremia with significant nervous system problems. The AHA recommends no more than 2,300 milligrams a day, but patients should move toward an ideal limit of no more than 1,500 mg per day for most adults. Excessive salt comes from packaged and preserved food which in any case need to be avoided.

• Avoid alcohol and nicotine, they may appear to reduce stress but eventually lead to low stress tolerance and mood instability.

• Drugs like pot/weed/grass/opioids and other designer drugs increase vulnerability to major psychiatric disorders.

For specific metabolic disorders like diabetes, obesity, PCOD or inflammatory condition, please consult a dietitian.

The writer is a Senior Psychiatrist and Founder & Director of Manasthali.

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Medically Speaking

COVID-19 PANDEMIC EXACERBATES BURNOUT RATE IN DOCTORS

Doctors at the frontlines of the pandemic are facing extremely challenging working conditions. Long gruelling working hours, constant emergencies, witnessing a high death rate, and a persistent struggle to save lives not just cause physical exhaustion but also result in an emotional and mental turmoil.

Dr Shuchin Bajaj

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Long working hours, emergency calls, a never ending stream of patients and prolonged stress are factors that are common in the lives of doctors. In countries with a low doctor-patient ratio like India, doctors often experience overwhelming workload and excessive pressure. Factors such as lack of safety and vulnerability to violence further adds to this stress. Even before the coronavirus outbreak challenges healthcare providers like never before, physicians were experiencing a high rate of burnout. Several studies have pointed this out in recent years. A small but powerful indicative study published in the Indian Journal of Psychiatry in 2018 suggested that a significantly higher proportion of doctors in Indian setting experience stress, depression, and burnout. Out of the 445 responders in the study, 30.1% were found to have depression and 16.7% reported having suicidal thoughts. More than 90% of the participants reported some level of burnout.

The coronavirus outbreak has hugely magnified this problem, exacerbating the burnout rate in doctors and other healthcare staff particularly those involved in treating Covid-19 patients. Burnout is a condition where an individual experiences overwhelming mental and physical exhaustion owing to excessive stress. It not just affects the mental and physical health of the individual but also impacts his/her job related outcomes.

COVID-19 BURNOUT IN DOCTORS

In China, a cross-sectional study published in JAMA Network Open Journal in March 2020 found that the coronavirus outbreak had a devastating impact on the mental health of healthcare workers. Out of the 1257 respondents, 50.4% were found to have symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety, and 71.5% reported distress. The researchers concluded that working in the frontline was an independent risk factor for worse mental health outcomes.

Doctors at the frontlines of the pandemic are facing extremely challenging working conditions. Long grueling working hours, constant emergencies, witnessing a high death rate, and a persistent struggle to save lives not just cause physical exhaustion but also result in an emotional and mental turmoil. In countries where severely ill patients exceeded the healthcare capacity to treat, doctors had to actually choose whom to treat and whom to let die. Absence of a clear treatment route is another major work challenge.

Wearing PPEs for long hours is itself a major challenge. Once your PPE is on your ability to eat, drink water or even go to the washroom is restricted. The grueling heat makes long hours of wearing PPEs worse. However, the most significant challenge is the threat from the disease itself. Being in the midst of patients every day puts doctors at a high risk of catching the infection themselves. By first week of May, over 500 doctors, nurses, and paramedics had already been infected by coronavirus in the country. An AIIMS doctors was applauded for putting himself at significant risk when he removed his goggles and face shield to be able to clearly see and re-intubate a seriously ill patient. This tells us how doctors are putting themselves at risk during this global pandemic. As doctors get infected and result in a further depletion of workforce, the remaining physicians face an even greater workload.

Apart from all the above concerns, one major concern for doctors and healthcare staff is the threat of carrying the infection to their home and families.

HOW TO ADDRESS THE BURNOUT CRISIS

As much as it is important to ensure the safety of doctors, it is equally important to help them address the mental and physical outcomes of burnout. Governments, healthcare providers, and hospitals must initiate a series of measures to help address this burnout crisis.

ADEQUATE AVAILABILITY OF PROTECTIVE EQUIPMENT

Strict adherence to properly wearing PPEs has been found to be effective in minimising infection rate among doctors and healthcare workers. It is extremely important therefore that governments and hospitals ensure adequate supply and sufficient availability of PPEs for doctors. Adequate supply of PPEs and addressing the shortage concerns also allays the mental stress and fear among doctors. It is also important to ensure that doctors do not have to wear the same protective equipment for more than 8-10 hours.

ACCESS TO COUNSELLING AND MENTAL HEALTH EXPERTS

The World Health Organisation has advised doctors to take extra care of their health by consuming healthy food, taking adequate rest, and staying active. The body has also recommended de-stressing and avoiding smoking or drugs. Hospitals must ensure that doctors have regular access to counseling support to advocate healthy living. They must also have access to mental health experts to give them a proper outlet for their mental and emotional turmoil.

OFFERING ALTERNATIVE STAY ARRANGEMENTS

Governments and private healthcare providers must also arrange for alternative accommodation for doctors and other healthcare staff members to allow them stay away from their families during the time they are treating Covid-19 patients. This takes off the extra pressure and concern about carrying the virus home.

REDUCE BURDEN BY ADDING TO THE MANPOWER

With the number of patients rising steeply every day, we need to find innovative ways to have sufficient backup resource of doctors. In this situation, it makes sense to train final year MBBS and PG medical students in critical care and keep them ready to be deployed in case the need arises.

The writer is Founder Director, Ujala Cygnus Group of Hospitals.

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Medically Speaking

Diet and Mental Health

Published

on

Lifestyle components like eating habits, exercise, sleep and work patterns etc affect our well-being on a regular basis and many health problems both physical and mental, are associated with dis balance in our routine life.

There is no specific diet which treats psychiatric disorders but certain dietary choices and patterns are helpful in improving overall health as well as promote physical and mental stress tolerance which leads to better psychological health.

Foods to eat-

Among common diet plans, the Mediterranean diet has the strongest evidence supporting its ability to reduce the symptoms of depression.

Compounds in the Mediterranean diet that have links to lower depression rates include:

                  •                omega-3 fatty acids

                  •                vitamin D

                  •                methylfolate

                  •                s-adenosylmethionine

The Mediterranean diet consists of:

                  •                plenty of fruits and vegetables

                  •                whole grains

                  •                potatoes

                  •                cereals

                  •                beans and pulses

                  •                nuts and seeds

                  •                olive oil

                  •                low-to-moderate amounts of dairy products, fish, and poultry

                  •                very little red meat

                  •                eggs up to four times a week

                  •                low-to-moderate amounts of wine

Foods to avoid-

A 2010 study showed that women who ate unhealthful Western-style diets had more psychological symptoms. The foods that these participants were eating included:

                  •                processed foods

                  •                fried foods

                  •                refined grains, such as white bread

                  •                sugary products

                  •                beer

Similar unhealthful dietary patterns that typically lead to obesity, diabetes, and other physical health problems can also contribute to poor mental health.

The balanced Indian meal plans have necessary components for health and well being.

Summary-

                  •                Eat a combination of locally grown products like whole grains, fruits and vegetables and limited amounts of un refined fat like cold pressed mustard oil and desi ghee ( clarified butter).

                  •                Fish, nuts and seeds like walnuts, pistachios, almonds, flaxseeds and chia seeds have high amounts of omega3 fatty acids which are good for nerve health.

                  •                Poultry, eggs and dairy products are rich in Vitamin B12 which is associated with nerve health and better stress tolerance.

                  •                Balanced calorie intake with good nutritional components (complex carbohydrates, proteins, vitamins, minerals and healthy fatty acids) is the key to good health and weight management. Over eating and under eating both have negative effect on physical and mental well being.

                  •                Regular eating patterns are helpful in maintaining stable sugar levels and boost energy.

                  •                Water makes 60% of body. Drink plenty of plain water for good health.

                  •                Good gut health is linked to balance of good bacteria in our intestines which are plenty in probiotic foods like curd, chaach and fermented eatables like idli, dosa and kimchi.

                  •                Sodium is an essential nutrient that controls blood pressure. It is also needed to make nerves and muscles work properly. For this reason, patients need to consume the right amount. Many medicines reduce sodium levels which can lead to hyponatremia with significant nervous system problems. The AHA recommends no more than 2,300 milligrams a day, but patients should move toward an ideal limit of no more than 1,500 mg per day for most adults. Excessive salt comes from packaged and preserved food which in any case need to be avoided.

                  •                Avoid alcohol and nicotine, they may appear to reduce stress but eventually lead to low stress tolerance and mood instability.

                  •                Drugs like pot/weed/grass/opioids and other designer drugs increase vulnerability to major psychiatric disorders.

For specific metabolic disorders like Diabetes, Obesity, PCOD or inflammatory condition, please consult a dietitian.

Continue Reading

Medically Speaking

COVID 19 exacerbates burnout rate in doctors: How to address this crisis

Dr Shuchin Bajaj

Published

on

Long working hours, emergency calls, a never ending stream of patients and prolonged stress are factors that are common in the lives of doctors. In countries with a low doctor-patient ratio like India, doctors often experience overwhelming workload and excessive pressure. Factors such as lack of safety and vulnerability to violence further adds to this stress. Even before the coronavirus outbreak challenges healthcare providers like never before, physicians were experiencing a high rate of burnout. Several studies have pointed this out in recent years. A small but powerful indicative study published in the Indian Journal of Psychiatry in 2018 suggested that a significantly higher proportion of doctors in Indian setting experience stress, depression, and burnout. Out of the 445 responders in the study, 30.1% were found to have depression and 16.7% reported having suicidal thoughts. More than 90% of the participants reported some level of burnout.

The coronavirus outbreak has hugely magnified this problem, exacerbating the burnout rate in doctors and other healthcare staff particularly those involved in treating COVID 19 patients. Burnout is a condition where an individual experiences overwhelming mental and physical exhaustion owing to excessive stress. It not just affects the mental and physical health of the individual but also impacts his/her job related outcomes.

The COVID 19 burnout in doctors

In China, a cross-sectional study published in JAMA Network Open Journal in March 2020 found that the coronavirus outbreak had a devastating impact on the mental health of healthcare workers. Out of the 1257 respondents, 50.4% were found to have symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety and 71.5% reported distress. The researchers concluded that working in the frontline was an independent risk factor for worse mental health outcomes.

Doctors at the frontlines of the pandemic are facing extremely challenging working conditions. Long grueling working hours, constant emergencies, witnessing a high death rate and a persistent struggle to save lives not just cause physical exhaustion but also result in an emotional and mental turmoil. In countries where severely ill patients exceeded the healthcare capacity to treat, doctors had to actually choose whom to treat and whom to let die. Absence of a clear treatment route is another major work challenge.

Wearing PPEs for long hours is itself a major challenge. Once your PPE is on your ability to eat, drink water or even go to the washroom is restricted. The grueling heat makes long hours of wearing PPEs worse. However, the most significant challenge is the threat from the disease itself. Being in the midst of patients every day puts doctors at a high risk of caching the infection themselves. By first week of May, over 500 doctors, nurses and paramedics had already been infected by Coronavirus in the country. An AIIMS doctors was applauded for putting himself at significant risk when he removed his goggled and face shield to be able to clearly see and re-intubate a seriously ill patient. This tells us how doctors are putting themselves at risk during this global pandemic. As doctors get infected and result in a further depletion of workforce, the remaining physicians face an even greater workload.

Apart from all the above concerns, one major concern for doctors and healthcare staff is the threat of carrying the infection to their home and families.

How to address the burnout crisis

As much as it is important to ensure the safety of doctors, it is equally important to help them address the mental and physical outcomes of burnout. Governments, healthcare providers and hospitals must initiate a series of measures to help address this burnout crisis.

Adequate availability of protective equipment

Strict adherence to properly wearing PPEs has been found to be effective in minimizing infection rate among doctor and healthcare workers. It is extremely important therefore that governments and hospitals ensure adequate supply and sufficient availability of PPEs for doctors. Adequate supply of PPEs and addressing the shortage concerns also allays the mental stress and fear among doctors. It is also important to ensure that doctors do not have to wear the same protective equipment for more than 8-10 hours.

Access to counseling and mental health experts

The World Health Organization has advised doctors to take extra care of their health by consuming healthy food, taking adequate rest and staying active. The body has also recommended de-stressing and avoiding smoking or drugs. Hospitals must ensure that doctors have regular access to counseling support to advocate healthy living. They must also have access to mental health experts to give them a proper outlet for their mental and emotional turmoil.

Offering alternative stay arrangements

Governments and private healthcare providers must also arrange for alternative accommodation for doctors and other healthcare staff members to allow them stay away from their families during the time they are treating COVID 19 patients. This takes off the extra pressure and concern about carrying the virus home.

Reduce burden by adding to the manpower

With the number of patients rising steeply every day, we need to find innovative ways to have sufficient backup resource of doctors. In this situation, it makes sense to train final year MBBS and PG medical students in critical care and keep them ready to be deployed in case the need arises.  

Continue Reading

Medically Speaking

RISING DELTA CASES AND EXPECTED HERD IMMUNITY: WHERE DO WE STAND?

Dr Rahul Pandit

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Even as India continues to fight against the deadly Covid-19 virus, SARS-CoV-2 variants are emerging, spreading and causing governments & public health experts to develop the best strategies to contain their spread constantly. There are currently 11 variants of the SARS-CoV-2 virus that the World Health Organization Trusted Source is monitoring. One of these variants, the Delta Plus variant — also known as B.1.617.2.1 or AY.1 —first detected in India, February 2021, has spread to many parts of the world. Towards the end of August, Maharashtra recorded 103 Delta Plus cases. Approximately 65% of the reported cases were amongst the unvaccinated population.  

So, how is this variant different, and can it escape vaccine protection? 

Delta Plus is a sub-lineage of the Delta variant first detected in India, acquiring the spike protein mutation K417N. In June, this variant was designated as a Variant of Concern (VoC) by the Indian government, citing its perceived increased transmissibility, ability to bind more strongly to receptors on lung cells, and potential to evade an antibody response.

Is the Delta plus variant more threatening?

The Delta variant has been held responsible for the second wave in India. Several other countries consider Delta as the factor behind a sudden surge of cases. It can be a trigger to the third wave. 

While India is battling against the Delta plus variant, few other parts of the world are bearing the brunt of C.1.2, a new SARS-CoV-2 variant. It was first reported in South Africa during May and eventually spread to China, England, the Democratic Republic of Congo, Mauritius, Portugal, and Switzerland. India has no cases of the new strain so far, and globally Delta variant is the more dominant one. However, what is of concern here is that the C.1.2 variant has a mutation rate of 41.8 mutations per year, i.e. twice the current global mutation rate of other strains, and it can evade the antibodies developed to ward off the Alpha or Beta variants. 

What impact does virus mutation have on the human body? 

The standard process of mutations impacts us when it leads to changes in transmission levels or on treatment. Mutations can have positive, negative, or neutral effects on human health. For example, negative impacts may include clustering of infections, increased transmissibility, ability to escape immunity and infect others who have poor immunity, neutralization escape from monoclonal antibodies, improved binding to lung cells and increased severity of infection.But positive impacts can make the virus becomes non-viable.

At this rate, how and when will we achieve herd immunity? 

A population is said to achieve herd immunity when large percentages of individuals become immune to a disease. Based on mathematical calculations, if vaccines could provide a lifelong, fail-safe shield against infection with SARS-CoV-2, it would need to reach 60-72% of people to establish herd immunity. But if vaccines are only 80% effective at preventing infection, 75-90% of people would need to be immunized — a high bar. 

If a third wave is triggered, a rise in infection rates may pose the toughest challenge yet for the government, owing to the weaker health infrastructure and staff availability. Robust serological surveys can show where the community is in terms of seropositivity, and in a way, low case numbers are an outcome of the spread slowing. However, in the journey towards herd immunity, many other factors determine daily case numbers and daily deaths, including the age and morbidity profile of those affected. 

Moreover, experts opine that herd immunity doesn’t confer immunity to the virus itself but only reduces the risk that vulnerable people will encounter the pathogen. 

However, most herd-immunity calculations don’t consider behavior changes, interventions, and rules. For instance, if people follow good physical distancing, the R0 (R0, pronounced “R nought,” is a mathematical term that indicates how contagious an infectious disease is) will go down, if they stop following the same after a while, the R0 will go up again. This will change the herd immunity threshold accordingly. 

Until large-scale vaccinations are made available, current forms of social distancing and use of face masks, along with all-inclusive case finding, testing, contact tracing, and isolation, need to continue. History tells us that we have never achieved herd immunity via natural infection concerning a novel virus, and SARS-CoV-2 is no different. Vaccination is therefore paramount. 

The writer is the Director-Critical Care, Fortis Hospitals Mumbai & Member-Maharashtra Covid-19 Taskforce

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