Chronic liver diseases are common worldwide, especially in developing countries. The rapid spread of Covid-19 leads to the infection of many patients with underlying chronic liver diseases. To discuss the same, we spoke to Dr Shiv Kumar Sarin, Director of Institute of Liver and Biliary Sciences (ILBS); Dr Anil Arora, Chairman, Institute Of Liver Gastroenterology & Pancreatic Biliary Sciences Sir Ganga Ram Hospital, and Dr Kaushal Madaan, principal director and head of Hepatology from Max chain of hospitals.
Q. What would be your advice regarding checkups to people with liver diseases and fear contracting Covid-19?
Dr Sarin: If somebody has cirrhosis, alcohol liver injury or cancer, they all require treatment and monitoring. So don’t put it away. Treatment for all liver diseases must be given and should not be delayed. Treatment is essential whether you opt for teleconsultation or go to the hospital. What you can do at home is to continue your diet and the prescription that the doctor has given.
Q. What would be your stand on alternative medication for liver diseases?
Dr Arora: Liver is an organ that does not require any servicing and maintenance till you intentionally or accidentally try to injure it. You don’t need any medication. You don’t need a specific diet. You don’t need any type of maintenance but do everything to prevent the damage.
Two major reasons why the liver gets damaged are if you are having too many of the calories in the diet, so initially, it gets deposited in the peripheral tissue that is subcutaneous tissue, and once those stores get exhausted, it tends to get into the vital organs. The liver is a central organ for the metabolism, production and synthesis of various proteins, and the integrated metabolism of fat, carbohydrates as well as proteins. It also is known to produce a number of coagulation and anticoagulation factors.
There have been guidelines from CDC, from our own ICMR and the Government of India and AIIMS, that stress on minimum medication. Even allopathic medicines are needed in minimum doses for a minimum duration of time. They will do more harm than good. Especially all chemicals, all ingestions, all food has to be metabolised through the liver. So anything and everything that you are taking for any purpose you have to take under the guidance of a registered medical practitioner, take it for a minimum period of time, at a minimum dose, for a minimum duration. Never self-medicate yourself.
Q. There were reports that drugs like azithromycin and remdesivir could affect the liver but they were widely prescribed by physicians. What would you say to liver patients?
Dr Sarin: Remdesivir cannot be given to patients with liver disease. Secondly, it is not proven beneficial. So I would be very hesitant to give. Azithromycin can also give liver injury. In fact, there is no reason to give these drugs if the patient has pre-existing liver diseases. Some Lancet papers stated that Covid-19 was more serious in those patients who had a BMI of about 25. In India, nearly 30%, one in three people, have a high BMI, they all have fatty liver. So, the disease is more common, more susceptible, injury is more progressive, and liver injury enzymes being abnormal or very high. Also, some people were mixing alcohol with Covid-19 pills as people were staying home and they were drinking.
Q. What would you say to those who have liver diseases, perhaps got Covid-19, have recovered and are craving alcohol?
Dr Arora: Drinking as a habit, when it is harmful for you, it is not recommended. If you look at our baseline population, which has non-alcoholic fatty liver disease coupled with so many metabolic abnormalities like diabetes, hypertension, these are all the risk factors that will aggravate the injury related to alcohol. Once in a while, socialising is understandable, but the problem is that alcohol is an addictive agent. If you look at the data from the US, the maximum number of cases that are being reported after cure from hepatitis is related to alcohol.
This is absolutely preventable. Not only on its own it causes problems, but in patients with underlying fatty liver or those with hepatitis B or C, this alcohol is an added synergistic effect to cause further liver damage. So, unless you are sure that there is nothing wrong, you should avoid alcohol.
Q. Does Covid affect more severely to liver cirrhosis and liver transplant patients?
Dr Madaan: There is ample data to suggest that patients who have the fatty liver disease will have a severe lung disease when they get Covid-19. They have very poor outcomes and more of them end up in the ICU. Patients, who are just at the stage of waiting for a transplant, are the ones with advanced liver diseases. So, if they get Covid-19, they are at high risk of dying. If they have a new liver, they already are immunosuppressed. Some schools of thought say that since they are already immunosuppressed, they’re not able to mount an immunoinflammatory response to Covid-19 so they may have mild disease. But this is a controversial issue.
Dr Sarin: If the transplant was done within the last three months, Covid-19 can be very severe, and you should act quickly. People who are on heavy immunosuppressants have rejections even after a year, and if they get a Covid infection, there is a problem again. Covid-19 does not make people’s health condition worse but they are already predisposed to other illnesses.
The liver is the root cause of diabetes and blood pressure and high triglycerides. If you have fatty liver or are obese, diabetic, comorbid, then you must look at the liver enzymes. Covid-19 gives you all a chance to lose weight. Become healthy, lean, and thin, so that unfortunately, if the third wave comes, you are strong, your liver is strong, and your body is strong.
Q. Tell us about the post-Covid care for liver patients?
Dr Sarin: Patients with liver disease have weak muscles. We call it sarcopenia. Even if they are obese, they have limited muscle power. If your liver is weak, your muscles are also weak and after Covid-19, there is extreme fatigue and loss of appetite. You have to be more careful about this and get your antibodies done if you need them. For a patient with cirrhosis after recovering from Covid-19, he needs to remember that the liver can digest more fats than pure carbohydrates. So avoid carbs. Your main diet should be protein-based and the energy source can be fat. Exercises are essential.
Dr Arora: All those who suffer from Covid-19 are likely to come down with ‘Long Covid’. There are many reasons for that. You may have a bit of virus or the immune process which may still be simmering around the body or an immune complex disease that may be present or activation of the immune system. Coming back to the liver patients, if you have a concomitant Covid, you may have multiple reasons why the liver can get affected. It may occur due to the hyperinflammatory syndrome which comes out from the lungs and gets disseminated in the body, of which the liver gets the major share of the blood. Several drugs that are given to treat Covid-19 have indirect toxicity on the liver. If you have had a recent infection, you are likely to come down with more complications. Regularly follow up with a liver specialist if you have underlying liver disease.
Q. Liver patients have compromised immunity, they may not have enough antibodies. So, is the vaccine good for them?
Dr Arora: In the initial registration trials that were conducted in the US and UK, they excluded patients who had chronic liver diseases or those with an immunocompromised state. There is data published on Pfizer’s registration trial that has shown that the chance of development of antibodies is only 20% in patients with advanced liver disease or liver transplantation. Not all those with the immunocompromised state will develop antibodies. All patients who have an immunocompromised state will not produce antibodies. But in case you have developed antibodies and can be more confident that you won’t have the viral infection, don’t be under the wrong impression that you have been protected. If you don’t have antibodies even after vaccination, you have to be extra careful. You must be extra cautious.
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Better mental health support needed for pregnant individuals during Covid-19
A team of researchers suggested that more mental health supports are needed for pregnant women after a survey found nearly three-quarters of individuals who had been pregnant during the pandemic reported moderate to high levels of distress and one in five experienced depressive symptoms. The findings appeared in the journal ‘Canadian Family Physician’. The researchers, led by clinicians at Unity Health Toronto, surveyed nearly 1,500 participants online, 87% of whom were Canadian—who had been pregnant during the pandemic. Nearly 69% of respondents reported moderate to high levels of distress and 20% had depressive symptoms.
“The high levels of distress highlight the importance of considering mental health centrally in support for this population,” said Dr Tali Bogler, study lead author and family physician and chair of family medicine obstetrics at St. Michael’s Hospital of Unity Health Toronto. “The findings also highlight the overall impact the pandemic has had on families and the downstream impact this will have,” she added. A limitation of the study is it didn’t have comparable data on distress levels among pregnant people prior to the pandemic. However, a population-based survey conducted in Japan before the pandemic found 28% to 32% of pregnant people reported distress.
Researchers also sought to learn more about the common sources of concern for pregnant women during the pandemic. Participants were provided with a list of 27 concerns. The top five concerns included hospital policies regarding support persons in labour; not being able to introduce their baby to loved ones; getting sick from Covid-19 while pregnant; not being able to rely on family or friends after labour for support; and conflicting medical information on Covid-19 in pregnancy and newborns, especially early in the pandemic. First-time parents were more concerned about the cancellation of in-person prenatal classes and hospital tours whereas second or third-time parents were more concerned about the transmission of Covid-19 from older children in the home. The authors said that family physicians are well placed to support perinatal mental health and can engage in screening practices and offer appropriate treatment such as counselling, public health nursing, and psychiatric appointments. They also recommend hospitals better utilise technology to help address parents’ concerns by arranging more virtual check-ins and hospital tours and provide more online resources with evidence-based information on Covid-19 relevant to expectant and new parents.
STUDY REVEALS MENSTRUAL CHANGES AFTER COVID-19 VACCINATION PLAUSIBLE
Some women say their periods changed after getting a Covid-19 vaccination. In a new study, Dr Victoria Male, a reproductive specialist at Imperial College London, has said that a link between menstrual changes after Covid-19 vaccination is plausible and should be investigated.
The findings of the study were published in the journal ‘BMJ’. Changes to periods or unexpected vaginal bleeding are not listed as common side effects of Covid-19 vaccination, she wrote. Yet more than 30,000 such reports had been made to the UK Medicines and Healthcare Products Regulatory Agency (MHRA) surveillance scheme for adverse drug reactions by 2 September.
However, most females found that their period returned to normal in the following cycle and, importantly, there is no evidence that Covid-19 vaccination adversely affects fertility. The MHRA states that its surveillance data does not support a link between changes to menstrual periods and Covid-19 vaccines, since the number of reports is low in relation to both the number of people vaccinated and the prevalence of menstrual disorders generally.
However, the way in which data is collected makes firm conclusions difficult, said Male. She argued that better equipped to compare rates of menstrual changes in vaccinated versus unvaccinated populations are needed and points out that the US National Institutes of Health (NIH) has made $1.67 million available to encourage this important research.
Reports of menstrual changes after Covid-19 vaccination have been made for both mRNA and adenovirus-vectored vaccines, she added, suggesting that, if there is a connection, it is likely to be a result of the immune response to vaccination, rather than to a specific vaccine component.
Indeed, the menstrual cycle may be affected by the body’s immune response to the virus itself, with one study showing menstrual disruption in around a quarter of women infected with SARS-CoV2. If a link between vaccination and menstrual changes is confirmed, this will allow individuals seeking vaccination to plan in advance for potentially altered cycles, she explained. In the meantime, she suggested clinicians encourage their patients to report any changes to periods or unexpected vaginal bleeding after vaccination to the MHRA’s scheme.
And anyone reporting a change in periods persisting over a number of cycles, or new vaginal bleeding after menopause, should be managed according to the usual clinical guidelines for these conditions. “One important lesson is that the effects of medical interventions on menstruation should not be an afterthought in future research,” she concluded.
Elevated stress hormones linked to higher blood pressure risk
In a study that included over 400 adults with normal BP, it was detected that those who had high levels of stress hormones—their urine was more likely to develop high BP over the next six to seven years. The findings of the study were published in the journal ‘Hypertension’. Higher levels of the stress hormone cortisol were also linked to an increased risk of cardiovascular events including heart attack and stroke.
Studies have shown that cumulative exposure to daily stressors and exposure to traumatic stress can increase cardiovascular disease risk. A growing body of research refers to the mind-heart-body connection, which suggests a person’s mind can positively or negatively affect cardiovascular health, risk factors and risk of disease events, and prognosis over time.
“The stress hormones norepinephrine, epinephrine, dopamine, and cortisol can increase with stress from life events, work, relationships, finances, and more. And we confirmed that stress is a key factor contributing to the risk of hypertension and cardiovascular events,” said study author Kosuke Inoue, MD, PhD, assistant professor of social epidemiology at Kyoto University in Kyoto, Japan. “Previous research focused on the relationship between stress hormone levels and hypertension or cardiovascular events in patients with existing hypertension. However, studies looking at adults without hypertension were lacking,” Inoue said. “It is crucial to examine the impact of stress on adults in the general population as it provides new information about whether routine measurement of stress hormones needs to be considered to prevent hypertension and CVD events,” he added.
Study subjects were part of the MESA Stress 1 study, a substudy of the Multi-Ethnic Study of Atherosclerosis (MESA), a large study of atherosclerosis risk factors among over 6,000 men and women from six US communities. As part of MESA exams 3 and 4 (conducted between July 2004 and October 2006), White, Black and Hispanic participants with normal BP from the New York and Los Angeles sites were invited to participate in the substudy MESA Stress 1. In this substudy, researchers analysed levels of norepinephrine, epinephrine, dopamine, and cortisol hormones that respond to stress levels. Hormone levels were measured in a 12-hour overnight urine test. The substudy included 412 adults aged between 48-87 years. About half of them were female, 54% were Hispanic, 22% were Black, and 24% were White. Participants were followed for three more visits (between September 2005 and June 2018) for the development of hypertension and cardiovascular events.
Norepinephrine, epinephrine, and dopamine are molecules known as catecholamines that maintain stability throughout the autonomic nervous system—the system that regulates involuntary body functions. Cortisol is a steroid hormone released when one experiences stress and is regulated by the hypothalamic-pituitary-adrenal axis, which modulates the stress response. “Although all of these hormones are produced in the adrenal gland, they have different roles and mechanisms to influence the cardiovascular system so it is crucial to study their relationship with hypertension and cardiovascular events, individually,” Inoue said. Their analysis of the relationship between stress hormones and the development of atherosclerosis found that over a median of the 6.5-years follow-up period, every time the levels of the four stress hormones doubled was associated with a 21%-31% increase in the risk of developing hypertension. During a median of 11.2-years of follow-up, there was a 90% increased risk of cardiovascular events with each doubling of cortisol levels. There was no association between cardiovascular events and catecholamines.
“It is challenging to study psychosocial stress since it is personal and its impact varies for each individual. We used a noninvasive measure, a single urine test, to determine whether such stress might help identify people in need of additional screening to prevent hypertension and possibly cardiovascular events,” Inoue said. “The next key research question is whether and in which populations increased testing of stress hormones could be helpful. Currently, these hormones are measured only when hypertension with an underlying cause or other related diseases are suspected,” he continued. “But if additional screening could help prevent hypertension and cardiovascular events, we may want to measure these hormone levels more frequently,” Inoue added.
A limitation of the study is it didn’t include people who had hypertension at the study’s start, which would have resulted in a larger study population. Another limitation is researchers measured stress hormones via a urine test only, and no other tests for stress hormone measurement were used.
COVID-19 ANTIBODIES PERSIST, REDUCE REINFECTION RISK FOR 6 MONTHS: STUDY
A new study has found that most patients with mild Covid-19 infections produce antibodies that persist and protect them from reinfection for up to six months.
The findings of the Michigan Medicine study were published in the journal ‘Microbiology Spectrum’. Researchers analysed nearly 130 subjects with PCR-confirmed COVID-19 illness between three and six months after initial infection. Three patients were hospitalised while the rest were treated as outpatients and experienced mild infection, with symptoms including headaches, chills and loss of taste or smell. The results revealed approximately 90 percent of participants produced spike and nucleocapsid antibody responses, and all but one had persistent antibody levels at follow-up.
“Previously, there was a lot of concern that only those with severe Covid-19 produced strong antibody responses to infection,” said Charles Schuler, MD, lead author of the paper and clinical assistant professor of allergy and immunology at Michigan Medicine. “We’re showing that people with mild bouts of Covid-19 did really well after their infection, made antibodies, and kept them,” added Schuler.
The prospective study’s participants were either Michigan Medicine health care workers or patients with a high risk of exposure to Covid-19. Most subjects took part in the same research team’s previous study, which found that Covid antibody tests are effective at predicting prior infection. During the observation period, none of the subjects who produced antibodies were re-infected, compared to 15 antibody-negative patients. Schuler’s team also found that the antibodies’ ability to neutralize Covid-19 did not differ significantly from the first visit, which occurred three months after infection, to the second visit at the six-month mark.
“While some studies have suggested antibodies against Covid-19 wane over time, these findings provide strong prospective evidence for longer-term immunity for those who produce an immune response to mild infection,” said James Baker Jr, MD, senior author of the paper and founding director of the Mary H. Weiser Food Allergy Center at Michigan Medicine.
“To our knowledge, this is the first prospective study that demonstrates such a risk reduction for clinical reinfection in this specific type of population,” added Baker Jr. The team of researchers is now analysing samples of this subject group taken up to a year after infection to further evaluate antibody responses. Meanwhile, they concluded that individuals with Covid-19 can delay vaccination for 90 days after infection ends.
The Centers for Disease Control and Prevention recommends those treated with monoclonal antibodies or convalescent plasma should wait 90 days after receiving treatment before getting vaccinated, and others should wait until they have recovered from Covid-19 and “have met the criteria to discontinue isolation.”
A study conducted in Kentucky found that unvaccinated people who already had Covid-19 were 2.34 times more likely than fully vaccinated people to be infected again, suggesting “vaccination provides additional protection against reinfection.”
Additionally, the research was conducted between March 2020 and February 2021, months before the highly transmissible Delta variant became the dominant strain of Covid in the United States. Amid rising cases and hospitalisations, Schuler said, remaining unvaccinated comes with “a high price” for immunity.
“These results are encouraging for those who have already run the gauntlet of Covid-19 infection,” he said.
“However, I do not recommend citing this study as a reason not to be vaccinated for those never previously infected. Vaccination decreases infectiousness, the risk of hospitalization and deaths from Covid-19, without having the actual infection. Achieving natural immunity by deferring vaccination in favour of infection is not worth going through the discomfort, risk to yourself and risk to others,” he concluded.
LOWER BACK PAIN: THE 10 PROMINENT CAUSES FOR IT
In India, 20 percent people of 16-34 age group are treated for back and neck conditions in India. The percentage of young population going for back pain treatment is the highest, whereas, 45% people neglect their pain for more than 7 weeks which results to delayed treatment. Seeing the prevalence, the question arises how does lower back pain happen? Our lower back has a complex structure and it’s made up of the five lumbar vertebrae – L1 – L5. These are held together to form a column, by muscles and ligaments. The lumbar spine provides support for the back and takes most of the weight of the upper body. Therefore, the lower back is more prone to back pain than the upper back because the lower part of the back bears the mechanical load.
Here are the 10 prominent causes of lower back pain, and some of them are connected to the spinal cord and nerves and others are linked to conditions:
TRAUMA OR INJURY:
Injury to low back and occur with small simple falls at home for example while walking down fast from the stairs or slipping in the bathroom. While road traffic accidents can cause very bad back injuries right from simple fractures to complete spinal cord injuries paralysing people.
Sports injuries often result in sprains and tears in muscles/ ligaments of the lumbar spine. More violent injury can cause an intervertebral disc to move out of its place like a toothpaste coming out of the tube and it creates pressure on the spinal cord.
Stooping or bad posture is the next most common cause of low back pain. Most people tend to slouch, while sitting for long hours and even while watching TV they do not take proper lumbar support. Long hours of continuous sitting can cause abnormal strain on the disc and can weaken the spinal muscles leading to back pain.
With age, our joints gradually deteriorate due to general wear and tear. The inter vertebral discs also similarly start to shrink and the nerve roots become strained. Even mobility of the spine is lost and it becomes stiff. In such a scenario, the spinal canal becomes narrowed, causing a serious condition where intense pressure on the spinal cord causes pain, numbness and difficulty walking called as neurogenic claudication.
VITAMIN D DEFICIENCY
Recognised to be another major cause for unexplained low back pain, vitamin D deficiency has come as an epidermic and can simply be treated by checking and confirming the low levels and proper exercise and supplementation of vitamin D.
Osteoarthritis and other type of arthritis including Rheumatoid arthritis and ankylosing spondylitis eventually affect our lower back. When arthritis occurs, it causes inflammation within the joints, erosion of cartilage and bone and consequent pain weakness of muscles.
REFERRED PAIN FROM ABDOMEN OR KIDNEY STONES.
When there is no structural or functional issue in the spine, still low back can happen due to referred in from Intra abdominal organs and kidney stones. Kidney stones can cause pain in the mod and lower back.
Backache or back pain is quite common during pregnancy, especially in the early stages. When a woman conceives, the ligaments become softer and it starts getting stretched to get her all set for the labour. This can put a strain on the joints of your lower back and pelvis, which can cause back pain.
Many spinal tumours don’t have any symptoms but there are some that cause extreme back pain and neurological shortfalls including numbness and weakness. The location of the tumour in the spine plays a crucial role. It actually destroys the healthy tissue such as the vertebrae (bones) in the spine, leading to back pain. About 70% of spinal tumors are located in the thoracic spine, which is located in the upper and middle part of the body.
CAUDA EQUINA SYNDROME
This is a emergency condition in which ruptured disc presses on the spinal cord causing symptoms in the lower limbs, and sometimes the bowel and bladder. If untreated it can result in permanent neurological damage and needs urgent surgical intervention.
The use of natural ingredients and therapies in daily needs for stable mental well-being
Our physical body responds to our mind’s interpretation of external sensory perceptions. Most of us feel good when we see a beautiful scene, a happy expression makes us feel relaxed, music has the ability to sooth us or excite us and even sadden us at times. Tasty food makes us feel pleasure and aroma therapy is based on the ability of pleasant sensory perceptions of smell to affect our mood and emotions.
So it’s but obvious that natural environment around us can be modulated to produce greater mental well-being.
Alternative and natural therapies are based on adding elements in our environment that are known to enhance a sense of well-being. These can include one or several sense organs.
1. Touch- A massage always works wonders when we feel tightness in our muscles. From Ayurveda to Physiotherapy, acupressure to socio cultural practices of massage, all rely on touch and pressure modalities to induce relaxation in body which has positive feedback effect of relaxing the mind and giving a sense of well-being. Many research papers have been published on effect of touch in modulation of feelings and emotions in normal population as well as people suffering from autism, mood disorders and even physical symptoms.
2. Vision- How do we feel looking at a dark, dirty space? And now imagine looking at blue skies, blooming flowers, gurgling waterfalls! ‘A thing of beauty’ is not just joyful for poets and writers but for everyone. Visual Imagery related relaxation techniques are based on using calming visions to help in relaxation exercised. Similarly, watching violence in real or virtual world increased release of adrenaline and other stress hormones which cause physical and mental stress leading to mood disturbance, anger, irritability and consequent physical manifestations of body aches, headaches and gastrointestinal side effects. Therapies and therapy environment are thus kept simple, spacious and pleasant to senses to induce a sense of well-being both as part of natural loving or illness management.
3. Hearing- The energy of sound is used widely in medical fields for how it affects cellular vibrations and hormonal secretions. Use of music is an age old method of improving mental well-being. From chanting mantras to latest sound baths, all rely on how pleasant sounds make us feel better. The negative impact of harsh sounds is all too understood and has even be utilised for criminal interrogation as means of breaking down people. The opposite is obviously true as well and hospitals, ICUs in modern medical facilities and surgeons in operation theatres use music to uplift mood.
4. Taste- According to Ayurvedic system of living, food makes us who we are and various flavours and combinations of edible products have the ability to affect our emotions. In psychiatric parlance, the disorders around stress eating and impact of sweet and bitter flavours is widely studied. It’s also well known that mood affects the taste of food. Alternative therapies have thus used taste and aromas to help create positive and relaxed mental states.
5. Smell- Aroma therapies need no introduction. Smells are potent memory stimulants and emotions of certain remote past are often felt intensely if associated with a certain smell. Thus use of lavender fragrance for calming the mind and inducing sleep, Jasmine fragrance for uplifting mood and desire, cinnamon fragrance for improving concentration etc are commonly known applications to improve mental well-being.
Other than the sensory impressions, natural therapy relies on diet, exercises and daily rituals which are supposed to improve wellness and keep illness at bay. The use of fresh and locally available ingredients, evidence based use of herbs and spices for boosting relaxation and immunity, yogic poses and breathing techniques and daily rituals of bathing and grooming along with spiritual norms and practices like prayer, gratitude and faith etc all come together to maintain a healthy lifestyle for a healthy mind and body.
The writer is a Senior Psychiatrist and Founder & Director of ‘Manasthali’
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