In a year when the pandemic of a communicable disease has pervaded human consciousness and health systems alike, it appears a bit incongruent to talk about chronic non-communicable diseases (NCDs) such as diabetes. However, NCDs have cast their shadow on even Covid-19, and there is unequivocal evidence that people with diabetes and heart disease demonstrate a significantly higher risk of adverse clinical outcomes including death. Such observations serve as a reminder that despite contemporaneous discussion and debate seemingly exclusively focused on how best to tackle the onslaught wreaked by SARS CoV-2, we cannot afford to take our foot off the pedal, that is prevention and control of NCDs. This year, World Diabetes Day was observed on 14 November 2020, with the theme “The Nurse and Diabetes” signifying and recognising the role of the nurse in providing essential care to patients with chronic conditions.
Diabetes and hypertension together are among the most common and deadly chronic conditions affecting over 275 million Indians and their families. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled.
Recognising the gravity and magnitude of this problem, the Ministry of Health & Family Welfare, Government of India, has implemented a strategy to integrate screening and management of these conditions into primary care under National Health Mission (NHM) and the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke (NPCDCS). A major component of the government strategy is to encourage universal screening for hypertension and diabetes of adults aged ≥30 years in the community and subsequent referral of potential cases to higher-level facilities.
This effort starts at the grassroots, with frontline workers— Accredited Social Health Activist (ASHA)—identifying individuals at high risk, referring them for screening at rural sub-centres, from where individuals are then sent up the pyramid of health care institutions, for confirmation of diagnosis and appropriate management. The establishment of health and wellness centres has strengthened this effort. A further fillip has been provided by creating an information technology backbone in the form of a digitised health record which is then accessible to health care professionals as the patient traverses up and down the health system.
Building on this platform, an innovative new initiative, the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) programme has been implemented as a pilot effort in District Shaheed Bhagat Singh Nagar in Punjab. This programme, resulting from a technical collaboration between the All India Institute of Medical Sciences, New Delhi (AIIMS), Centre for Chronic Disease Control (CCDC), and Emory University has been embedded within the existing infrastructural and administrative scaffolding provided by the government of Punjab.
This first of its kind hybrid model has two core components: Technology and task shifting. The technology component is an integration of two entities—an Electronic Case Record Form (eCRF) superimposed on which is a Clinical Decision Support System (CDSS)—that generates customised evidence-based treatment advisories for patients with diabetes and hypertension. The CDSS algorithms provide the clinician with an instantaneous advisory regarding medication titration based on patient history and current clinical examination as inputted into the eCRF.
To enable the efficient implementation of this process, the fulcrum of care has been shifted from the physician to the nurse provider. The clinic workflow is now modified such that it is the nurse who first interacts with the patient, adds information to the electronic case record form, following which the CDSS working at the backend generates guideline-based recommendations for the physician. Physicians thereby receive a suitably triaged patient with a draft management plan based on evidence-based guidelines, which ensures efficient utilisation of their time and enables objectivity in decision making. Since everything is digitised, the patient record can be seen at any level of the government health facility enabling seamless care, delivery of routine care, and facilitating clinically-mandated referral to an appropriate facility.
This nurse-facilitated, technology-assisted model of care, which has now successfully been implemented in rural Punjab stands at the threshold of wider dissemination – and is a significant endorsement of the theme of the World Diabetes Day 2020 – “The Nurse and Diabetes”.
Dr Nikhil Tandon and Hanspria Sharma are from the department of endocrinology and metabolism at All India Institute of Medical Sciences, New Delhi.
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Obstructive Sleep Apnea (OSA)
Poor sleep induces excessive daytime sleepiness, morning headache, dry mouth, inattentiveness & irritability are the common presenting symptoms. OSA has a great impact on quality of life at school, working place & at home.
Sleep apnea & hypopnea is a sleep disorder in which cessation/ reduction of respiratory effort at the nostril level for a few seconds to a few minutes. It is subdivided into central, obstructive & mixed types. Obstructive sleep apnea (OSA) is the commonest subtype. Sedentary lifestyle, faulty eating habits & lack of physical activities are the predisposing factors for obesity. The collection of fat within & around the upper aerodigestive tract reduces the dimensions of the airway lumen which increases the turbulence in the air current. Snoring is induced by turbulent airflow during sleep. The snoring loudness increases with the severity of airway narrowing. The anatomical abnormalities (nasal, nasopharyngeal, oropharyngeal, hypopharyngeal & laryngeal) is generally responsible for OSA in young patients. Abnormal anatomy can worsen the symptoms of obesity-related OSA. The commonly found anatomical abnormalities are a deviation of the nasal septum, hypertrophy of inferior turbinate’s, adeno-tonsillar hypertrophy, retrognathia, weak epiglottis & mass lesions of upper aerodigestive tract (nasal polyposis, bulky tongue). The reduced muscle strength secondary to the fat deposition in & around the upper aerodigestive tract is unable to maintain the adequate airway lumen required for healthy sleep. The moderate to excessive narrowing of the airway lumen, easy collapsibility of pharyngeal part of airway & induced negative pressure distal to the site of obstruction generates partial to complete blockage of the airway. The oxygen level in blood decreases in OSA due to the reduced volume of available air for gas exchange at the lung alveoli level. The arousal episodes occur during sleep due to induced signals from the brain when blood oxygen level reaches below a threshold level. Poor sleep induces excessive daytime sleepiness, morning headache, dry mouth, inattentiveness & irritability are the common presenting symptoms. OSA has a great impact on quality of life at school, working place & at home. Daytime sleepiness increases the chances of road traffic & household accidents. The induced negative pressure in the airway, episodic fall in blood oxygen level affects almost all of the body systems. OSA increases the risk of stroke, & heart attack by many folds. Polysomnography helps in differentiating OSA from other mimicking diseases.
A multidisciplinary approach is required to manage the OSA. A detailed airway assessment is required from the ENT doctor for anatomical features. The site of airway narrowing is determined by a combination of clinical assessment with site localizing investigations. Apneograph, sleep MRI & DISE are investigations used by ENT surgeons to localize the site of obstruction. The site-directed surgery increases the long term effectiveness of surgery. The majority of anatomical abnormalities are correctable by surgical intervention. Young age OSA can be completely reversed by surgical correction in abnormal anatomy patients. The severity of obesity related to OSA can be reduced by a healthy lifestyle, regular exercise, balanced diet & correction of the sleeping position. PAP therapy is mostly followed treatment for obesity-related OSA. The machine maintains the blood oxygen level during obstructive episodes but the long term compliance falls around 50%. The correction of abnormal anatomy can remove and/or increase the compliance of PAP therapy. Surgical success is persistent if an OSA patient follows a healthy lifestyle.
The author, Dr. Hitesh Verma, is an Additional Professor(ENT) at AIIMS, New Delhi.
EVERYTHING YOU NEED TO KNOW ABOUT WORK FROM HOME AND SPINE ISSUES
While working from home has many personal and professional benefits, but have you ever thought that it is actually making you susceptible to spine related issues due to your poor posture during work. Since most of us are working long hours in this new set up, the uncomfortable chair and no break within the work are all leading to back pain.
Here are some of the things you need to keep in your mind:
One needs to take care of his/her posture to relieve the stress from the elbows and neck. When we sit for a long time, our ‘S’ curve of the spine changes into ‘C’ curve, thereby putting more stress on your muscles, ligaments and tissues. Below are the tips for right posture:
• Your ears should be over your shoulder
• Elbows should be by your sides with wrists comfortably resting on a round or soft surface
• Support your back with your chair, using a small lumbar pillow or towel roll.
• Feet should be flat on a surface. If they don’t reach the floor comfortably, use a footrest.
Adjust your seat
When you are working on a laptop, it’s necessary to adjust your seat so that it can be comfortable for your eyes as well as your back. Your eyes should be lined up 3 inches below the top of your screen if using a desktop computer, or tilt your laptop screen back to 120 degrees. The screen should be at least an arm’s length away.
Change your position frequently
Don’t get immersed in your work. Take small breaks. Instead, try to get up every 45-50 minutes, even if it’s just to walk around the room. Our body comprises 360 joints and they all need to move in order for the proper circulation of blood. Therefore, stretch breaks are important and try out these stretching exercises:
• 3 big shoulder circles moving shoulders backward.
• 3 neck rolls from neck to shoulder; roll forward along the chest to the other shoulder.
• 2 large breaths to fill your lungs and then blowing air forcefully out.
• 5 squats in front of your desk chair.
Exercises for a stronger back
Exercise can help strengthen and support your back. A scheduled walk, every day for 30 minutes, can do a lot to strengthen your lower back and the muscles that support your spine. Other great exercises for your back include:
• Knee to Chest Stretch
• Chin to Chest Stretch
• Ear to Shoulder Stretch
• Hip Stretch
• Back Flexion Exercise
One needs to make exercise a priority to get rid of the spinal issues. There are many great and effective home workouts that you can do with basic household items. These are just a few simple steps you can take to help relieve back pain. If you still are struggling with pain that interferes with your daily life, consider talking to a specialist.
(The author is Dr.Shubhang Aggarwal, senior joint replacement surgeon ,NHS Hospital Jalandhar)
Youth with ASD should be screened for cholesterol levels
According to the physicians at Kennedy Krieger Institute, children with autism spectrum disorder (ASD) should be screened for abnormally high or low cholesterol levels at least once during their childhood.
The recommendation resulted from a recent study that found reduced levels of high-density lipoprotein cholesterol (HDL-C), known as the good cholesterol, in individuals from families with two or more children with ASD. In addition, they found reduced or elevated levels of other lipids, apolipoprotein A1 (ApoA1) and apolipoprotein B (ApoB). Individuals with low HDL-C levels or ApoA1 levels had lower adaptive functioning than other individuals with ASD.
Autism Speaks funded part of this study and supplied the plasma samples from participants in the Autism Genetic Resource Exchange (AGRE). Physicians and researchers from the National Heart, Lung and Blood Institute of the National Institutes of Health also participated in the research. Physicians from Children’s National Hospital assisted with the cholesterol recommendations.
This latest research is part of our ongoing work to understand some of the co-occurring conditions with ASD,” said Elaine Tierney, MD, a child and adolescent psychiatrist with Kennedy Krieger Institute.
“Our work indicates that lipids are abnormal in many individuals with ASD. Our findings, in addition to studies that show an increase in heart disease in individuals with ASD, lead us to recommend that children with ASD be screened for abnormal total and HDL cholesterol levels. We hope our work underscores the importance of cholesterol screening and raises awareness for families in the ASD community,” she added.
Prior to the completion of this research, Dr Tierney and her colleagues identified that Smith-Lemli-Opitz Syndrome (SLOS), a genetic condition of impaired cholesterol biosynthesis, was associated with autism. A 2007 study completed by her and other researchers led to a recommendation that all children with ASD be screened for SLOS if they exhibit some of its characteristics, such as slow growth, microcephaly, mental retardation and other birth defects, although the severity of this rare disease can vary.
As an extension of this latest study, Dr Tierney and researchers with the Department of Genetics, Genomics and Informatics at the University of Tennessee Health Science Centre are performing analyses of whole-genome sequencing data with study participants to determine if there are lipid-related genetic alterations in patients with ASD and abnormal lipid levels. A next step for the research team is to study populations of individuals who have only one person in their family with ASD to see if the abnormal cholesterol and other lipid levels are different in those families than they are in families with at least two individuals with ASD.
The study was funded by Autism Speaks, the Smith-Lemli-Opitz/RSH Foundation, the U.S. National Institutes of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Heart, Lung and Blood Institute, the National Human Genome Research Institute and the National Centre for Advancing Translational Sciences.
The Study has been published’ Translational psychiatry Journal’.
Regular exercise decreases risk of pneumonia, death: Study
According to new research, people who exercise regularly have a lower risk of developing pneumonia as well as dying from it.)
The benefits of regular exercise are well-known and can reduce the risk, length or severity of infectious diseases. Previous research had suggested that regular exercise might be associated with a reduced risk of pneumonia, but the studies have had mixed findings with some reporting evidence of a relationship and others no evidence.
The researchers carried out a pooled analysis of all published studies to re-evaluate the relationship between regular exercise and the risk of developing pneumonia.
The questions the study aimed to answer included:
1. Is there an association between regular physical activity and future risk of pneumonia?
2. If there is an association, what is the strength and nature of the association?
3. If there is an association, is it stronger or weaker in specific groups of people?
The study found people who exercise regularly had a lower risk of developing pneumonia and pneumonia-related death compared to those who were the least or not physically active. The relationship was shown for cases of pneumonia that did not result in death and those that resulted in death. The results did not change on taking into account known factors that can affect pneumonia such as age, sex, body mass index, socioeconomic status, alcohol consumption, smoking, and pre-existing diseases. The strength of the association did not vary by age or sex.
Dr Setor Kunutsor, Senior Lecturer in Evidence Synthesis in the Bristol Medical School: Translational Health Sciences (THS) and corresponding author on the paper, said, “In this first-ever pooled analysis of all studies conducted on the topic, we found strong and convincing evidence of a relationship between regular exercise and reduction in a person’s risk of developing pneumonia as well as death from the disease.”
“Though our study could not determine the amount and intensity of physical activity, which is essential to prevent pneumonia, some of the results suggest that walking for 30 minutes once a week has a protective effect on death due to pneumonia,” he added.
“During the winter months and with COVID-19 still circulating, developing severe pneumonia from COVID-19 and other respiratory diseases is a common occurrence. Taking regular physical activity could reduce the risk of respiratory diseases such as COVID-19 especially in at-risk groups like older adults and those with underlying health conditions,” he explained.
The research did not prove cause and effect and further studies are needed to show if the associations demonstrated are causal. Also, additional work should be carried out to confirm the amount and intensity of physical activity, which is essential for the prevention of pneumonia or pneumonia-related deaths.
Finally, because the regular exercise was self-reported, the values could be biased so future studies should focus on accurately assessing physical activity with the use of accelerometers or pedometers.
Pneumonia is an infection of the lung tissue usually caused by bacteria or viruses and is a leading cause of death among older people, the young, and people with pre-existing health conditions. In 2016 the disease was the fourth leading cause of death in the world.
Pneumonia is also associated with ill health, reduced quality of life, and high healthcare costs. Smoking, heavy drinking, respiratory conditions such as asthma, and chronic diseases such as diabetes and kidney disease, are well known to increase the risk of pneumonia, which is a preventable cause of death and disability.
The study’s findings added to the well-documented evidence that regular physical activity has the potential to reduce the risk of several chronic diseases, infectious diseases such as pneumonia, as well as death. Physical activity has huge benefits on overall health, as well as reducing healthcare costs caused by pre-existing health conditions.
(The Study has been published in the Geoscience Journal ‘)
FEMALE HYGIENE DURING HIGH HUMIDITY
As we are all aware, the months of July to September is the time when humidity is at its peak causing onset of many skin problems causing great discomfort to most.
In my 20 years of practice as a gynecologist, I have noticed the particular onset of rashes, itching and discomfort in most women in their intimate areas in this weather. The most common reason for this is high humidity which leads to thriving bacterial and fungal infections.
Most women complain of itchiness causing them discomfort to this extent that they are unable to even sleep at night and carry out their daily office and household chores.
Extreme wetness due to wearing of synthetic underclothes, improperly dried undergarments or keeping poor personal hygiene are the most common underlying reasons. If one is overweight or obese ,one tends to sweat even more which aggravates the condition.
Also women with preexisting diabetes are more predisposed to this condition because thrush and bacterial infections tend to thrive in uncontrolled diabetes. In diabetes, the ph of the vagina is altered due to which common fungi on the skin like thrush grow in copious amount causing severe infections. Lack of adequate fluid intake, physical activity and intake of diet which does not have adequate fruits and veggies leads to growth of harmful bacteria on the skin which in extreme cases even lead to foul odor and skin discolouration in many instances.
The only way to prevent this problem of itching and rashes in females is by wearing dry, loose and cotton underclothes. Keeping blood sugar under strict control , maintaining weight and taking a healthy well balanced diet with daily physical activity can prevent this condition from happening. Over the counter intimate washes and ointments do more harm than good, so before reaching out for your attractively packaged jar at your local chemist, make sure you are doing the above.
(The Author is Dr Ritu sethi, senior consultant, Gyenaecology, cloud nine hospital)
UNDERSTANDING IMPACT OF SHAME ON HIV PATIENTS BETTER MAY IMPROVE HEALTHCARE: STUDY
A new study has found that ensuring healthcare workers better understand the psychological, social and physical impacts of shame on HIV patients could lead to improving their medical treatment.
Doctors and nurses should be more aware of how shame related to stigma can contribute to ill health, especially in experiences of chronic illnesses such as HIV.
Shame can act as a chronic stressor that can lead to psychobiological changes in the body which can exacerbate physical conditions. It can also lead to a range of behaviours and outcomes which can negatively affect health treatment.
Professor Luna Dolezal, from the University of Exeter, who carried out the research, said, “The experience of shame, particularly shame anxiety, is central to understanding how stigma causes harm, especially in experiences of chronic illness such as HIV. Shame is not only part of the affective climate when considering HIV disclosure, prevention and care, but also one of the core mechanisms within HIV-related stigma that lead to distress, harm and an increased burden of illness.”
“If we want to understand how health-related stigma, and its related social phenomena, are experienced by an individual and how this might impact on health-related behaviour and health outcomes, then we must understand how stigma-related shame is experienced. Theorizing the potential for shame, or shame anxiety, as a structural possibility in experiences of stigma may be a powerful means to understand the mechanisms through which stigma can cause distress and exacerbate negative health outcomes,” Luna added.
Professor Dolezal examined how Welsh rugby player Gareth Thomas publicly disclosed his status as HIV-positive in 2019. He decided to make a public statement because there was a possibility that his HIV status would be revealed without his consent.
In his emotive testimony in a Twitter video and subsequent media interviews and a BBC documentary, he described what it is like to live with the fear of being found out. He described his reasons for concealing his illness, and the anticipated consequences of its revelation, and how he wanted to discuss his HIV diagnosis to lift the burden of shame.
The study argued that when people felt the threat of shameful exposure regarding their HIV status they can feel “immobilised” because their possibilities for action, engagement, and sociality may be reduced. They can be disempowered socially and politically. This is compounded by intense negative feelings regarding oneself and one’s social standing.
(The Research has been published in the “lambda nordica Journal “)
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