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How does underlying Cirrhosis influence Covid-19?

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Experts recommend treatment and follow-up care for people with chronic liver disease.

Chronic liver diseases are common worldwide, especially in developing countries. The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/(COVID-19) leads to the infection of many patients with underlying chronic liver diseases. To discuss about the same, we interviewed Dr. Shiv Kumar Sarin, Director of Institute of Liver and Biliary Sciences (ILBS); Dr. Anil Arora, Chairman, Institute Of Liver Gastroenterology & Pancreatico Biliary Sciences Sir Ganga Ram Hospital and Dr. Kaushal Madaan, principal director and head of Hepatology from Max chain of hospitals.

Question: Since there is a lot fear among people as far as Covid is concerned, how should a liver patient, someone who perhaps has fatty liver, liver cirrhosis, how should they go about their regular checkups? Should they visit hospitals? Should they consult you all over? What are they supposed to do?

Dr. Sarin: First of all we should know that liver is located on the right side of the body and weighs a kilogram and a half. It is one of the largest organs in the human body. If you put a lot of stuff on the liver, then it is not a healthy liver. If there is extra fat for too long, the liver will shrink and it may become fibrous, discard and late stages of cirrhosis.

Question: Those who already perhaps have these diseases, they also have a lot of apprehensions as far as their regular checkups are concerned, because that’s also extremely important for them. Should they skip it as of now, should they visit hospitals, or should they stick to video consultation? What would be your advice to those who already have liver diseases, but perhaps don’t have Covid, have an anxiety or fear of Covid in the back of their mind.

Dr. Sarin: Those who have fatty liver certainly are not having the disease. Fatty liver itself is just extra fat. But if somebody has cirrhosis and he knows somebody who has got alcohol liver injury or has 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 use a teleconsult or go to the hospital. What you can do at home is, of course, continue your own diet and the prescription that the doctor has given.

Question: We all know that because of the fear of Covid, there is a lot of concoction of medicines which many of us are consuming already. There are alternate medications that many people are taking. There were reports that Giloy could cause some liver damage, then later there were reports no it doesn’t do that.

What would be your stand on this alternative medication when it comes to avoiding Coronavirus or just taking these medications as a precaution?

Dr. Arora: Liver is an organ that does not require any servicing, does not require any maintenance till you intentionally or accidentally try to injure it. You do not need any medication. You do not need a specific diet. You do not need any type of maintenance, but do everything to prevent the damage.

Two major reasons why the liver gets damaged is, if you are having too much 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 integrated metabolism of fat, carbohydrates as well as proteins. It also is known to produce a number of coagulation and anticoagulation factors.

In fact, there have been excellent guidelines from CDC, from our own ICMR and the Government of India and AIIMS, which tell us that we need 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 metabolized 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.

Question: But I specifically mentioned giloy because there is a lot of debate around it. And also it’s not just giloy, but a lot of as I said ayurvedic, alternative medication which people are taking. Dr. Kaushal, would you also perhaps tell your patients to stay off this concoction of alternative medicine, medicine that claim to be herbal and perhaps give you better immunity against Coronavirus?

Dr. Kaushal: These herbal and alternative medicines, even before this pandemic of Covid started, we have been advising our patients, whether or not they have underlying liver disease, to avoid taking herbal medicines of whose ingredients we are not sure of. When this pandemic came, we realised that there were many patients who were coming into us with unexplained liver failure and liver injury and some of them had even died. Only after a few months, we realised that they were taking a concoction and the most common ingredient of that concoction in these particular patients was Giloy. In fact, you would have recently seen a publication published in an indexed journal that presented about five or six cases similar to what I have been talking about and I think all of us would have seen such cases. See, how we make a diagnosis is by the exclusion of all other possibilities. We could not find any cause and only this thing stood apart, as patients were using kadhas… I don’t know what kind of mixtures they were having, what kind of concoctions… Two times a day, three times a day, for almost a year they were having it and they landed up with liver injuries. So I definitely think that these are the culprits in such cases.

Question: Could it also affect a healthy patient, someone who has a healthy liver and they start to take alternate medication? What would be your advice to them?

Dr. Sarin: Any medicine whether allopathic, homoeopathic or ayurvedic or preparation can be harmful or beneficial. I do not know much about the homeopathic or allopathic medicines. I can certainly say that there are certain herbs that can be harmful. No medicine should be consumed without a scientifically proven safety.

Secondly, a healthy liver is a necessity for better immunity. As far as covid is concerned, the infection initially transits to the lungs and then to the liver where it finally settles. This is called bystander hepatitis. Bystander implies that whatever Corona does, harm to the liver is possible.  has severe Covid, he will have something like 70% of them will have liver enzymes being normal. In mild Covid, 10-20% will be having liver enzymes normal. Food can injure the liver, drugs which are taken, preparations that are taken, all can cause injury to the liver.

Question: Talking of drugs, there were reports that azithromycin, remdesivir, those drugs could also affect the liver, but they were widely prescribed by physicians. What would you say to liver patients? Should they stay off these drugs? And those who get serious, perhaps their families are told to administer remdesivir. What are they supposed to do then?

Dr. Sarin: So, remdesiver 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. If you have read some very interesting Lancet papers, Corona 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. Secondly, if somebody is also mixing alcohol with Corona pills and ppl were staying home, they were drinking.

Question: Dr. Arora, I know a lot of patients, not liver patients but younger ones who are comorbid, have diabetes etc. The day they recovered, the first question they have in mind is that can I have a drink now? What would you say to those who have liver diseases, perhaps got Corona, have recovered and are craving a drink?


Dr. Arora: See 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, socializing 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 something that 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.

Question: Does Covid affect them more severely if they have liver cirrhosis? And what about those who have had a liver transplant?

Dr. Kaushal: There is ample data to suggest that patients who have fatty liver disease have a very severe lung disease when they acquire Covid. They have very poor outcomes and more of them end up in the ICU, end up with ventilatory support. Patients who are just at the stage of waiting for a transplant, are the ones who have advanced liver diseases. So, obviously, if they acquire 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 immunossuppressed, they’re not able to mount an immunoinflammatory response to Covid so they may have mild disease. But this is a controversial issue and more and more data is coming in.

Question: Is the severity or risk of Covid a lot more once they catch it? Secondly, is the treatment for them different? Is it special treatment or they take the same medication as the general population who catches the virus? And if someone has liver disease, generally when people catch Covid, they go to general physicians. Should they also consult their liver doctor in the loop about the medications they are taking?

Dr, Sarin: If the transplant was done within the last three months, corona 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 corona infection, there is a problem again. Corona does not make people worse, but they are already predisposed to other illnesses.

Liver is the root cause of diabetes and blood pressure and high triglycerides. If you have fatty liver or is obese, diabetic, is comorbid, he must look at the liver enzymes. Covid 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.

Question: What about liver patients? Once they recover, what is the post-Covid care that they need? What are the tests which are required and why would you say they shouldn’t throw caution to the wind? Perhaps why would you say that those who have liver diseases have recovered from Covid should still be cautious and should still measure their parameters? 

Dr. Arora: All those who suffer from Covid are likely to come down with something called ‘Long Covid’ There is a multitude of reasons for that. You may have a bit of virus or the immune process which may still be simmering around the body. Or you may have an immune complex disease that may be present or activation of the immune system. Now coming back to the liver, in patients with liver disease, if you have a concomitant Covid, you may have multiple reasons why the liver can get affected. It may occur because of 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.

A number of drugs that are given to treat Covid have indirect toxicity on the liver. If you have had a recent infection, you are likely to come down with more complications. You have to regularly follow up with a liver specialist if you have underlying liver disease.

Question: what would you tell all your patients, should they go, and get vaccinated at the earliest? Perhaps it is these patients who already are susceptible, who already have compromised immunity, who need to get vaccinated at the earliest.

Dr. Kaushal: I totally agree. I feel that there is a lot of vaccine hesitancy, especially in patients who have comorbidities. Since they have an underlying disease, they have anxiety that whether the vaccine will suit them or not or whether it is going to cause harm to them. So we keep getting phone calls and patients want to ask one thing that should we get vaccinated? So answer for all of that is whether they have early liver disease or advanced liver disease, they are best in a vaccinated state. So they should all get vaccinated, whichever stage of liver they are in. Because if they don’t take and if they have advanced liver disease and if they catch the infection then definitely the outcomes are going to be worse. So one-line answer is that any patient who has any kind of liver disease must take a vaccine.

Question:  What is the post-Covid care? I would like to ask you also this question because a lot of people seem to be ignoring that.

Dr. Sarin: First, patients with liver disease have weak muscles. We call it sarcopenia. Even if they are obese, they have very limited muscle power. If your liver is weak, your muscles are also weak and after Covid there is extreme fatigue, loss of appetite. You have to work extra, be more careful about this, and get your antibodies done if you need them.

The second important thing for a patient with cirrhosis after Covid is gone is to remember that the liver can digest more fats than it can digest pure carbohydrates. So just avoid carbs. Your main diet should remain protein-based, good whey protein or something and then next, the energy source can be fat. But yes exercises are very essential. It’s very difficult for patients who have got cirrhosis and Covid.

Question: A question that comes to the mind of liver patients is that they already have compromised immunity, they may not have enough antibodies. So, is the vaccine even good enough for me? What if I don’t end up making antibodies?

Dr. Arora: If you look at the various registration trial which was conducted in both US and UK, the initial registration trial excluded patients who had chronic liver diseases or those with an immunocompromised state. In fact, there is data published on Pfizer’s registration trial which has shown that in patients who have advanced liver disease and those who had undergone liver transplantation, the chance of development of antibodies is only 20%. So 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 you can be more confident that you won’t have the viral infection, do not be under the wrong impression that you have been protected. If you do not have antibodies even after vaccination, you have to be extra careful. You have to use double the precaution which a normal person uses. You just cannot move out to public places. You must be extra cautious.

Question: As we conclude what will be your one message to all the liver patients, all those who are suffering from liver diseases, one as far as prevention is concerned and two, in case they get Covid?

Dr. Kaushal: So I think in terms of prevention, I think everyone knows in the last one and a half years what they have to do in order to prevent getting Covid, that is masking, social distancing and washing hands. So that is one message which is true even for patients who have underlying liver disease. Second, they should not fear. Patients who have the early liver disease may not fear. They will have outcomes that are similar to the normal population. Only, those patients who have advanced liver disease, advanced fatty liver, obese, diabetic and post-transplant patients are the ones who need to fear and therefore need to take more precautions and they should get vaccinated as early as possible. And they should avoid like we said the herbal and these kinds of concoctions which contain unscientific mixtures of medicines that might harm the liver. So these are my messages.

Question: What would you say to assuage the fear of perhaps those who already have liver diseases and generally have a fear of Covid? We were speaking earlier of transplant as well, should perhaps people keep such procedures at bay or go ahead with them?

Dr. Sarin: Well the first message for those who do not have liver diseases is to reboot yourself. Lose weight, be careful. Only a healthy body will sustain the onslaught of any Covid infection. So be ready and be healthy. For those who have liver disease, be extra cautious. Transplants are going on and in fact, nearly a hundred have been done during the Covid era at ILBS and I’m sure at many many other centres. So please if you need a transplant, you should go, get yourself transplanted. But yes those who are not… one in a hundred gets a transplant, all other patients, 99 out 100 please be careful. Be in touch with your doctors and specialists. Do not miss your drugs and get your regular screening done. Must get vaccinated for Covid and do not let your guards down. Have Covid appropriate behaviour. You will live normally and you will pass through this Covid. Don’t be worried. But be careful, don’t make a mistake. 

Question: as far as Covid is concerned, we were speaking of course in extensive detail about managing your liver diseases, preventing Covid. Final question for those who have liver diseases, should they continue the medication which they were taking earlier or should they halt at a time when they have Covid and perhaps are taking Covid medication coz there is a lot of confusion amongst the laymen on the same?

Dr. Arora: Ya. I think almost all medication that is necessary for the management of liver diseases can be continued under the supervision of a trained doctor. That goes without saying. We have very few active Covid cases now and I am sure that doctors are good enough to know what sort of combination is safe for them. Coming on to the message that I have to give. Starting with what Dr. Sarin said about the liver on the right side, I think you should always listen to your heart. The heart is always on the left side but it is always right. So if you have learnt any lesson during this devilish perfidious second wave which has killed millions of people. If you have learnt something then have some civility, behave properly, get vaccinated and do not just move out of the house. You should remember till everybody is safe, you cannot be safe. The whole world has to get vaccinated before you can lower your guard. So listen to your heart if you have understood something from this devilish virus.

One clear message coming from all the doctors collectively here is that prevention is better than cure. Stay home. It gains all the more significance considering we have those viral pictures of people holidaying in Manali. Don’t do that. We have these doctors who are working a lot for us. Let’s keep ourselves safe.

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Medically Speaking

Punjab populace more hypertensive than the nation: NFHS Survey

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When the national average is 25.3% in terms of hypertension prevalence, Punjab is shooting up at 35.7%. As per National Family Health Survey that was conducted in 2020-2021, it is clear that Punjab is the only state where the populace is more prone to hypertension than any other state in India. All thanks to trans fat and the lifestyle of Punjabis makes them easy victims of cardiovascular diseases.

The Daily Guardian spoke to the Community Medicine Professor Dr Sonu Goel on this. Dr Goel exhorted that it has been concluded in many surveys including the NFHS survey that trans fat is an invariable component of industrial fat and one of the major dietary factors associated with cardiovascular disease mortality, increasing the risk of heart disease by 21% and deaths by 28%. Many in the early age group of 35 to 50 years in Punjab have become victims of uncontrolled high blood pressure, says Dr Goel.

“It’s being seen in people with a family history of premature chronic heart disease or stroke and a raised triglyceride level. Besides this, modifiable risk factors include unhealthy diets, excessive salt consumption, a diet high in saturated fats and trans fats, and low intake of fruits and vegetables,” says Dr Goel.

“Non-communicable diseases (NCDs) are the most found cause of disease burden. In recent years, the rising burden of cardiovascular diseases and high disease severity has been one of the significant threats in low-income and middle-income countries compared with high-income countries. People who are young believe in the myth that heart attacks can occur only in old age. They should wake up and adopt a healthy lifestyle at the earliest. One should give at least one hour to physical activity and make sure not to ignore the body’s signals,” he adds.

There has been an increase in the rate of coronary artery disease (CAD) in India in the last three decades.

A study published by the Journal of Clinical and Diagnostic Research in 2016 states that Indians have three, six, and twenty times greater risk of hypertension than Americans, Chinese, and Japanese populations respectively. “It is a matter of concern and there is a requirement to identify the factors responsible for its increasing prevalence, concludes Dr Goel.

Punjab is the only state where the populace is more prone to hypertension than any other state in India.

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HOW TO KEEP CHILDREN SAFE AMID RISING TEMPERATURE AND HEAT WAVE

Here are some tips to beat the heat that parents can try to ensure their child’s health and well being.

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The country is experiencing a heatwave with temperatures in many parts of India above 46 degrees Celsius, resulting in states issuing orange alerts. High temperatures and extreme heat can cause children to become sick very quickly.

What is heat-related illness?

Heat-related illness occurs when the body severely overheats. This can occur when a child is exposed to high temperatures for a long period of time and the body’s ability to cope with the heat wears out. The health impacts of Heat Waves typically involve dehydration, heat cramps, heat exhaustion and/or heat stroke. The signs and symptoms are as follows:

Heat Cramps: Edema (swelling) and Syncope (Fainting) generally accompanied by fever below 39°C i.e.102°F.

Heat Exhaustion: Fatigue, weakness, dizziness, headache, nausea, vomiting, muscle cramps and sweating.

Heat Stoke: Body temperatures of 40°C i.e. 104°F or more along with delirium, seizures or coma. This is a potential fatal condition. Heat stroke can lead to damage of a child’s brain, heart, kidneys, and muscles.

During summer months, research shows that children may be more likely to visit the emergency department not only for heat-related illness, but also for bacterial intestinal infections, ear infections, nervous system diseases, or for any reason.

Exposure to extreme heat may also make it more difficult for students to do well in school.

Children at increased risk of heat- related illnesses

Anyone can develop heat-related illness, but some children may be at higher risk than others. Infants and young children, especially with chronic medical conditions like asthma and diabetes; Obese children; children on medications that can make it harder to cope with heat and Children living in urban slums.

Useful tips

Some useful tips to protect the children from heat-related illness and hazards are:

• Encourage children to drink water frequently and have it readily available—even before they ask for it.

• Dress children in clothing that is light-coloured, lightweight, and limited to one layer of absorbent material that will maximise the evaporation of sweat.

• Provide extra rest time to children.

• Keep the surroundings cool and when child is feeling hot, give him or her a bath or sponge the body with water to cool down.

• Never leave child in a car: The inside of a car can become dangerously hot in just a short amount of time, even with the windows open.

Government response

 Ministry of Health & Family Welfare, Govt. of India has asked all states and union territories to review their health facility preparedness for the availability of all essential medicines and equipment amid the rising temperature and heatwave in several parts of the country. States have been advised to continue efforts on sensitisation and capacity building of medical officers, health staff and grassroots level workers on heat illness, its early recognition and management.

National Disaster Management Authority (NDMA), Government of India advises following measures to minimise the impact during the heat wave and to prevent serious ailment or death because of heat stroke:

§ Avoid going out in the sun, especially between 12.00 noon and 3.00 p.m.

§ Drink sufficient water and as often as possible, even if not thirsty

§ Wear lightweight, light-coloured, loose, and porous cotton clothes. Use protective goggles, umbrella/hat, shoes or chappals while going out in sun.

§ Avoid strenuous activities when the outside temperature is high. Avoid working outside between 12 noon and 3 p.m.

§ While travelling, carry water with you.

§ Avoid alcohol, tea, coffee and carbonated soft drinks, which dehydrates the body.

§ Avoid high-protein food and do not eat stale food.

§ If you work outside, use a hat or an umbrella and also use a damp cloth on your head, neck, face and limbs

§ Do not leave children or pets in parked vehicles

§ If you feel faint or ill, see a doctor immediately.

§ Use ORS, homemade drinks like lassi, torani (rice water), lemon water, buttermilk, etc. which helps to re-hydrate the body.

§ Keep animals in shade and give them plenty of water to drink.

§ Keep your home cool, use curtains, shutters or sunshade and open windows at night.

§ Use fans, damp clothing and take bath in cold water frequently.

Parents are advised to be vigilant and aware on protective measures during heat wave. They should immediately seek medical care if child develops symptoms like extreme tiredness, feeling faint, intense thirst, vomiting, headache, fever, fast breathing, muscle aches or spasms.

The writer is a Senior Consultant Health, Save the Children.

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Better mobility in frail older people linked to regular exercise with dietary advice

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A programme of regular exercise along with expert dietary advice is linked to a reduction in mobility problems among frail older people living in the community, finds a trial.

The findings were published in The BMJ. The combination of aerobic (walking), strength, flexibility, and balance exercises alongside personalised nutritional counselling reduced mobility disability by 22 per cent over three years.

US and EU data indicate that about 13 per cent of adults aged 70 years and older living in the community have mobility disability, which is linked to poor quality of life, admission to hospital or residential care, and death, as well as greater healthcare costs.

It is therefore important to find safe and effective ways to preserve mobility in older people at risk of further decline.

So researchers designed the SPRINTT trial to find out whether a combined intervention of physical activity with technological support and nutritional counselling prevents mobility disability in frail older adults compared with education on healthy ageing.

Their findings are based on 1,519 men and women (average age 79 years) with physical frailty and sarcopenia (a combination of reduced physical function and low muscle mass) recruited from 16 clinical sites across 11 European countries between 2016 and 2019.

Physical frailty and sarcopenia was defined as having a physical performance battery (SPPB) score of 3 to 9 points (score range 0 to 12, with lower scores indicating poorer physical function) and low levels of muscle mass, but able to independently walk 400 metres in 15 minutes.

In all, 760 participants were randomised to the intervention, 759 received education on healthy ageing (controls), and all were monitored for up to 36 months.

The intervention group received twice weekly moderate intensity physical activity sessions at a centre and up to four times weekly at home alongside personalised nutritional counselling. Activity was measured by an actimeter worn on the thigh.

Controls received education on healthy ageing once a month and a brief instructor led programme of upper body stretching exercises or relaxation techniques.

Among participants with SPPB scores of 3-7 at the start of the trial, mobility disability occurred in 47 per cent assigned to the intervention and 53 per cent controls.

Persistent mobility disability (inability to walk 400 m on two consecutive occasions) occurred in 21 per cent of intervention participants compared with 25 per cent of controls. SPPB scores increased more in the intervention group than in controls at both 24 months and 36 months (average differences of 0.8 and 1 point, respectively).

Women in the intervention group lost less muscle strength (0.9 kg at 24 months) and less muscle mass (0.24 kg and 0.49 kg at 24 months and 36 months, respectively) than control women, but no significant group differences were seen in men.

The risk of adverse events was, however, greater among intervention participants (56 per cent) than controls (50 per cent).

In a separate analysis of participants with better mobility (SPPB scores of 8 or 9 at the start of the trial), the intervention did not affect the risk of developing mobility disability and had marginal effects on physical performance.

The researchers acknowledge some limitations. For example, older adults with important cognitive deficits were not included, and almost all participants were white, so findings may not apply to other ethnic groups.

However, retention and adherence to interventions were high compared with other similar trials, and their use of validated tests in a geographically and culturally diverse group of frail older people across Europe, suggests that results are solid.

As such, they conclude that such an intervention “may be proposed as a strategy to preserve mobility in older people at risk of disability.”

This fresh evidence confirms the benefits of structured physical activity in community living older adults, says Thomas Gill at Yale School of Medicine in a linked editorial.

He acknowledges that translating even the best designed trial findings into clinical practice can be challenging, but says these findings, along with those from another large US trial (the LIFE Study), “provide compelling evidence that mobility in the community can be preserved among vulnerable older people through structured physical activity, with walking as the primary modality.”

He notes that the cost effectiveness of the LIFE programme “was found to be comparable to that of many commonly recommended medical treatments.”

Confirming these findings in SPRINTT “would further strengthen the case for developing, implementing, and supporting community based physical activity programmes to preserve independent mobility among vulnerable older people,” he concludes. (ANI)

US and EU data indicate that about 13 per cent of adults aged 70 years and older living in the community have mobility disability, which is linked to poor quality of life, admission to hospital or residential care, and death, as well as greater healthcare costs.

It is therefore important to find safe and effective ways to preserve mobility in older people at risk of further decline.

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50% of brain’s cells execute new functions

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In a new study at Tufts University, researchers came across a previously unknown function performed by a cell type that contains almost half of all cells in the brain.

The findings of the research were published in the journal ‘Nature Neuroscience’. The scientists say this discovery in mice of a new function by cells known as astrocytes opens a whole new direction for neuroscience research that might one day lead to treatments for many disorders ranging from epilepsy to Alzheimer’s to traumatic brain injury.

It comes down to how astrocytes interact with neurons, which are fundamental cells of the brain and nervous system that receive input from the outside world. Through a complex set of electrical and chemical signaling, neurons transmit information between different areas of the brain and between the brain and the rest of the nervous system.

Until now, scientists believed astrocytes were important, but lesser cast members in this activity. Astrocytes guide the growth of axons, the long, slender projection of a neuron that conducts electrical impulses. They also control neurotransmitters, chemicals that enable the transfer of electrical signals throughout the brain and nervous system.

In addition, astrocytes build the blood-brain barrier and react to an injury. But they did not seem to be electrically active like the all-important neurons–until now. “The electrical activity of astrocytes changes how neurons function,” said Chris Dulla, associate professor of neuroscience at the School of Medicine and Graduate School of Biomedical Sciences.

“We have discovered a new way that two of the most important cells in the brain talk to each other. Because there is so much unknown about how the brain works, discovering new fundamental processes that control brain function is key to developing novel treatments for neurological diseases.”

In addition to Dulla and lead author Moritz Armbruster, the study’s other authors include Saptarnab Naskar, Mary Sommer, Elliot Kim, and Philip G. Haydon from Tufts University School of Medicine; Jacqueline P. Garcia from the Cell, Molecular and Developmental Biology program at Tufts Graduate School of Biomedical Sciences; and researchers from other institutions.

To make the discovery, the team used brand new technology to devise a technique that enables them to see and study the electrical properties of brain cell interactions, which could not be observed previously.

“With these new tools, we’ve essentially uncovered completely novel aspects of biology,” said Armbruster, research assistant professor of neuroscience at the School of Medicine.

“As better tools come along–for example, new fluorescent sensors are being developed constantly–we’ll get a better understanding of things we didn’t even think about before.”

“The new technology images electrical activity with light,” Dulla explained. “Neurons are very electrically active, and the new technology allows us to see that astrocytes are electrically active, as well.”

Dulla describes astrocytes as “making sure everything is copacetic in the brain, and if something goes wrong, if there’s an injury or viral infection, they detect it, try to respond, and then try to protect the brain from insult. What we want to do next is determine how astrocytes change when these insults happen.”

Neuron-to-neuron communication occurs through the release of packets of chemicals called neurotransmitters.

Scientists knew that Neuron-to-neuron communication helps to make sure that neurons stay healthy and active.

But the new study reveals that neurons also release potassium ions.

which change the electrical activity of the astrocyte and how it controls the neurotransmitters.

“So the neuron is controlling what the astrocyte is doing, and they are communicating back and forth.

Through a complex set of electrical and chemical signalling, neurons transmit information between different areas of the brain.

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HOW SLEEP HELPS IN PROCESSING EMOTIONS

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Researchers at the Department of Neurology of the University of Bern and University Hospital Bern identified how the brain triages emotions during dream sleep to consolidate the storage of positive emotions while dampening the consolidation of negative ones.

The work expands the importance of sleep in mental health and opens new ways of therapeutic strategies. Their findings were published in the journal Science. Rapid eye movement (REM or paradoxical) sleep is a unique and mysterious sleep state during which most of the dreams occur together with intense emotional content. How and why these emotions are reactivated is unclear. The prefrontal cortex integrates many of these emotions during wakefulness but appears paradoxically quiescent during REM sleep. “Our goal was to understand the underlying mechanism and the functions of such a surprising phenomenon”, says Prof. Antoine Adamantidis from the Department of Biomedical Research (DBMR) at the University of Bern and the Department of Neurology at the Inselspital, University Hospital of Bern.

Processing emotions, particularly distinguishing between danger and safety, is critical for the survival of animals. In humans, excessively negative emotions, such as fear reactions and states of anxiety, lead to pathological states like Post-Traumatic Stress Disorders (PTSD). In Europe, roughly 15 percent of the population is affected by persistent anxiety and severe mental illness. The research group headed by Antoine Adamantidis is now providing insights into how the brain helps to reinforce positive emotions and weaken strongly negative or traumatic emotions during REM sleep. This study was published in the journal Science.

A DUAL MECHANISM

The researchers first conditioned mice to recognize auditory stimuli associated with safety and others associated with danger (aversive stimuli). The activity of neurons in the brain of mice was then recorded during sleep-wake cycles. In this way, the researchers were able to map different areas of a cell and determine how emotional memories are transformed during REM sleep.

Neurons are composed of a cell body (soma) that integrates information coming from the dendrites (inputs) and send signals to other neurons via their axons (outputs). The results obtained showed that cell somas are kept silent while their dendrites are activated. “This means a decoupling of the two cellular compartments, in other words, soma wide asleep and dendrites wide awake”, explains Adamantidis. This decoupling is important because the strong activity of the dendrites allows the encoding of both danger and safety emotions, while the inhibitions of the soma completely block the output of the circuit during REM sleep. In other words, the brain favours the discrimination of safety versus danger in the dendrites, but blocks the over-reaction to emotion, in particular danger.

A SURVIVAL ADVANTAGE

According to the researchers, the coexistence of both mechanisms is beneficial to the stability and survival of the organisms: “This bi-directional mechanism is essential to optimize the discrimination between dangerous and safe signals”, says Mattia Aime from the DBMR, first author of the study. If this discrimination is missing in humans and excessive fear reactions are generated, this can lead to anxiety disorders. The findings are particularly relevant to pathological conditions such as post-traumatic stress disorders, in which trauma is over-consolidated in the prefrontal cortex, day after day during sleep.

BREAKTHROUGH FOR SLEEP MEDICINE

These findings pave the way to a better understanding of the processing of emotions during sleep in humans and open new perspectives for therapeutic targets to treat maladaptive processing of traumatic memories, such as Post Traumatic Stress Disorders (PTSD) and their early sleep-dependent consolidation. Additional acute or chronic mental health issues that may implicate this somatodendritic decoupling during sleep include acute and chronic stress, anxiety, depression, panic, or even anhedonia, the inability to feel pleasure. Sleep research and sleep medicine have long been a research focus of the University of Bern and the Inselspital, Bern University Hospital. “We hope that our findings will not only be of interest to the patients but also to the broad public”, says Adamantidis.

The work expands the importance of sleep in mental health and opens new ways of therapeutic strategies.

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Health & Wellness

ABHA WILL ENHANCE DIGITAL HEALTHCARE SYSTEM IN THE COUNTRY

The health insurance sector in India is expecting a growth at a rate of 10.1% in the years between 2021 and 2027. Distribution and affordability are two keywords to get a large number of people insured, said experts.

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Introducing the challenges and the need for new policies in health insurance in India, a conference on ‘Health Insurance 2042- Let us Plan for Ambitious Target for 2042’ was organised in Vigyan Bhawan, New Delhi. The conference organised by the PHD Chamber of Commerce and Industry (PHDCCI) highlighted the need to boost the digital healthcare system in the country.

Speaking about the Ayushman Bharat Digital Mission (ABDM), Dr. Malti Jaswal, a Senior Consultant, World Bank and Advisor with the National Health Authority, said, “ABDM plans to create a healthcare infrastructure that will bridge the existing gap amongst different stakeholders in the healthcare ecosystem through digital highways.” A health id for all Indian citizens-ABHA (Ayushman Bharat Health Account) will help maintain personal health records digitally and easily accessible.

The Ayushman Bharat scheme has also been able to cover the bottom 50% and several voluntary schemes cover almost 20%. The government must focus on the remaining 30%. Pradeep Multani, President, PHDCCI, said, “The health insurance sector has undergone a lot of change in the last two years of the pandemic, with people realising its importance.” He also focussed on the need for customising products as per the customers.

Also, while discussing the growth of digital healthcare, Dr. Harsh Mahajan, Chair, Hospital & Diagnostics Committee, PHDCCI and Founder & Chief Radiologist, said, “The digital healthcare market, valued at $116 billion in the year 2018 is expected to touch $485 billion by the year 2024, a growth of 3.5 times. The spurt in growth is primarily due to the pandemic, which accelerated the diagnostics sector to grow at a rate of 20.5 percent. It is valued at $32 billion now, up from just $5 billion in the year 2012.”

Mr. S K Sethi, Co-Chair, Banking, Financial Services and Insurance (BFSI) Committee, PHDCCI & Founder & CEO, Insurance Foundation of India, stated that from Rs 690 crore in 2001 to Rs 73,300 crores in 2022, the sector has grown approximately 106 times. He stated that blockchain technology would help in eliminating the fraud taking place in the insurance sector

Although the pandemic taught us the significance of mental health, health insurance policies exclude the challenges of mental health. According to Deepak Singh, CEO and Co-founder of Tatsam, insurance companies have developed plans but, except for psychiatrists, have yet to recognise counselors and therapists. Most people have often faced a treatment gap while claiming their insurance. Dr. Steward Doss, Professor, National Insurance Academy, Pune, stated that there is a significant treatment gap in India. A lot of these issues can be resolved with insurance cover.

The knowledge paper on Health Insurance 2042 was also released at the event. Other members who participated in the event were Kanya Saraswathy C, Head Commercial and Reinsurance Practice, Insurance Advisory Group & Lead – US West Accounts, BFSI, Tata Consultancy Services Limited, Ashish Agrawal, Co-Chair, BFSI Committee, PHDCCI, Ravi Bhati During the seminar, Teena Jain Kaushal, Senior Editor of Business Today, and so on.

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