Medical

Battling with brittle bones

Osteoporosis means just as the name suggests - porous bones (also often called thinning of the bones). It's remarkably common yet few people are aware of it or the damage that it can lead to. Bones are an active dynamic organ which, just like other organs in the body, is in a constant process of cell growth, repair and change in order to maintain their function. And this process can go wrong. Bones are made from a honeycomb mesh of strands formed by a protein called collagen and hardened by calcium salts and other minerals.

The honeycomb is filled with bone marrow and blood vessels, and protected by a dense outer shell. Scattered through this are millions of living bone cells which continually break down old bone and build new bone. The bones in the body are completely renewed over a period of about 10 years. While we are young our bones continue to grow and get denser and stronger.

This reaches a peak of maximum strength at 25-30, known as peak bone mass. After that bone is lost faster than it can be replaced, as part of the ageing process.

The holes of the honeycomb become larger so the overall structure is less solid and the bone is weaker and more likely to break . Unless special precautions are taken, osteoporosis can develop, especially if particularly vulnerable. In women, loss of oestrogen after the menopause makes them even more susceptible to the condition as this hormone plays an important part in bone formation. Risk factors for osteoporosis include:

*Getting older - Although osteoporosis results from age-related changes, it can also affect children and adolescents.

*Infrequent periods, especially linked to anorexia or excessive exercise

*Long term use of high dose steroids

*Lack of exercise

*Smoking

*Excessive alcohol consumption

Treatments include:

*Hormone Replacement Therapy - The oestrogen hormones significantly reduce the risk of osteoporosis if taken long term as well as the risk of heart disease.

*Calcium and Vitamin D supplements (especially for those on a limited diet or who are housebound.)

*Calcitonin - A hormone made by the thyroid gland, which inhibits the cells which break down bone.

*Testosterone supplements for men. -SERMs (Selective Estrogen Receptor Modulators) - These are a new type of drug which act like a synthetic form of hormone replacement. They reduce the risk of osteoporosis and heart disease, but do not increase the risk of breast or endometrial cancer.

Trouble in the bowel

By Chris Fernando

Q: I am a 24-year-old working girl. Recently, I started passing blood with diarrhoea. As this lasted over a few days, I saw my doctor who diagnosed it as inflammatory bowel disease and advised me to see a specialist. Doctor what is wrong with me? Am I suffering from something serious?

Dr. Maiya says:

Inflammatory bowel diseases refer to idiopathic bowel disorders, ulcerative colitis and Crohn's disease.

Ulcerative Colitis is an inflammatory disorder of the mucosa of the rectum and colon. The rectum is virtually always involved in this inflammatory process and if any portion of the remaining colon is involved, it is in a continuous manner, extending upwards along the large bowel in continuity.

On the other hand, Crohn's Disease typically affects all layers of the bowel wall and may do so in a patchy distribution throughout the gastro-intestinal tract. In Crohn's disease, you may have a segment of the large bowel and a segment of small bowel involved in this inflammatory process at the same time with normal bowels in between. Even the swallowing passage, which is called the oesophagus can be involved. On the contrary, Ulcerative Colitis is purely confined to large bowels only.

The small intestine is most often involved in Crohn's disease and most often it is the end part of the small bowel that is tucked up in the right side of the lower abdomen which gets involved and this may present as a lump in the lower right side of the abdomen. Crohn's Disease is a chronic disease and granulotamous condition which involves all layers of the bowel wall and as a result, the affected part gets narrowed, constricted and shortened and can later give rise to mechanical bowel obstruction which has to be relieved by surgery. So, very often in Crohn's Disease, the symptoms may not be diarrhoea, but can be a recurrent abdominal pain.

Most interestingly, these two diseases have also extra intestinal manifestations. Patients suffering from Crohn's and Ulcerative Colitis can also suffer from joint complications such as arthritis, skin manifestations, eye conditions such as conjunctivitis, problems with the liver and abnormal liver functions and kidney diseases. Sometimes, the first manifestation of the disease may not be the loose stools or the abdominal pain, but can be skin complications, arthritis or liver problems.

This is because in inflammatory bowel diseases, an immunologic mechanism is assumed to be the cause of the disease. This means that there is a failure in your body's immune mechanism and therefore multiple systems of the body can get affected. But however the inciting causes are not yet known, and if we knew the real triggering factor, a definite cure could be instituted.

Hereditary factors appear to play a role in these two diseases. Patients with Ulcerative Colitis or Crohn's Disease have a 10 - 15 % chance of having a first or second degree relative who also has one or other type of this inflammatory bowel disease.

In patients with Crohn's Disease, the stools usually are not grossly bloody and the pain may be more on the right lower abdomen. a patient may even feel a lump in the right lower abdomen. Therefore, the patient will experience cramp-like abdominal pains whereas in Ulcerative Colitis, the main complaint is a bloody diarrhoea, with or without severe abdominal pain.

Of course, a colonoscopy and biopsy will give a100% diagnosis for Ulcerative Colitis because this is a disease confined to the colon. You may get a Crohn's Disease lesion in the colon, which gives a diagnosis in a biopsy through the colonoscope. But however, if the disease in Crohn's Disease is confined to the small bowel, the diagnosis will be revealed by tests such as a barium or gastro graphine meal. Here, a patient is given to drink this substance so that the entire small bowel can be viewed by a series of x-ray films, which show the affected segment of the small bowel.

Sometimes, you may confuse these specific two conditions with other conditions such as bacterial and parasitic colitis which can give severe diarrhoea with blood and a very inflamed colonic mucosa similar to Ulcerative Colitis. However, the biopsy from a colonoscope will give you a definite diagnosis.

Ischemic colitis and radiative colitis are two other conditions which can be confused with Crohn's Disease but specific laboratory stools examination, endoscopic biopsy, radiological studies such as barium meals and CT Scans will help to arrive at a specific diagnosis.

New blood tests that measure certain antibodies also make it easier to differentiate Crohn's Disease from Ulcerative Colitis.

So the treatment will depend on the diagnosis. in inflammatory bowel disease, the medical treatment can be long drawn out but surgery will have to be considered for complications arising more frequently from Crohn's Disease than from Ulcerative Colitis. If bloody stools, like in your case, are due to a bacterial or parasitic colitis, then specific antibiotics can be given after a stools examination.

Drugs cannot cure inflammatory bowel diseases but they are effective in reducing inflammation and the accompanying symptoms for long periods.

Dietary recommendations:

Although no evidence exists that any specific foods reduce inflammation in Crohn's Disease and Ulcerative Colitis, certain foods have been associated with a lower or higher risk of inflammatory bowel disease or its symptoms.

The foods linked to a lower risk were fruits for both conditions and vegetables and green tea for Crohn's Disease.

certain studies have found that large doses of fish oil which is rich in Omega Three fatty acids improves Crohn's Disease.

Foods most often blamed for aggravating existing symptoms are milk, milk products, spicy foods, fats and sugars. When symptoms erupt, we recommend a bland, low fibre diet and patients are given plenty of fluids.

Not too little, not too much

The term "balanced diet" has become one of those health mantras that one constantly hears, but which no one ever really stops to explain. What it really means is a diet that includes a combination of several different food types.

These food types include grains and pulses, fresh fruit and vegetables, dairy products, and fats and oils. But how much of these different foods should you have? Critical to the idea of a balanced diet is including food in the right proportions, because the aim is to get all the nutrients your body needs while maintaining a healthy weight.

For example, some fats or oils are important in the diet for various reasons, from absorption of fat-soluble vitamins to providing children with energy. But you only need a small amount of fats and oils compared to a food type such as fruit and vegetables. Foods are often classified as belonging to a pyramid: foods at the top of the pyramid - fats, oils and sweets - should be included sparingly, while those in the middle (such as protein-rich foods, and dairy foods) are needed in moderate amounts. Take care that these protein sources don't bring a lot of fat with them, so trim fat off meat, and skin off chicken.

Fresh fruit and vegetables take a major slice of the pyramid. Low in fat, calories and salt, they are an excellent source of vitamins, minerals and fibre. Most of us simply don't eat enough to meet the recommended amounts of fruits and vegetables! The base of the pyramid represents great heaps of grains. These carbohydrate-rich foods, such as bread, rice, noodles and cereal provide long-term energy and should be the basis of our diet and this we appear to be consuming in adequate amounts in this country.

Impotence: facing the hard facts

Impotence is at last something that can be discussed out in the open. For years, millions of men have been suffering in silence and making their situation worse. Thankfully, the subject of impotence is no longer a taboo subject or one that only raises a smile when mentioned.

It's now one where men are quite rightly asking for help. Impotence is also called "erectile dysfunction." It's defined as the inability to achieve or sustain an erection that is hard enough or lasts long enough to have satisfactory intercourse. Most men experience temporary failure of their erections at some time in their lives. Usually, this is due to tiredness, stress, or excess alcohol. However, for around 1 in 10 men, impotence persists. In a significant proportion of the majority of cases there's a physical cause for the impotence where nerve damage or poor blood flow underlies the problem.

If a man has early morning erections and can masturbate to climax then the cause is likely to be psychological, which makes up the remainder of cases. However, many men suffer a combination of physical and psychological reasons. It's very easy for a man with impotence to become stressed and depressed about his situation and this makes matters worse. Men then tend to suffer in silence and are often too embarrassed or ashamed to talk about the problem to anyone. So even if the cause was physical to start with, the psychological effects will compound the problem.

The list of possible treatments has lengthened over the past few years, offering a wider range of more acceptable choices for men. Lifestyle changes are important since many bad habits contribute to the problem.

Also opening up and discussing the situation with their partner is essential, reassuring each other that it's nobody's fault.

Sometimes it's a side effect of medication being taken for other medical conditions and, when this is the case, switching to a different type can solve the problem.

An American car mechanic developed one of the early treatments for impotence, the vacuum pump. Although it solved the problem, for many it created a new one since it was so inconvenient to use. Penile prostheses (semi-rigid rods or inflatable devices) can be surgically placed inside the penis. However, with the advent of newer drug treatment, this is less often the option chosen by men. Over the past few years drugs have successfully helped men to overcome their situation. Many men have used injections given into the side of the penis or tiny pellets placed into the urethra.

The impotence treatment revolution came with the drug sildenafil (Viagra), which was the first effective treatment in tablet form. More tablet treatments are currently in development, as is a nasal-spray. The prognosis for those suffering from impotence then is better now than it was ever before.

However, the most important factor is that men should confront the problem in a discussion with their doctor- rather than confining it to their bedrooms.

Let sanity prevail before it's too late

The Annual Scientific Sessions of the Sri Lanka Psychiatric Association were held recently and in his presidential address, Dr. Buddhadasa Waidyasekera critically reviewed the state of mental health care in Sri Lanka. Excerpts from the address:

"Today, for very strange reasons psychiatry has been given more recognition than ever before. Adverse publicity given to long-term patients at mental hospitals, a rise in suicide rates, war victims and the refugee crisis are probably the reasons behind this recognition. However, it is too late as the country has already lost over four-fifths of its psychiatrists to developed countries. And, the few of us who have returned to our motherland to serve are now disillusioned by the way in which psychiatrists and psychiatric services are treated in this country.

"Yet, are psychiatrists in a position to help war victims and refugees? My personal view is that our contribution to the manifest socio-economic problems is minimal. "Men will always be mad," said Voltaire "and those who claimed they could cure them are the maddest of them all". He was merely repeating what the Buddha too said: "sabbe pruthagjana unmaththaka".

"Let psychiatrists therefore be humble in their pursuits in trying to cure mental disorders, especially those of social origin. They must not undertake to solve problems that they cannot; they must know their limitations; or else, they will discredit their art. It is worthwhile then to dwell upon Sri Lanka's psychiatric services as at present. The mental hospitals at Angoda and Mulleriyawa are the nucleus of psychiatric services in the country. The Angoda hospital, begun as an asylum for the mentally ill is now a teaching hospital. Not only does it serve as the major teaching unit but it is also the largest acute treatment centre with facilities for medium and long-stay patients.

"The Angoda hospital recently celebrated its 75th anniversary. In reality there is nothing to celebrate, being subjected to destruction due to political interference and administrative inefficiency over the years. Angoda in the seventies was a therapeutic community. The gardens were well maintained with majestic trees and blooming flowerbeds. Patients did agro-therapy, occupational therapy and livestock management. In 1982, a block of wards collapsed killing six female patients, an event that was worse than the bombing it endured in 1942 and an event that accelerated its downfall. Patients were evacuated to Mulleriyawa and Hendala and a new thousand-bed hospital was built in a hurry with little planning.

"Today, the newly built wards are in a state of disrepair with no proper water or sewerage system. Despite these shortcomings, work goes on due to a dedicated set of psychiatrists, doctors, staff nurses and attendants. The Mulleriyawa mental hospital is in a worse state than the Angoda Hospital. It is a ruined city with scrub jungle covering the collapsing wards. Its playground is no longer available for the patients and political motives are depriving patients' needs. In its heyday Mulleriyawa was a haven for the mentally ill, such was the tranquility and beauty of this hospital.

"These two institutions form the backbone of psychiatric services in the country and must be preserved and improved at all cost. The day when these two institutions close down, our prisons will overflow and the suicide and homicide rates will rise sky high. Sri Lanka must not repeat the mistakes committed in the west by closing mental hospitals in the name of community psychiatry. What of the provincial psychiatric units that emerged in the sixties? They remain in the same state and have failed to fulfill the demands of the community. If these units expanded this crisis would have been averted.

What of the future? The Department of Health has formulated yet another 'mental health programme'. The proposals of this programme are virtually the same as what has been proposed before. If at least a few of these proposals could be implemented on a priority basis we can expect a better future for psychiatry. One other important area needs urgent attention is the law relating to psychiatry. An excellent legal document, the draft Mental Health Act 2000 prepared by the National Advisory Board on mental health has gone into cold storage and in its place another proposal is undergoing labour pains to see the light of day. Those who are in power must therefore be reminded that unless we get rid of the Mental Diseases Ordinance, we cannot make any radical progress in psychiatry in this country. It is my fervent hope and dream to see a National Institute of Mental Health emerging at Angoda with the modernization of the Angoda and Mulleriyawa hospitals and the expansion of peripheral psychiatric services. It is indeed a dream but as the American poet Longston Hughes said, "Hold fast to dreams for if dreams die, life is a broken winged bird that cannot fly..."

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