Dr.Sm Bose

Former Head of Surgery PGIMER,Chandigarh,India
Former president Asscon.of Surgeons of india
Former President Ind. Association of Surgical Gastroenterology.

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HEALTH AWARENESS

Dr.Bose has been writing articles since a very long time for the health education of the people, and these articles have been published in leading news papers and magazines.

A few articles are available here and one can get them online.

Dr.Bose has written a very informative book "CANCER" dealing with all aspects of the dangerous disease Cancer . Ther book has been translated into many languages - assamese, oriya, urdu, marathi, It has been published by Govt. of India and is priced at Rs. 50.00 only .

HEALTH TRIBUNE	Wednesday, March 1, 2000, Chandigarh, India
Day-care surgery Quick, cheap, effective By Dr S.M. Bose There is a perpetual shortage of beds in hospitals, particularly in government hospitals, where the majority of the patients seek admission. This is not a problem unique to India. It is being faced by almost all the developing countries. The developed countries have already faced it and come up with the idea of day-care surgery, also known as outpatient surgery or short-stay surgery.

More light on breast cancer
Breast cancer is the second most common form of cancer affecting women in India. There has been a steady rise in its incidence. It is affecting Indian women at a much younger age as compared to those in the West. Obviously, the disease here is seen at an advanced stage.

Day-care surgery
Quick, cheap, effective
By Dr S.M. Bose

There is a perpetual shortage of beds in hospitals, particularly in government hospitals, where the majority of the patients seek admission. Although new hospitals are being started and more beds are being added in the existing hospitals, there are long waiting lists in every government or charity centre. It is not uncommon to see a patient making multiple trips to a hospital to seek admission. He fails to do so, gets frustrated and ultimately gives up the idea of getting admitted only to land up in the hospital as an emergency case. He may start visiting the hospital again when the condition becomes worse as in cancer.

This is not a problem unique to India. It is being faced by almost all the developing countries. The developed countries have already faced it and come up with the idea of day-care surgery, also known as outpatient surgery or short-stay surgery.

Day-care surgery has been known for a long time. This means that the patients spend only a few hours in the hospital after the operation and are subsequently sent home. But the concept has been implemented on a larger scale over the past 10 years only.

Dr Sujit Pandit, Professor of Anesthesia from Ann Arbor, University of Michigan, delivered an informative lecture at the PGI recently and I would like to share the interesting points in it and the crux of the lively deliberations that it generated.

About a decade back, only 10 per cent of surgical operations were done as day-care procedures, but over the years it has become such a successful venture that almost 50 per cent of 37 million operations performed in the USA every year are now being carried out as day-care procedures. More and more major operations are being included in this programme.

The advantages or day-care surgery are many. Some of these are mentioned below:

(i) Prevention of cross infection to the patient from the hospital's atmosphere and other patients.

(ii) Sparing the much-needed hospital beds for seriously ill patients who require hospitalisation and close monitoring.

(iii) Sparing the doctors and the nurses the burden of monitoring very sick patients.

(iv) Cutting down the expenses. Health-care has become a very costly affair. In the USA an average hospital bed costs $600 per day and in India it may cost Rs 500 to Rs 5000 a day in a good nursing home. Even the PGI charges about Rs 1000 for a bed only. Other charges are inescapable.

(v) Psychologically, the patient and his relations feel happy to go back home and recover in their known environment.

(vi) The inconvenience to the patients and their relations are minimised.

But all said and done, the implementation of any new system requires planning, infrastructure and proper execution; success is achieved only if periodic evaluation is carried out, followed by the required restructuring and modification.

Here are some of the basic requirements for day-care surgery.

(i) The patient should be thoroughly examined in the outpatient department, not only about his present illness but also to evaluate his suitability for undergoing anesthesia and the operation.

(ii) All the relevant investigations must be carried out as outpatient tests.

(iii) Facilities must exist to receive the patient in the operation theatre complex at least three hours before the operation.

(iv) Pre-operative steps liked the change of clothes, the preparation of the part to be operated upon, the administration of premedication, the attestation of the consent form and other formalities have to be gone through before the operation.

(v) Facilities must exist to keep the patient in the post-operative ward till he comes out completely of anaesthesia and is able to travel to his residence.

(vi) The hospital facilities should be available round the clock so that the operated patient can be cared for promptly if he develops any problem.

(vii) Communication facilities are most necessary.

(viii) Arrangement should be made for a doctor or a nurse to visit the patient at home at night for evaluation and advice — particularly for pain relief, the administration of antibiotics, etc.

(ix) It is desirable that the patient should stay within a radius of 20 to 25 km from the hospital.

(x) The patient should be given complete instructions at the time of discharge.

I am of the opinion that the most important factor is the establishment of mutual trust between the patient and the operating team.

The PGI has been undertaking day-care surgery in a small way and it is likely to get a big boost with the opening of the new OPD complex where day-care surgery has been planned with six operation theatres and various facilities. But we shall have to move cautiously and progress slowly but steadily to make this a successful venture. A multidisciplinary approach and proper organisation are the key to success in this field.

More light on breast cancer

Breast cancer is the second most common form of cancer affecting women in India. There has been a steady rise in its incidence. It is affecting Indian women at a much younger age as compared to those in the West. Obviously, the disease here is seen at an advanced stage.

The management of breast cancer is controversial. The confusion is multiplied as there is no recommended standard management protocol for the disease in India. To eliminate this lacunae, Prof S.M. Bose of the PGI, who has written the article on day-care surgery, has brought out a book, "Consensus on Breast Cancer" which covers all aspects of the disease, right from classification to follow-up.

The contributors to the book are eminent medical persons interested in the subject.

The volume was released during the inaugural function of the International Breast Cancer Conference held at Nagpur recently.

Dr Bose, the eminent cancer surgeon, received the prestigious Dr B.C. Roy National Award for Eminent Medical Teacher last year. His popular book titled "Cancer", published by the Government of India and written for the health education of the people, has been translated into many languages. The specialist has also been elected a Fellow of the National Academy of Medical Sciences.

MALE MENOPAUSE : THE ANDROPAUSE

Dr.S.M.Bose, MS,FRCS,FACS,FAMS,FACS,FICS
Former Head of Surgery, PGI, Chandigarh
www.drsmbose.com

It may come as a surprise and may be as a rude shock to the male chauvinists that like their female counterparts, males also attain menopause. In males it is actually not Menopause, which literally means pause or cessation of menstruation; it is known as Andropause or Viropause or Male Climacteric and this physiological state is similar to menopause in females.

Andropause was conceptually described in medical literature about seventy years earlier but realization seems to be coming now. Longevity of life has increased, life style is changing fast and the desire to live better and happier in all aspects have drawn the attention of medical personnel to look into this aspect of aging male population.

By the age of 50 to 55 years, a male person may start feeling the first sign to suggest the onset of Andropause; of course, neither all get it nor all start at the same age and obviously the severity and perception also varies in individuals. In contrast to females where cessation of menstruation is the obvious signal for this physiological change, in males there is no definite signpost and that defies easy recognition.

The physiological ( natural ) reason for this transformation is the decreased levels of sex hormone, oestrogen in females and testosterone ( He – hormone ) in males. The decrease in sex hormones can be also due to diseases - pathological causes, but here we shall restrict ourselves to normal aging process. As the man reaches the age of 50 years ( it can vary a lot, can be less or more ) , his testosterone level starts declining ; again the degree of decline is not the same in all men population. This decline is gradual and may take years together to manifest its full effect. This decrease in testosterone level and its manifestation resulting in Andropause varies with the physiological and psychological state of the person, presence of any disease or infection, intake of alcohol or medicines, physical stress due to injury or any major operation.

Andropause may cause a number of problems, the main ones being:

1. Decreased libido resulting in lack of interest in sexual activities.

2. Loss of muscle mass leading to decreased muscle power. You must have heard of athletes , weight lifters taking drugs ( testosterone being one of them ) to strengthen their muscle power and decreased testosterone level weakens the muscle power.

3. Obesity , commonly resulting in paunch , is seen after the middle age and it is not only due to lack of activity but also because of deficient hormone also.

4. Psychological and behavioural changes so that the interpersonal and social relations change. Loss of memory and concentration, delayed reflexes, lack of alertness ; nervousness and irritability, sleep disturbances, indecisiveness , loss of interest and self-confidence all are supposed to be aging problems and these to some extent are due to decreased levels of hormone. In short it may be said that an active person goes into a shell.

5. Low testosterone level results in decreased bone density , 15 to 20% , and this gives rise to Osteoporosis or Weakness of bones. This results in low back pain, fractures after trivial injuries - like hip fracture after a fall.

6. Circulation problems - Preliminary research has shown that like women, men are also prone to develop atherosclerosis due to diminished testosterone levels, but it requires to be clearly documented.

Ignorance and lack of awareness about andropause results in nondiagnosis of the condition in a significant number of cases. The awareness for andropause is very poor both amongst common men and also amongst physicians ; resulting in poor and delayed diagnosis. The symptoms are very vague. Moreover the man gets this at such a stage when retirement, psychological stress, aging problems etc. are present and the symptoms of andropause are taken as results of changed life style. Neither the patient nor his relations or his family physician take him seriously and he is just prescribed a few medicines – vitamins, antidepressants , mood elevators etc. and advised to devote his time in meditation and prayers. On many occasions the patient may be labeled a psychological problem and referred to a psychiatrist., the patient hardly ever follows the advice and the problem persists .

How is Male Menopause produced?

Testosterone is the male sex hormone , produced by testis and the adrenal glands. Testosterone level keeps on increasing from puberty and starts declining from the age of 30 years , almost 10% per decade. This decline may be very fast and steep in some resulting in marked andropausal symptoms whereas in some it may not be that bad. It is estimated that approximately 30% of the men folks in their fifties develop low levels of testosterone resulting in marked manifestations of andropause.

Testosterone acts on many organs of the body, male sex organs , liver, bone, muscles, brain, kidney etc. It has varied functions, some of the important ones being - growth of secondary sexual organs and characters, sexual behaviour including libido, protein and carbohydrate metabolism, bone formation, and production of blood cells from the bone marrow.

Low level of testosterone brings about a few changes in the person _ diminished muscle power, decreased libido and sexual activity, behavioural changes, weakening of bones ( Osteoporosis ) resulting in backache and fractures, indecisiveness , loss of hair, obesity particularly in the mid part of the body. Decrease in testosterone level is also supposed to increase the risk of heart problems, the most important being atherosclerosis – the narrowing and hardening of the blood vessels.

All these features are commonly seen in old age and are linked to aging. It is not widely recognized that in a large percentage of cases this is due to decreased levels of testosterone and this can be kept under control by rationale replacement treatment.

Diagnosis :

As already mentioned earlier, andropause is not a newly discovered problem but its impact has been recognized recently. New and more sensitive blood testing methods are available now for the estimation of bioavailable testosterone resulting in accurate diagnosis of the condition.

Treatment :

The treatment is HRT - hormone replacement treatment , and this is done by prescribing testosterone , usually in the dose of 40 mgs per day. The drug is available in the form of oral capsules, injections or skin patches. The effect is usually noticed after 3 to 6 weeks and the replacement therapy should be continued for very long time.

The medicine should be started only after a careful medical check up to rule out the presence of any other medical problem. Blood testosterone level should be also determined and the medicine is only given if the level is on the lower side.

Testosterone should not be used by the persons who have or had breast cancer or prostatic cancer. It is also not prescribed to the persons who want to father a child as testosterone may cause infertility. Similarly the presence of any of the following conditions should caution a person and the medical specialist would take decision after evaluating the details of the ailment with the help of investigations :

Heart or circulation problem

Enlarged prostate

Kidney disease

Diabetes Mellitus

Liver disease

Edema or retention of fluid in the extremities

History of allergy following intake of testosterone or androgens

A bed ridden person

A person who is on anticoagulants – blood thinning medicine

Science is progressing very fast and so also the medical science. Present day medical practice is committed to help a person, not necessarily to treat the diseases only but to make the life more comfortable and enjoyable. Treatment of male menopause or andropause is an effort in this direction, it has been realized late as compared to female menopause. But now effort is needed on the part of the affected persons to do away with shyness and consult their doctors and the medical doctors should take initiative not only to counsel their patients but to treat the person who may not be harbouring a disease in the true sense but who desires and deserves a happier and comfortable life.

Effects of Andropause:

2. Loss of muscle mass and muscle power

4. Psycho-social behavioural changes

6. Decreased bone density resulting in backache

and fractures

Treatment

Effects of andropause can be kept under control by judicious use of Testosterone –

the male hormones; under the supervision of a doctor.

CANCER : FEW BASIC QUERRIES ANSWERED

Dr.S.M.Bose. , MS , FRCS, FAMS, FACS, FICS, FACG,
Former Prof. & Head of Surgery, PGI, Chandigarh
Author of Books CANCER & CONSENESUS IN BREAST CANCER

Q. 1 What is cancer and how does it spread?

Ans. Cancer is a serious disease and can affect any part of the body. It is caused by very rapid and irregular multiplication of the cells. The daughter cells are not like their mother cells.

The cancer cells have the characteristic of getting separated from the main tumour mass. The separated cell can travel to distant parts of the body either through direct extension of through the blood and lymphatic streams. These cells start multiplying over there and produce what is known as secondary deposits or metastasis.

Q2. What is the cause of cancer?

Ans. The exact cause of cancer is not known although world wise research has been going on in this direction. Cancer is caused by constant irritation by some factors and some of the known factors being:

Tobacco in any form

Radiation

Chemical agents

Hereditary

Faulty diet

Few chronic diseases

Q3. What are the danger signals of cancer ?

Ans. There are seven danger signals of cancer as described by WHO. These signals do not mean that the person has cancer but they only caution the person that in cast the person continues to have these inspite of normal treatment then one should visit a specialist to rule out the possibility of cancer being responsible for these.

The danger signals are :

1. Change in bowel or bladder habits

2. A wound that refuses to heal

3. Unusual bleeding or discharge from any source

4. Thickening or swelling anywhere in the body

5. Indigestion or difficulty in swallowing

6. Obvious change in mole or wart

7. Nagging cough or hoarseness of voice

Q4. How do you diagnose cancer?

Ans. Cancer can be suspected by examination by a doctor but it requires several investigations to find out the type and stage of the disease.

Biopsy can only confirm the presence of cancer and hence it must be undertaken whenever there is doubt of cancer.

Q5. How is cancer treated?

Ans. Cancer is treated by multimodality treatment schedule and this comprises of

Surgery

Chemotherapy

Radiotherapy

Hormone therapy

Immunotherapy

The patient may require all the modalities of treatment or only a few of these.

Q 6 . How can a woman suspect cancer of breast in herself.

Ans. Cancer of breast can be suspected by the presence of any of the following:

Swelling in the breast or in the armpit

Bleeding from the nipple

Ulceration or wound of the breast skin

Thickening of the breast skin so that it looks like orange peel

Q.7 What are the important factors in the treatment of cancer?

Ans. The following are the important factors in the cure of cancer: