Month: July 2019

How to choose your Doctor!

/ Subash Rau / Leave a comment

I write this article to help the reader choose the correct doctor for himself. I see a lot of patients in my daily practice and have had the chance to see how they connect with different doctors, how they struggle with their chosen doctor. I write with an intention to put things clearly for my own patients as well as those who are keen to know more about how to select a good doctor for themselves. In India, patients have a pretty unique problem in that there are no standards for doctors. You may find doctors of very varied abilities, treatment philosophies and standards in the very same institution. For example, you could find doctors following the American/European/British and Indian guidelines to treat the same disease in the same hospital. I hope that this article will help the patient understand and choose the best doctor for himself.

How people choose their doctors normally!

Usually patients are brought to a particular doctor by an “interested third party” (referred). It may be a close friend, family member, relative, neighbour or even just a well intention-ed do-gooder! Sometimes people search online or just walk into the hospital, ask around and walk into the Doctor’s Out-patients’. Some, would have met a doctor on a social occasion and would then decide to go to him when the need arose.

People also look for doctors only when they are unwell. Some would go to the local/neighbourhood GP (easily reachable, easy on the wallet and with walk-in appointments) and then start searching for higher levels of expertise only when they don’t respond to the treatment given.

For many people, finding a good doctor is by chance/Luck!

Different Strokes for different folks!

Patients come in with different mindsets. Some of the different approaches are as follows

1. Some patients have Blind Trust – Such people accept without question all recommendations and “submit” to the Doctor’s care and give them a free hand to investigate and do the needful.

2.Some patients need convincing – Some come with an attitude of listening to what the doctor has to say. They may not accept all the recommendations made, they may ask for explanations and then accept them only if convinced.

3.Some will do as they please – Some patients come to the doctor for a diagnosis but then would go on to not taking the recommendations given or designing their own treatment. I have a patient who come to me for a diagnosis and then take homeopathic medicines on her own (including homeopathic vitamins!)

4.Some are doubting Toms – Some patients would google around, question the doctor (the inquisition!) and get second opinions for the same problem and then do as they please. they may or may not accept any of the recommendations made. Their belief in Dr.Google is much higher than any doctor that they can meet face to face!

5.Some are pessimistic – and would doubt if anything would work at all.

Doctors are not all the same:

1. Some have a patriarchal attitude – would like to play God, not tolerate any questions and would demand a free hand to deal with the medical problem as they wish.

2. Some will be very patient and hear you out fully.

3. Some doctors will be willing to give you limited time only. For example, I set out to give my new patients 20 mins and 10-15 mins for the old (review) ones in my Out Patients. Of course sometimes it would take longer.

4. Some doctors will be willing to explain in detail and involve you in the management planning and some may not. Some will not share information such as the blood reports (especially if you are the attendant) and some will share all details with you.

5. Some doctors are “commercial“. (requesting too many tests)

6. Some doctors rely solely on their clinical judgement. (one man show)

7. Some doctors are excellent Team players and have an excellent network of specialist to support their practice.

8. Some doctors work in small clinics, some in small and medium hospitals and some in large Corporate Hospitals and reputed Centres.

Unfortunately, there is no easy way to grade these doctors based on where they work. Patients therefore often rely on second hand information to choose their doctors. And this isn’t the right way to do it.

There are different qualities that go to make a good doctor!

1. Theoretical knowledge and keeping yourself up to date.

2. Diagnostic abilities

3. Therapeutics and knowledge of medication and how to use them.

4. Procedural skills (Operative skills especially for the surgeon)

5. People and communication skills.

6. Speciality knowledge (of other specialities)and knowing when to refer.

7. The Team (of Doctors -of quality specialists who support the Doctor’s practice)

8. “AFFABLE, APPROACHABLE, AVAILABLE AND ABLE!”

Doctors working in different setting may have different abilities, perspectives, Intentions and shortcomings!

A m in a small clinic may have limited knowledge, limited contacts and therefore limited ability to help you. The advantage may be of low cost treatment with short waiting times.

A may have a better team (of supporting specialists) to treat you in case of serious illness. The quality of the team could however be variable. The patient may need to travel outside the hospital for specialised tests such as MRI/PET scans etc. The quality of care could depend on the philosophy of the hospital owner and the supporting specialists.

In a Corporate Hospital, the care could be of a very high standard but could also be very expensive or without personal touch. Improved hospitality and facilities (all under one roof) would come at a tremendously increased cost. The Quality of the treating doctor may also vary and personalised care may not always be possible especially if the doctor is too busy. The doctor may have too little time to spend talking to the patient.

So what I recommend to those looking for a Doctor is

1. Begin your search for your Doctor much before you actually need one.

2. Have a doctor who is interested in coaching you on how to stay healthy.

3. Find a doctor who isn’t too busy to give you “enough” time and whom you could approach for every small ailment.

4. Find a Doctor who has a good Team to treat you in case of more advanced disease and who can give you impartial advice based solely on your needs and who can refer you on to the right specialist for you.

I wish you my very best in your search for your perfect doctor!

Hormone therapy at Menopause

/ Subash Rau / Leave a comment

Menopausal Hormone Therapy (MHT) is predominantly indicated for 3 purposes – Vasomotor symptoms, to reduce fracture risk and to treat genitourinary syndrome of Menopause.

Vasomotor symptoms affects 70% of mid life women. Hot flushes and night sweats affect sleep, daily functions, quality of life and affect cognition and cause mood swings. MHT is the most effective treatment for Vasomotor symptoms. In the absence of Vasomotor symptoms alternative therapies must be used to reduce fracture risks and treat genitourinary syndrome of menopause.

General notes on MHT

-MHT provides very low doses of Estrogen compared to physiologic levels and has a high degree of safety compared to Oral Contraceptive Pills.

-The lowest effective dose is used and therefore the patient must be warned that it may take a considerable time before the benefits are noted (up to 3 months).

-Only Estrogens are given for people without a uterus. Both Estrogen and Progestogens are given for women with intact uterus (to prevent endometrial hyperplasia). Estrogens are taken daily as pills or transdermal patches (once or twice a week) and as transdermal gels and vaginal rings. Progestogens are available as oral pills and are either take as a combined pill or cyclically for 12-14 days every cycle. The combined pill is preferred by many women in whom it induces amenorrhea. Cyclical Progestogens induce predictable withdrawal bleeding. Transdermal Estrogen patches are useful in obese women with cardiovascular risk factors.They have a “hepatic first pass” mechanism and do not increase coagulation factors and hepatic binding proteins, therefore they do not increase risk of DVT even in obese or thrombophilic patients. Progestogens cause drowsiness and may be taken at night.

– Women experiencing early or surgical menopause (<45 yrs) must be encouraged to use MHT till the age of 51 unless contraindicated.

– The decision to initiate MHT should involve careful assessment of potential benefits and risk.

– Optimum duration of treatment of MHT can vary from woman to woman.

Absolute Contraindications for MHT

1. Breast Cancer

2. Endometrial cancer

3. CArdiovascular disease

4. Active Liver disease

5. Undiagnosed Vaginal bleeding

Side effects of MHT

1. Increased risk of Strokes (additional 0.5 cases per 1000 women per year.

2. Increased Venous thrombotic events with Estrogen pills and not with transdermal patches.

3. Increased Breast cancer risk but only after prolonged use (4-5 yrs)

4. Gall bladder disease with Estradiol pill and not with Transdermal patches.

Bromhidrosis – Bad Body Odour

/ Subash Rau / Leave a comment

Bromhidrosis refers to excessive foul smelling sweat. Other synonyms include Osmidrosis and Ozochrotia. It is diagnosed when noticeable body odour has a negative effect on an individuals self view, social interactions and Quality of Life.

2 types of Sweat glands are seen
Apocrine – It develops at puberty and usually disappears in the elderly. It usually affects axilla, anogenital (perinatal) areas and the breasts. The primary role of Apocrine glands is to secrete Pheromones.

Eccrine glands are distributed all over the body especially over the palms and soles.They are not found in the External Auditory Canal, Lips, Clitoris, Labia minora and Glans penis. Eccrine glands are primarily responsible for thermoregulation and secrete water based secretions. Eccrine Bromhidrosis can occur at any age and can be localised or generalised.

Pathogenesis of Body odour
Sweat is usually odourless and its secretion is controlled by the sympathetic nervous system. Heat, exercise, emotion, certain foods and medicines stimulate its secretion.

Apocrine glands secrete odoriferous fatty acids bound to odour binding proteins. Bacterial action releases odour causing fatty acids leading to the malodour. A variety of bacteria such as Corynebacterium, Staphylococcus, Cutibacterium (previously called Propionobacterium) and Sphinogomonas act on the apocrine secretions and produce odour. Pheromones such as Androsterone and Androsterol are also malodorous. Poor hygiene especially in diabetics and obese individuals cause odour especially with skin conditions such as Erythrasma, Intertrigo and Trichomycosis axillari.

Eccrine Bromhidrosis: Sweating leads to maceration of skin and secondary bacterial growth and skin degradation. Eccrine bromhidrosis can occur due to:
Diet – garlic, onion, curry and alcohol
Medication – Penicillins and bromides
Toxins – heavy metals
Metabolic causes – Phenylketonuria, Trimethylaminuria, Isovaline acidaemia, Hypermethioninemia.
Systemic diseases– Liver and Renal failure, Gout, Scurvy and Typhoid.

Diagnosis requires elicitation of a detailed history.
Usually Lab tests are unnecessary.

Treatment of Body Odour
1.Personal hygiene: to bathe regularly and daily but not excessively. Excess washing may cause skin irritation. Intertrigo, erythrasma need to be treated.
2.Clothing: wearing absorbent clothes/cotton clothes may help. Sweat soaked clothes need to be change immediately. Washed clothes need to be sun dried.
3.Exfoliation: to remove stratum corners may help.
Hair removal by shaving, chemical epilation, electrolysis and laser treatment may be helpful.
4.Antibiotics – applied topically may help. Topical Erythromycin and Clindamycin are commonly used. Prolonged continuous therapy may be needed.
Oral Roxithromycin 150 mg twice daily for 7-10 days may help.
5.Topical antiperspirants: Antiperspirant contain aluminium salts that plug sweat ducts and reduce seating.
6. Antifungal dusting powders may also be helpful.
7. Botulinum toxin Injection: Skin injections can temporarily reduce sweating.
8. For Refractory Localised Bromhidrosis- destruction of Apocrine glands is an option by surgical excision,Liposuction, microwave and Nd-YAG or CO2 laser can be helpful.
9. Thoracic sympathetectomy can be done with good results.

Treatment options for Axillary Hyperhidrosis (sweaty armpits)
1.Topical Antiperspirants (Aluminium containing gels) need to be applied nightly without occlusive wrappings. Topical Glycopyrrolate 2.4% can reduce sweating significantly.
2. Systemic agents – Anticholinergics- Glycopyrrolate can take up to a week for effect.
Clonidine 0.1 mg twice daily, Beta Blockers, Benzodiazepines will reduce sweating.
3. Iontophoresis
4. Microwave Thermolysis
5. Botulinum toxin injections can temporarily reduce sweating.
6. Surgery: Endoscopic thoracic sympathetectomy

News on Cholesterol

/ Subash Rau / Leave a comment

2 articles have been published recently in the JAMA adding a little more confusion regarding dietary cholesterol and its association with Cardiovascular disease and mortality. The recent publication of the dietary guidelines for Americans proclaimed that it would no longer include the recommendation to limit dietary cholesterol to <300mg/day, as there was no appreciable relationship between dietary cholesterol and serum cholesterol. Although the guidelines advise to eat as little dietary cholesterol as possible, it sent the opposite message to the public. Recent study pooled individual level data from 29615 participants in 6 prospective cardiovascular disease studies in the US. The authors observed the following:

– The risk of dietary cholesterol affecting cardiovascular outcomes is probably modest only. However, consumption of every additional 300mg of dietary cholesterol was associated with a higher risk of incident cardiovascular disease and total mortality.

– The increased risk ranged from 1 to 4% over a 17.5-year follow-up period.

– The studies done so far also suggest dietary cholesterol could have variable effects on different cardiovascular diseases i.e. strokes, heart attacks and heart failure.

– The risk of adverse events was not seen in those who had a very low cholesterol at base line i.e. those with elevated base line cholesterols (LDL) had a higher risk for adverse cardiovascular events.

– The authors assert that high sodium foods and foods rich in simple carbohydrates (sugars, sweets and polished cereals) and trans fats should be avoided altogether. They also advised that the individual checks his cholesterol levels and adjusts his diet accordingly.

In another study published this month in the JAMA, TMAO (Trimethylamine N-oxide) was identified as a possible culprit in producing cardiovascular disease and increasing all cause mortality. In the previous decades, doctors had pinned the blame for heart disease on saturated fats. The long chain saturated fatty acids in meat steaks, butter and coconut oil which raised the LDL cholesterol was thought to be the culprit for heart disease and death. Recent meta-analysis of dietary recall studies seems to suggest that this relationship was not as tight as previously thought. Researchers are currently homing in on another possible culprit i.e. TMAO which is possibly an additional biological pathway by which red meat increased heart disease risk. The body makes TMAO from foods with choline and L-carnitine which are found abundantly in meat, poultry, fish, dairy and egg yolks. These proteins are broken down by gut bacteria to form trimethylamine (TMA) which is then converted into TMAO in the liver. Red meat is high in L-carnitine and has been shown to raise the TMAO levels more than white meat or non-meat proteins. It also tends to shift the gut microbiome, fuelling more bacteria to produce TMA. The authors conclude that the carnitine-TMAO pathway is a partial reason for the heighted mortality and cardiovascular risk with chronic red meat diet. They conclude that TMAO generation requires the right gut bacteria and this could be another path to reducing cardiovascular events.

Author’s note:

– This may be another reason to take pro-biotic rich foods although we are still unsure as to which bacteria are truly beneficial.

– There are so many different processes that affect what happens inside the body. It is therefore important not to get carried away with every new theory and finding but to adopt moderation in dietary habits and to focus on having adequate plant-based, whole-grain, fibre-enriched and balanced diet.