IF YOU MUST GO TO BANGKOK, TAKE YOUR SPOUSE ALONG!

The heading of this article must sound strange but I have been pushed to write this article after another of my patients came back from Thailand, all stressed out and looking depressed. This young man had gone to Thailand with a few of his friends and had had a “regrettable” encounter with a commercial sex worker! During the course of my 25 yrs as a doctor, I have seen many a good man being remorseful after coming to his senses and (out of his alcohol or drug induced fugue) filled with guilt and fear on returning to his wife and life in Chennai. I write this article for the benefit of someone planning on being naughty on a holiday and hopefully, to give you enough information to help you stay safe during your trip.

What are the common sexually transmitted infections?

Syphilis, Gonorrhoea, Chancroid (Bacterial infections), Lymphoma granuloma venereum (Chlamydial infection), HIV, Genital herpes (HSV), Genital warts (HPV) (viral infections) and Trichomonas vaginalis (protozoal). Hepatitis A, B, C and pubic lice can also be transmitted during sex. HIV chlamydia and gonorrhoea are transmitted by sexual (body) fluid, HIV and Hepatitis B are transmitted via blood and Genital herpes, papilloma viruses and Syphilis are transmitted by skin to skin contact. Except for HIV, all STIs are curable if detected.

What are the risks of transmission of STD after a single heterosexual encounter?

The risks for women are much higher than it is for men. Syphilis has a 50-65% risk per sexual act, Gonorrhoea has a 20% risk for men and 60-90% risk for women to catch an STI after a single unprotected sexual act. Chlamydia has a 4.5% risk per sexual act and Mycoplasma has a 20-65% risk. HPV and genital warts are transmitted 4% for men and 3.5% for women after a single sexual act. The risks for HIV transmission is 0.05-0.1% for men and 0.08-0.19% for women after a single act. Receptive anal and vaginal intercourse has a 10 fold increased risk of infection transmission compared to Insertive anal and vaginal intercourse. Luckily the risk of catching HIV is a lot lower than for other infections. You should consider all sexual encounters with people not known to you in a foreign country as a high risk (for infection) encounter. Receptive Anal/Vaginal sex is more dangerous for catching an STI compared to Insertive sex and oral sex!

How soon will you see the effects if you catch any of the common infections?

Different infections have different incubation periods ( the time taken for the first symptom after entry of the pathogen into the body i.e., infection).

So what symptoms should you look for in case you have had an unprotected sexual encounter?

Common symptoms to look out for are Genital ulcers, enlarged lymph nodes in the groin, urethral discharge with burning on urination, vaginal discharge and fever, body aches, joint aches, headaches and rash etc. Most symptoms would show up a few days to upto a month after unprotected intercourse.

What tests are useful in the diagnosis of STIs?

Swabs from ulcers, from mucous membranes of the penis, vagina and mouth. Serological tests (to check for antibodies to certain infections) can be done for Chlamydia, syphilis and for HIV.

For syphilis, TPHA and FTA-ABS can be done. Nuclear antigen amplification tests or PCR can be done for HIV, Chlamydia, Chancroid, Gonorrhoea, Herpes, Trichomonas, Candida and bacterial vaginosis can be done. Biopsy can be done for genital warts.

What antibiotics are useful after unprotected sexual intercourse?

Azithromycin 1gm stat will treat Chlamydial infections and Chancroid.

Doxycycline 100mg twice daily for 14 days for Syphilis and Donovanosis.

Valacyclovir 1gm twice daily for 10 days for Genital Herpes.

Fluconazole 200mg at night for 3 days for Candidal infections.

Metronidazole 500mg twice daily for 7 days for Trichomoniasis.

Inj. Ceftrioxone 500mg IM stat for Gonococcal infection.

Inj. Benzathine penicillin 2.4 MU IM stat for primary syphilis.

Taffic (Bictegravir 50/Emtricitabine 200/Tenofovir Alafenamide 25) once daily or Viropil (Dolutegravir 50/Lamivudine 300/Tenofovir Disoproxil fumarate 300) once daily for 28 days, to be started as soon as you suspect that you may have caught HIV infection.

How do you protect yourself from catching a STI/STD?

1. Avoid going to places of temptation in the first place. If you must, take your spouse along with you!

2. Avoid mixing alcohol and drugs with sex. These substance will reduce your inhibitions and fear and make you do things that you wouldn’t do if you were in your senses.

3. Limit the number of sexual partners.

4. Use barrier methods of contraception. Use condoms, oral dams etc and avoid skin on skin contact and exchange of body fluids. Oral sex isn’t safe!

5. Get to know your partner before hand and if possible have an honest talk about previous sexual contacts, sexual habits and preferences and history of previous STIs.

6. Get yourself vaccinated against all possible sexually transmitted infections such as Hepatitis A and B, Human Papilloma virus etc.

7. Test yourself regularly especially if you have had numerous sexual contacts with multiple partners.

To sex or not to sex, that is the question you need to ask yourself! (All pun intended) If you choose to have sex, take all necessary precautions. If you have had unsafe sex or if you can’t remember, see your doctor as soon as you return and start relevant prophylactic medicines (as no test will be positive in early infection especially when you are asymptomatic).

So plan now and don’t regret later.

Secrets of Centenarians – the 9 habits of successful Centenarians!

As a doctor I have always been interested in knowing the secrets to a long life. Many people who lives long lives have very few if any diseases, apart from an old body (if you can consider that a disease) and remain surprisingly sprightly even in their 90s. Many others bravely tackle their medical and age related challenges and live a long life aided by modern medical treatments. So it was extremely exciting to find an article in The National Geographic Traveller magazine (Indian edition -May June 2022) which spoke about food and lifestyle habits of people who had a greater chance of living long lives (Centenarians) in certain areas of the world. The article quoted from research done by Dan Buettner, a longevity researcher who called the 5 specific areas of the world, where people were more likely to live up to a 100 yrs, the BLUE ZONES. The article seemed to suggest that these elderly people were living long lives because they were healthy rather than because of modern medicine.

These geographic areas are the following:

1. Greece- Icaria

2. Italy – Ogliastra, Barbagia, Seulo of Sardinia.

3. Japan -Okinawa.

4. Costa Rica – Nicola peninsula

5. USA – Loma Linda, California (Seventh day Adventists)

While the article highlighted the various food cultures of the people in these areas, I was more interested in Buettners “Power of Nine”,the factors/cultural/societal habits that were common to the people who lived in these 5 areas. Lets have a look at these habits.

1. Moving naturally – daily walking and gardening.

2. Purpose – motivation to get up in the morning.

3. Down shift – activities like prayer, meditation and naps and evening drinks with friends)

4. The 80% rule – to always eat only until 80% full.

5. Plant slant – significant portions of beans and greens and small portions of meat.

6. Wine @5 – moderate drinking.

7. Belong – to be part of some faith based community.

8. Loved ones first – to have close family ties.

9. Right tribe – strong social circles.

Many of these points are what I suggest to patients who have clinical depression. It would seem that happiness could be the answer for a long life if one were to remain physically active and eat right ( if you have read about what my grandfather had told me mentioned in my earlier article on longevity). Stress release by exercise and being physically active, stress control by meditation and living in a supportive/encouraging and positive social environment and consuming moderate amounts of alcohol could hold the key to a long life.

I hope and pray that you will incorporate these factors into your life and live long!

SHANTAMANAM BHAVATI!

A Earache – what you need to know!

Most of us would have at some point had a severe ear ache or seen someone else (usually a child) crying out in severe ear pain. The article will provide you with some information on the common causes and what you can do if you have someone with a earache to look after. Of the common causes for ear ache the first 4 conditions are more common in children and the last few ones are commoner in adults. Before that, lets have a quick look at the anatomy of the ear to get a better understanding of the problem.

The external ear or the Pinna behaves like a funnel collecting the sound waves from outside the body and directing it inside the ear where they hit the eardrum and make it vibrate. The portion of the ear upto the eardrum (from the outside) is called the External ear. Touching the eardrum are bones that sequentially transmit the vibration to the snail like Cochlea which is the organ that converts the sound vibration to electrical impulse which is conducted by the auditory nerve to the brain where the electrical impulse is interpreted as meaningful sound/voice/music or noice. In the diagram above, the 3 bones that conduct sound waves to the cochlea (i.e., Malleus Incus and Stapes) lie in the middle ear and this chamber is connected to the back of the throat by the Eustachian tube (in pink). The Eustachian tube maintains equal pressure on both sides of the ear drum permitting free undampened vibrations of the ear drum to incident sound. The inner ear (found deep inside the bone) also contains the organs of balance – Utricle and saccule and the semicircular canals.

Therefore the ear has 2 functions – hearing and balance!

Conditions causing Ear ache

1. Otitis externa (External ear infection) – is usually caused by trauma or injury caused by over enthusiastic ear cleaning with the finger or the ear bud. Less frequently it can happen after a swim in the pool. The tissues of the outer ear are tightly attached to the underlying bone and therefore any infection or boil, produces severe pain. The ear lobe could be red and swollen. Looking into the ear with a torch may show the boil or if pressing on the tragus (the small prominence just in front of the opening into the ear) or pulling the ear give severe pain – this would also indicate external ear infection. This would need antibiotic ear drops prescribed by your doctor.

2. Shining a light into the ear may also show an insect that can be the cause for pain. Shining a bright light may draw the insect out. Please don’t put oil into the ear (especially if you know that the ear drum is perforated)

3. Eustachian tube dysfunction – When the person has a mild cold, the excess mucous secreted may occlude the Eustachian tube. The air in the middle year then get absorbed and this negative pressure would draw the eardrum insides and reduce its vibrations to sound. Therefore people may have a feeling of reduced hearing. This is very common during a aeroplane flight. Sudden changes in altitude can even cause rupture of the ear drum (Barotrauma). The ear could pop open on yawning or blowing out with a pinched nose giving some relief. Using a nasal decongestant drop or using Vicks inhaler might help. Eustachian tube dysfunction commonly occurs in those with respiratory allergies, dust exposure and infections. If this condition doesn’t resolve, persisting negative pressure may draw out the fluid into the middle ear from the blood vessels causing serous otitis media. If bacteria invade and proliferate here, it becomes Acute suppurative (pus producing) Otitis media (middle ear infection).

4. Acute Suppurative Otitis media (ASOM) – this often presents with severe ear pain, reduced hearing and often with fever. Pulling on the ear or looking into the ear would not give severe pain. Sometimes there could be a spontaneous rupture of the ear drum and release of copious pus from the ear, also relieving the pain to an extent. This condition requires specific antibiotics and requires you to go to the local ENT surgeon for advice. If inadequately treated, the infection could become chronic (CSOM) and also spread inwards to the bone and the brain.

5. Herpes Zoster Oticus – relapse of the chicken pox virus affecting the ear could be a cause for severe earache with a rash around the ear. It may also cause hearing loss, ringing in the ear, vertigo, difficulty in closing the eye and a dry mouth.

6. TMJ Dysfunction – Temperomandibular joint is formed between the jaw bone and the undersurface of the skull. People who have a habit of biting only on one side or grinding their teeth can develop pain around the ear. This pain would be worse on opening the mouth widely and on chewing.

7. Pain referred to the ear due to stimulation of commonly innervated body parts- The tonsil and the ear may be supplied by the same nerve (the glossopharyngeal Nerve) Therefore irritation of the nerve due to Tonsillitis would cause pain to be referred to the ear. Similarly other nerves such as the Trigeminal, Facial, Vagal and somatic cervical nerves may also in certain conditions cause an earache.

Take home points:

Any medicine that you have taken for pain before would work to relieve an ear ache. Paracetamol or any other anti-inflammatory medicine can be given until you see the doctor.

What do you do when you have a Red Eye?

There are many causes for a red eye and most people get very alarmed on seeing a very red eye. This article hopes to share some information about the common causes for a red eye and what one should do after developing a red eye. Before we go into the causes and the a development of a red eye, lets briefly look at the anatomy of the eye in the picture below.

The eye is like a ball made of the tough sclera (white part of the eye) all around except in the very front of the eye where the transparent cornea is attached. The front part of the sclera is covered by the protective conjunctiva which folds under the eyelids. The conjunctiva has a rich supply of blood vessels and they open up whenever there is an irritation and make the eye red.

The cornea is the transparent window that allows the light inside the eye. The amount of light allowed in is controlled by the iris and its central opening called the pupil. The lens of the eye which is biconvex focuses the light on to the fovea , an area on the retina where light is transduced into electric impulses that are carried by the optic nerves for interpretation in the brain.The retina is the inner most layer (of nerves) inside of the sclera and is separated from the sclera by the vascular choroid layer.

The eye is an extremely sensitive organ and the body does everything to protect it. Therefore any irritation which may be due to injury, abrasions, allergy, infection immediately stimulates an increase in the blood flow into the eye to help contain and repair the damage sustained. So a red eye is an indicator that all is not well with the eye.

So when should you go immediately to an Ophthalmologist or to a Eye hospital?

You need to go immediately to an eye hospital if you have severe pain in the eye or if your vision is impaired or if your pupils are irregular. There are 6 conditions that should make you seek help immediately.

1. Severe conjunctivitis : the eyes would be red, painful and with a lot of pus like discharge from the affected eyes.

2. Corneal ulcer is an extremely painful condition and can happen due to accidentally touching the eye, rubbing the eye or due to some caustic fluid splash on the eye or due to herpetic infection. The eye will be red with excessive tearing and patient would find it difficult to open eye and look at light.

3. Uveitis – is when the iris and the ciliary body are inflamed due to an infection or any other condition. The eye will be red, painful with visual loss and inability to look into the light (Photophobia). On examination the pupils could be small and irregular and pus collection inside the eye may be made out (Hypopyon)

4. Acute angle closure glaucoma – can happen with those with farsightedness.The eye is filled with fluid that must be circulated. For many reasons when the drainage of this fluid is blocked the pressure increase inside the eye leading to the condition. The eye of such a person is red, very painful, vision is blurry, and nausea and vomiting may happen. On examination the cornea may be hazy and the pupil is dilated.

5. Herpes Zoster ophthalmicus- is a condition when the ophthalmic division is affected by the Varicella zoster virus (which causes chicken pox). Much after the initial chicken pox is overcome, the virus comes out of hiding along certain nerves to produce small vesicles on the skin. When this process affects the eye, it is a ophthalmic emergency.

6. Scleritis – also shows up with red painful eye with visual loss.

The way to approach a red eye when there are no worry signs is as follows-

1.Look out for discharge from the eye-if there is no discharge it could be sure to a sub conjunctival bleed which is usually seen in an elderly patients who may be on blood thinners and might have strained hard recently (or even after a bout of violent coughing or sneezing) This can

happen suddenly and may be noticed after a overnights sleep leading to severe anxiety.

2. If the discharge happens only intermittently- it could because of dry eyes, again something that is common in the elderly. Dry eyes can happen after prolonged screen times and in conditions such as Sjögren’s syndrome. Using artificial tears eye drops will make things much better.

3. If the discharge is continuous – to see if the discharge is watery or purulent (pus like).Pus like discharge always indicates infection and will get better with antibiotics (eye drops and tablets). If the watery eye discharge is associate with mild itching, it could be due to viral conjunctivits and if the itching is severe, it could be due to allergic conjunctivitis.

Take home message:

1. If the red eye is very painful, with visual loss and irregular pupil – rush to the Eye doctor/hospital.

2. If the red eye is not or minimally painful, with clear vision, mild irritation and discharge – you can probably wait till the next day before going to see an ophthalmologist.

3. If you are very anxious or in doubt – see the ophthalmologist immediately.

WHAT A HEADACHE!

We all get headaches sometime or the other in our lives! I remember my first episode of migraine which I got when I was in 7th grade. My mother rightly diagnosed me to have migraine (being from a family of doctors), gave me some paracetamol and had asked me to go to sleep. I got my eyes checked a few days later, started wearing prescription glasses and never had migraine again for several years. My father told me that only intelligent people got a migraine and that made me very proud of my headache as none of my other siblings had a migraine till then. Apart from Migraine, one can have a headache from many causes such as head injuries, cervical spondylosis, dental caries, sinusitis, high BP,depression, malocclusion and Temperomandibular joint dysfunction etc.

So when should you go to the doctor and hospital immediately?

What are the danger signs in headache?

1. The worst headache in your life or a “bolt out of the blue” type of a headache.

2. Headache associated with slurred speech, visual disturbance, weakness of limbs, inability to walk due to loss of balance, confusion or memory loss.

3. Headache that happens after weight lifting or sex.

4. Headache after a head injury (however mild especially in the elderly)

5. Headache with recurrent vomiting.

6. Headache that wakes you up from sleep or is the worst after waking up in the morning.

7. If you have a chronic headache but its character and severity has changed recently.

Headaches may be classified as primary or secondary to other illnesses. The primary headaches are Migraine, Tension type and Cluster headaches. So lets look at the classic presentation of the common headache syndromes.

Migraine – this headache is usually episodic (can last for a few hours to 3 days) , usually unilateral, throbbing or pulsation and often associated with nausea, vomiting, visual disturbances (aura) and inability to look at the bright lights and handle loud sounds. Sufferers would usually prefer to lie still with their eye closed as the headache could be made worse by movement. Migraines are often precipitated by certain foods (cheese, chocolate, Agina Moto – MSG) sleep deprivation, hunger and stress. Migraine could get much better after sleep and after vomiting. A variety of medicines are available for the treatment of Acute Migraine and prophylaxis (preventive) therapies are available if the patient has more than 2 attacks of migraine a month.

Tension type Headache– this headache usually affects the back of the head and usually in the evenings. It may be associated with scalp tenderness and may be provoked by emotional stress, fatigue,notice and glare. Treatment of anxiety and depression may be needed.

Headache due to Sinusitis – headache due to sinusitis may feel more like head heaviness. The sinus are air pockets in the skull bones that are lined by mucous producing membranes and they drain the mucous produced into the back of the nose. They exist to make the head feel lighter and to provide resonance to the voice. When the drainage passages of the sinuses are blocked, they fill up with mucous, bacteria migrate into the sinuses and the mucous changes colour to yellow. Typically patients have a constant dripping from the sinuses into the back of the throat and there may be tenderness over the affected sinus. Sometimes the headache gets worse on ending downwards.

Cluster headaches are not so common. The headache is severe, unilateral, behind the eye and associated with a blocked or a runny nose on the same side and a red tearing eye. The headache can occur in clusters, lasting 15min to 3 hrs, daily for several days together. They can happen at night and wake the person up from sleep and can have specific triggers like migraine. But in contrast to migraine, the headache is non-throbbing/pulsatile.

Headache due to cervical spondylosis – severe spondylosis affecting the upper cervical vertebrae can give a severe headache which affects the back of the head right upto the vertex ( the top of the head on looking down). Movements of the neck are painful and could be restricted with neck stiffness.

Headaches due to a brain tumour– brain tumours increase the pressure in the brain and cause pain by displacing the pain sensitive structures. The headache is worse on lying down, can wake the person up from sleep or worsen and peak on waking after a nights sleep. Sometimes the headache can worsen after coughing or sneezing. The headache may be associated by visual disturbances or loss of balance, loss of power in limbs, confusion and memory disturbances.

Other headaches occur acutely due to a cerebrovascular catastrophe like a subarachnoid bleeding where it is severe, associated with vomiting, visual disturbance and abnormalities of consciousness. Meningitis can also cause a headache with fever and neck stiffness (inability to bend neck forwards)

Headaches can also occur with high BP usually above a systolic value of 180mmHg. The headache could be quite variable in character as well as in severity.

So what must you do if you have a headache?

The first thing is to see if it has any danger signs. If yes, please go to the emergency department of a good hospital. If not, you could take a paracetamol tablet, go to sleep and fix an appointment to see you doctor the next day. Most headaches are curable and they just require the doctor to find the best medicine for its control or cure.

Male Sexual Dysfunction

Male sexual dysfunction includes the following: decreased Libido, Erectile dysfunction (ED), ejaculatory disorders and disorders of orgasm. All types of sexual dysfunction increase with age.

Libido is the medical term for sexual drive or the desire for sex and decreased libido can occur in 5-15% of adult males. Libido is influenced by biological, psychological and social factors. Sex hormonal levels, stress and depression, endocrine conditions such as hypothyroidism, drugs such as antidepressants,antipsychotic, opioids, beta blockers, substances such as smoking and alcohol can affect libido.

Erectile dysfunction refers to the inability to attain and maintain a sufficiently rigid penis to permit penetrative sexual intercourse. It is very common and is estimated to affect 50% of all men between the ages of 40-70 yrs sometime during their lifetime. Common causes for ED are Vascular (arterial and venous), neurogenic, hormonal and psychogenic. Erections are Neuro vascular events provoked by thoughts, visual images or dreams.

Erections start when the mind is stimulated by erotic thoughts, visual stimuli or sounds. These electric discharges from the brain stimulate the erection centre in the lower spinal cord (segments T11-L2). Impulses generating from this area, stimulate vasodilation of the blood vessels flowing into the penile muscles. Rapid filling of the penis leads to compression of the penile veins until it leads to the attainment of an erection. When nitric oxide (vasodilatory mediator) is metabolised and also in stimulation of the Noradrenaline system, vasoconstriction occurs and the blood flow into the penis is reduced with subsequent drainage of blood out of the penis and loss of erection (detumescence). Therefore attaining an erection requires appropriate Mental and psychological function, intact neurological pathways, open blood vessels and hormonal activities. Erections can also happen to penile stimulation and spontaneously during sleep (normally 3-4times per night)

Ejaculatory disorders could be premature ejaculation, retrograde ejaculation, delayed ejaculation, anejaculation and anorgasmia. Premature ejaculation refers to when the man ejaculates within a minute of vaginal penetration or sooner than desired. It can occur in upto 30% of men. Retrograde ejaculation refers to backwards discharge of semen during intercourse into the bladder which then comes out during urination. This is one of the causes for infertility and may not require treatment unless fertility is desired. Ejaculation occurring after a reasonable period of sexual activity is called delayed ejaculation. Anejaculation is when there is no ejaculation after sexual stimulation and may be associated with anorgasmia.

What is required to find the cause for male sexual dysfunction?

1. A thorough medical history including a history of diabetes, hypertension, prostate disease, obesity, dyslipidaemia, depression, chronic kidney disease, sleep apnoea, substance abuse and medications (including off label medications) used. A detailed sexual history of the patient, including that of sexual preference, frequency of dysfunction and the circumstances associated with dysfunction needs to be elicited. History of injury to hip or genitals or pelvic surgery may be causative. A history of spontaneous erections occurring at night would make a vascular or neurological disease unlikely and a psychological cause more likely.

2. A thorough medical examination including examination of the genitals and a rectal examination to examine the prostate gland would be needed.

3. A thorough psychological assessment by an experienced counsellor.

4. To do appropriate tests such as general screening tests (CBC, ESR, RFT-E, LFT, Lipid profile, Hba1c, urine complete, stools complete and an ECG. More specific tests might include Thyroid function tests, Testosterone and LH assays, Penile Doppler and Ultrasound whole abdomen and Rectal ultrasound in select cases.

There are 5 broad categories that cause male sexual dysfunction. They include 1.Systemic diseases such as Diabetes, hypertension, heart disease, chronic kidney disease, 2.Psychological causes, 3.medicines (25% of all causes) 4.endocrine disease such as thyroid dysfunction and androgen deficiencies and 5.Neurological causes such as spinal cord diseases, multiple sclerosis and dementia.

Commonly prescribed medicines that can cause sexual dysfunction in men are:

1. Antidepressants – SSRIs

2. Antihypertensives medications: Betablockers, Amlodepine, Chlorthalidone, Enalapril and Doxazosin.

3. Antiandrogens – Androgen deprivation therapy

4. Others- Clonidine, methyldopa, ketoconazole and Spironolactone.

Treatment of Male sexual dysfunction

1. Lifestyle changes – advice patient to stop using recreational drugs including alcohol and cigarettes and help him with Deaddiction. Weight loss and physical activity will also help improve the situation.

2. Professional counselling – counselling patient with partner by a sex therapist may be helpful.

3. To stop medicines that can cause sexual dysfunction.

4. To correct androgen deficiencies and other endocrine disorders ( Thyroid, Prolactin and Estradiol). To stop antiandrogens including Finasteride and Dutasteride if possible.

5. To provide a prescription for a phosphodiesterase 5 inhibitor – Sildenafil, Tadalafil etc.

6. To consider surgery – penile prosthesis

7. Other therapies – use of a vaccine device, intraurethral alprostadil suppository etc. Premature ejaculation can be treated with counselling and use of Lignocaine/Prilocainegel on penis before intercourse.

Patient stories: One gentleman who was 70 yrs old and was on treatment for benign prostatic hypertrophy on Urimax F (Tamsulosin and Finasteride) came to me with a history of erectile dysfunction. I suggested that he change his Tamsulosin to Alfuzocin, stopped the Finasteride and also gave him a prescription for Tadalafil.

Patient 2 was a 50 year old who was on SSRI antidepressant and who reported loss of libido. I asked him to change his Escitolopram to Mirtazapine with good effect.

Patient 3 was a retired banker who had had presented with dullness, slurred speech and memory deficits. Investigations had shown low sodium, hypopituitarism, hypogonadism and atypical tuberculosis.1 yr after recovery he was started on Testosterone injections for lack of libido and ED and reported good improvement in his complaints.

Male sexual dysfunction has many effective therapies but often needs a multidisciplinary approach to providing the best care.

What are the 5 medically proven things that you can do to live longer?

There are many people in this world who would love to live upto a 100 yrs of age. My own grandfather was very keen to live to see a 100 but unfortunately died 4 months past his 99th birthday. The average lifespan of an Indian has been constantly increasing over the last 30 yrs. In medical college I had learned that the life expectancy at birth of the average Indian male was 56 yrs (in 1988) but it has risen to 69.6 years in 2019. WOW! The Indian male can today expect to live 13-14 yrs longer than 30 yrs ago! Of course the Indian lady has always lived much longer than the man! I have always been curious about longevity ever since I heard my 7th grade classmate claim that his grandfather was 90 yrs old because he took one Badaam (Almond) a day, everyday! I had asked another grandfather what his secret to his long life was and he had replied, “no worries, hahaha”! I have read many books by current authors who claim their methods will get you to live upto 120 yrs but none of them,I am sure are even a day older than 60! Surely it wouldn’t be prudent of me to wait 60 yrs to know if there were right! It so happened that one day as I was shifting my books from the old cupboard to a new one, I stumbled upon a book that was with me for many years but had never been leafed through. And to my surprise, the author a physician/cardiologist mentioned that there were only 5 things proven with reasonable certainty in published medical literature that could prolong life. Hold your breath folks, the answer is coming up shortly…………..

1. Non-smoking – didn’t your mother tell you “never to smoke”, didn’t she tell you that it causes cancer, heart attacks, strokes, kidney failure and impotence!! Smoking is injurious to your health and your dynasty! That is a no brainer, NOT smoking will help you live longer and better.

2. Modest (daily) Alcohol consumption – hail Bacchus, the God of good times! May every party start with salutations to you. The important word to watch out is MODEST alcohol intake. Modest alcohol refers to 3 units (1 unit = 30ml) for men and 2 units for women a day. The daily intake recommendations are intended for societies where it is normal for people to drink daily. Like the French who may drink a glass of wine with lunch and even be allowed to fly a plane for Air France!If you are a teetotaller,I wouldn’t recommend that you start drinking for health! It is also recommended that you don’t add your daily quota for a binge during the weekend.That is sure to make Bacchus unhappy and shorten your lifespan.

3. Vigorous daily exercise for at least 30 mins. Daily deliberate exercise ensures that your heart, lungs, all muscles and joints of the body are well oiled and in good condition. Surely you must have heard that “all work and no play makes Jack a dull man”! I would recommend gradually increasing your exercise quota to an hour every day targeting 7 days a week. The intensity can vary depending on you freshness/fatigue levels! Exercising in the evenings have the benefit that you don’t have to spend much time warming up.

4. To achieve your ideal body weight – I have seen many people who go to the gym who are very happy with their physical prowess but are in denial of the fact that they are overweight. So how do you calculate your ideal body weight (IBW)? The simplest way is to subtract 100 from your height in centimetres. I am 185cm in height and so my ideal weight is 185-100=85kg. There is another way to calculate using the BMI. The BMI is calculated by dividing the weight in kilogram by the square of the height in meters. Using my values ……..

The Americans (AHA) have recently reduced the upper value of the ideal BMI for Indians to 23.5 (how dare they!) So to calculate your ideal weight using the recommended BMI value, you will need to do the following sum – 23.5 X 1.85X1.85 = 80.42Kg. So according to the AHA, I would be 4.6 kg overweight! So all I have to do now is to eat less and exercise more to achieve my ideal body weight and live longer – Oh what a beautiful idea Sirji!

5. The last one! The Ideal diet – to eat more fruits and vegetables. It used to be said that “an apple a day keeps the doctor away”. That was appropriate for the days when the average Indian male lived upto the age of 56. But not anymore!! I ask some of my young patients if their parents and grandparents are alive and most would answer in the negative. When I ask them why they had passed on, they would often reply “of old age” and when I ask how old they were, the reply would come “65”! 65 yrs is young by me as I had 3 grandparents alive with me until 10 yrs ago. We need to eat right to live long. The WHO recommends that one consumes nearly 800 gms of fruits and vegetables every day. For a family of 4, it would be 3.2kg of fruits and vegetables every day! This does not happen in even the most affluent families. I think that is important to eat more fruits and vegetables of every colour every day. Salads salads salads is the way to go!

So, these are the 5 proven secrets to a long life. You may want to “Live Young and Live Free” my friend but I pray that you will Live well, Live long……….my best wishes!

Credits:

1. For the last 10 yrs I have been VEGAN. I would recommend a few documentaries on Netflix for you to see. Athletes and Medical doctors recommending similar things for your improved health.

Forks over knives

Game Changers

What the Health

2. Living Longer, Living Better – Dr. Harold H Opie

3. Prevent and Reverse Heart disease – Dr. Caldwell Esselstyn Jr. My respects for this gentleman are sky high for not just be a great doctor but more for his being a Gold medal winner in Rowing at the 1956 Olympic Games! And by the way, Bill Clinton endorse his programme for cardiac health!

How do you tell if your chest pain is serious!

Recently I had a friend come to my clinic with a history of severe chest pain which started off at night and was so severe that she had to go to the hospital nearby for treatment. Apart from the pains what was most terrifying was that she was alone and she was afraid that she was having a heart attack. Luckily, her ECG at the ER was normal, her pain subsided with antacid therapy and she was sent back home. I write this article to tell you how to analyse your pain and what you must do. Of course if you are unable to analyse what you are going through or if the pain is very severe, I would advise you to go straight to the hospital and not lose time pondering as to the cause of the pain.

What are the Alarm signs in a person with a chest pain, things that would require you to go to the ER immediately?

1.Compressive chest pain with severe sweating.

2.Chest pain with severe dizziness

3.Chest pain with new onset breathlessness.

4.Chest pain followed by fainting or loss of consciousness.

5. Chest pain with a low or a very high Blood pressure or with low oximeter readings ( < 92%)or with a high pulse rate (>100bpm)

Lets look at the common causes of chest pain, see how they present typically.

1. Cardiac pain – Pain arising due to a heart attack or angina is typically central, compressive, it could radiate to the left shoulder, arm, jaw or ear and is associated with severe sweating, nausea or vomiting, dizziness and breathlessness. The key words would be pain and sweating. This pain is usually worse on exertion and could be relieved by rest. The typical patient is a middle aged to elderly man who has cardiac risk factors such as obesity, cigarette smoking, high cholesterol levels, diabetes, high blood pressure etc. Postmenopausal women are at higher risk for a heart attack compared to premenopausal women. Also women may have a heart attack with atypical symptoms and even without pain!

2.Acid reflux can also give pain behind the sternal (breast) bone. The pain could be sharp or dull, localised or diffuse. The pain could also be burning and be associated with bile/bitter water rash to the mouth. This is worse after a meal and on lying down in bed after food.

3. Chest pain due to Gas! Pain due to gas is usually sharp localised to a small area and can move quickly from one part of the chest to another or even the back. It could feel like a catch in the chest or like being stabbed and make breathing difficult. This pain usually happens after a meal and is relieved by belching/burping. The key words would be moving pain and relief by belching.

4.Pleuritic chest pain -this pain is sharp and felt on the side of the chest. It worsens on deep breathing coughing and sneezing. This is usually caused by irritation of the pleura , which is the covering of the lung and it occurs when there is a pneumonic infection of the lung. This could be associated with cough, phlegm production and breathlessness. The key words would be chest pain on deep breathing.

5. Musculoskeletal chest pain- this pain can be quite severe localised and can increase on movements, deep breathing and local pressure (which is diagnostic) If the pain increased on pressing the affected part of the chest, it is highly unlikely to be from the heart or the lung and must be from the muscles and bone of the chest. Localised pain on touch and pressure on the side of the sternal bone (2nd Costo-chondral junction is called Tietze syndrome). The key words would be localised chest pain worse on local compression. Similar pain can also happen after a rib fracture.

Other cause for chest pain:

1. Mitral valve prolapse syndrome is characterised by repeated sharp pricking anterior chest pain which may be associated with palpitations and anxiety. It affects women more often than men.

2. Sudden sharp “pleuritic” chest pain with breathlessness and low Oximeter reading could be an Acute Pulmonary Embolism. The usual patient is a woman on contraceptive pills or an elderly person who has made a long haul flight (Economy class syndrome) and has developed a Deep venous thrombosis (DVT). This could also be due to a Pneumothorax. (Punctured lung)

3. Herpes Zoster – the pain of herpes zoster can precede the typical rash by a few days. The pain is severe lancinating continuous and may have a pleuritic component i.e., it worsens on deep breathing.

So what should you do if you develop a chest pain?

1. The first thing would be to check your pulse rate, oximeter reading and your Blood pressure. These equipments are now available in nearly household. If the parameters are very abnormal, it would be sensible to go to the hospital immediately.

2. If you have any alarm signs – a hospital visit is a must urgently.

Spinal Pain – how to tell what kind of a pain it is, so you can get the right medicines for relief!

The vertebral column is made up of 33 vertebral spinal bones stacked one on top of the other like carrom coins. Each vertebral bone is separated from the one above and below by a intervertebral disc which functions as a cushion or a shock absorber.

Each vertebra is made up of a body, pedicle, transverse process, articular process (facet) and spinous process.

The body of each vertebral bone is separated from its fellow above and below by the intervertebral disc in the front and the inferior articular process of the upper vertebra sits on the superior articular facets of the lower vertebra forming the Facet joints. The opening at the centre of the bone is called the Vertebral foramen through which the spinal cord passes. The spinal nerves exit sideways in between the vertebral bones.

The vertebrae are supported and kept in alignment by strong ligaments.

And the ligaments are covered by muscle which not only support the spine but also move and turn it.

There are 4 types of pain that you can feel around the spine – Radicular pain, muscle spasm pain, Facet joint arthritic pain and muscle inflammation (tear) pain.

1. Radicular pain – is pain that runs along the direction of the nerve that is touched/compressed by the degenerative process of the spine as indicated in the diagram below.

Sciatica is a type of Radicular pain that runs down the back of the leg upto the toe. It is described as sudden shooting and electric shock like!

Anti neuritic treatment along with a week’s bed rest will reduce this pain

2. Muscle spasm are a dull continuous and distressing kind of pain which stops you from bending down. The pain is diffuse and the exact location cannot be shown to others.

Muscle relaxants work very well to reduce this discomfort. A variety of different medications are available.

3. Facet joint pain is usually sudden sharp and localised to a small area in the back.

This pain responds very well to anti inflammatory pain killers.

4. Muscle tear pain usually happens from severe stress to the spine leading to a muscle tear. The pain is localised to one muscle which is swollen and tender (pain generated by local pressure)

Anti inflammatory pain killers will work very well to reduce pain. Trapezitis is the term used to describe pain and tenderness of the Trapezius muscle in the neck and shoulder area.

Ice pack for acute pain and Hot fomentation once the severity of pain reduces is helpful.

Spinal support from a neck collar and Lumbar corset can also be quite helpful.

If you develop a little insight into your pain, you may be able to help your doctor prescribe the correct medicine for you.

Finally, once the back pain reduces with medicines and physiotherapy, regular core and neck strengthening exercises are the only way to keep back pain from any cause from recurring.

Common fevers of Chennai

Chennai (previously known as Madras), is the capital of this southern state of Tamil Nadu. The weather is so hot that the British have a dish named after this city called Chicken Madras. Despite being dry most of the year, many infectious disease are prevalent throughout the year, only that some are more common during the rainy season. Infections are an important reason for high temperatures in the city.

The 5 common endemic infections in Chennai are:

1. Malaria – Vivax malaria is seen more often compared to falciparum malaria and typically cause high fevers with intense shivering (rigors). A person suffering typically experiences a cold phase with shivering, a hot phase with high fever and a sweating phase with drenching sweating. This happens periodically once a day or once in 2-3 days.

2. Typhoid fever (Enteric fever) – this is food borne infection caused by salmonella gastroenteritis. This can present variously but what is usual is that there would be some degree of a gastrointestinal upset. The patient could present with fever,shivering, body pains, headache,rash etc.

3. Dengue Fever – is another mosquito borne viral infection spread by the day biting Aedes aegypti (tiger mosquito – with white stripes on it) which is believed to bite below the knee. Fever can be high with shivering and severe back pain. A rash is also possible in light skinned patients.

4. Leptospirosis or Rat fever is caused by a family of 400 bacteria and causes fever with severe body pains. Some subtypes can cause jaundice, bleeding tendencies along with the fever whereas some others can cause kidney failure. This bacteria enters the body when water contaminated by rat urine (containing the bacteria) comes in contact with the body of the patient.

5. Scrub Typhus -happens due to a organism called Rickettsia and is a mite borne infection. The bite usually occurs in people who travel to heavily wooded areas such as IIT Madras or Raj Bhavan. The fever can be very high and the patient can have a very severe headache. Usually a black ulcer is found in the flexures of the body (under the breasts and in the groins)

The number one fever in Chennai over the last 2 years has been Covid 19. Patients usually have a fever with upper respiratory symptoms such as a headache, sore throat, runny nose, sneezing and cough with some phlegm production. A small proportion of patients develop a severe immune mediated pneumonia during the second week of the infection.

Urine infections, Intestinal infections, Skin infections are other common causes for fever. These infections are usually easily treated.Early diagnosis will help ensuring an early cure and rapid return to normal living.