Why do we develop Goitre?

Enlargement of the thyroid gland is called Goitre. The thyroid gland is situated in the front of the neck on or just below the thyroid cartilage (Adam’s apple). The thyroid gland is made up of lobules, each of which has 20-40 follicles. The follicles are lined by epithelial cells and contain in their centre, colloid (Thyroglobulin).

The thyroid gland produces two thyroid hormones, T4 which is converted to the active T3. These are mostly bound to carrier proteins that transport them to every corner of the body. These proteins maintain an constant blood level of free hormones for use by the cells of the body. The hypothalamus senses the amount of thyroxine in circulation and adjust the dose of TRH (Thyrotropin releasing hormone) secreted. TRH stimulates the anterior pituitary gland to produce TSH (Thyroid stimulating hormone) which sits on the receptor on the thyroid cells and stimulate the production of T4 and T3 from Thyroglobulin in the colloid centres of the follicles. These hormones by a negative feed back mechanism inhibit the TRH production. In this way, the levels of thyroid hormones are closely controlled by the Pituitary gland (the master gland of the body).

Thyroid hormones play a very important role of contolling the body’s metabolism and energy generation. It stimulates the breakdown of carbohydrates and fats and increases protein synthesis in all the cells of the body. Thyroxine plays a critical role in the development of a baby’s brain.

The thyroid gland is controlled and maintained by the TSH hormone. If for any reason, the production of T4 is affected, the increased TSH released, stimulates the growth of the thyroid gland in order to increase hormone production resulting in the development of a goitre.

Initially under the influence of TSH, the follicles start to grow (hyperplastic phase)where the goitre is diffusely and symmetrically enlarged (with a smooth surface) and later on they start involuting and get filled up with colloid. With continued stimulation by TSH, certain follicles enlarge excessively (due to relative increased sensitivity to TSH) to produce a large irregular (bumpy) gland called a multinodular goitre. The rapid growth of the follicles can lead to rupture,scarring, calcification and haemorrhage (with a sudden increase in size).

Goitres of this size are pretty common in a doctors practice!
A large multinodular goitre!
Common causes for Goitre

Large goitres apart from looking unsightly, may press on neighbouring structures in the neck to produce a variety of symptoms. Often a spontaneous bleed into the goitre can lead to a sudden increase in size and provoke discomfort in a hitherto asymptomatic person. I myself developed a thyroid lump overnight after being elbowed by my son, about 10 yrs ago when I was playfully wrestling with him. This was aspirated (bloody fluid was removed with a syringe) with complete resolution of the swelling. Compression of the esophagus could cause diffculty in swallowing. I had a patient recently who had a mass pressing the esophagus from the side. After extensive evaluation it was confirmed that it was of thyroidal origin and she was recommended surgery. Her neck was completely normal looking without any swelling whatsoever. But the goitre had grown downwards into the chest.

Compression of the wind pipe (trachea) could cause difficulty in breathing and stridor (noisy breathing). Thyroidal swellings could also cause hoarseness of voice due to compression of the nerve supplying the vocal cords (usually due to a malignant thyroid). The superior vena cava (the largest vein in the neck) could be compressed causing Superior Vena Caval syndrome with symptoms of congestion of the face, distension of the veins of the neck and a “bursting” headache on bending down! Large goitres could also harbour cancer.

How do you know if the neck swelling that you have is a Goitre? All thyroid masses move upwards on swallowing as the thyroid gland is enveloped by the deep fascia of the neck and is connected to which the thyroid cartilage of the larynx which moves upwards during swallowing.

An overactive thyroid may present with the following symptoms: increased appetite, increased sweating, heat intolerence, diarrhoea, palpitations, weight loss, reduced menstrual flow.

An underactive thyroid may present with reduced appetite, weight gain, cold intolerence, constipation, slowed heart rate and mental activity, increased body weight and increased menstrual blood loss.

Ofcourse, you may have no symptoms if your thyroid levels are normal (Euthyroid state).

What are the indications for surgery for someone with a thyroid mass?

The following are indications for surgery:

1.Large goitre with pressure symptoms.

2.Cosmetic reasons and if patient wishes for surgery.

3.Hyperthyroidism due to toxic adenoma.

4.When an FNAC is done and if cancer is suspected or proven – surgery is indicated if the patient is elderly, male, with a hard thyroid mass which is fixed to the neck structures, with a hoarse voice or with enlarged lymph nodes in the neck.

So if you have a thyroid swelling, see your doctor who may arrange some tests and the have a discussion with him/ her as to what you must do further.

Intermittent Fasting

Intermittent Fasting is a method of voluntary fasting, usually for a certain number of hours a day with a specific goal to reduce body weight and change body shape or to achieve certain metabolic endpoints. Although it is quite a new fad the reason why it is gaining popularity is the thinking that for primitive man, food would have been scarce and that he would have had to go without food for prolonged periods of time. So Intermittent Fasting as apposed to frequent feasting (as we do in the 21st century) may actually have been the way we humans were biologically designed to eat. And that the habit of having three square meals and innumerable snacks in between is a modern one and probably the one that is causing an explosion of lifestyle diseases starting with the obesity and then progressing onto dyslipidaemia, hypertension, diabetes, cardiovascular disease and finally cancer. Further everything we do culturally and socially involves food and this therefore makes it very difficult for most of us to even consider Intermittent Fasting as a choice for better health (would you call it a party if food wasnt supplied by the host??). For a long time, I was a sceptic of intermittent fasting methods but the more I read and saw, the more I tended to believe in its benefits. Recently an uncle who at 85 yrs is a retired doctor and a national level athlete spoke about following a 18:6 IF regimen and triggered my interest in researching the medical evidence for IF. So here are some extracts and excerpts from what I have read.

What are the popular I.F regimens?

Daily time restricted feeding i.e., fasting for >12 hrs a day, alternate day fasting and 5:2 intermittent fasting (starving 2 days each week and eating normally on other days) are the. 3 most popular methods of IF.

So what happens in the body when you start Intermittent Fasting?

During I.F the energy producing mechanisms essentially change from being glucose based to one dependant on ketone bodies. All food that is digested is stored in the the liver as glycogen. Glycogen is essentially a long string of glucose molecules bound togetherin chains. In times of need, individual molecules of glucose are released for the use of the body. When one does intermitted fasting, the glycogen stores are already depleted and so the body starts to dissolve the fat stores by releasing triglycerides which are converted to Ketone bodies in the liver. Ketone bodies are a denser source of energy for a variety of cells especially for the brain. Ketone body production starts to rise only after 8-10 hours of fasting suggesting a minimum of 12 hrs of fasting for any real benefit from I.F. Switching to Ketone bodies to provide energy results in reduced respiratory exchange ratio i.e., reduce usage of O2 and therefore reduced production of Carbondioxide, representing a more efficient process for production and usage of energy.

While it is not clear if the benefits of IF are due to simply weight loss alone or because of metabolic switching, the many benefits of IF include improved glucose regulation, improved blood pressure and heart rate control, improved endurance training and loss of abdominal fat and body weight. Other benefits include increased life span, improved memory, balance and coordination (in Alzheimers and Parkinson syndrome), reduced blood pressure, lipids and reduced occurence of spontaneous cancers and slowed growth of certain other cancers.

So what are the cellular changes brought about by I.F?

Reduced Oxygen usage in ketone body metabolism results in reduced production of corrosive free radicals and therefore reduced oxident mediated cellular damage. Ketone bodies have an effect in suppressing inflammation and reducing cellular stress and improving specific tissue growth and plasticity. Ketone bodies are potent signaling molecules and regulate the expression of various proteins and molecules that are known to influence health and aging. (PGC-1gamma, Fibroblast factor 21, NAD, sirtuins, PARP1 and ADP ribosyl cyclase).

IF and Obesity and Diabetes:

Compared to women who only reduced their food intake by 25%,women who followed a 5:2 IF program had a greater increase in insulin sensitivity and reduction in waist circumference although both groups showed equal overall weight loss. In young men who fast fo 16hrs a day and hit the gym for weight training have fat loss along with preserved muscle mass. IF is as effective as standard diets for weight loss. In rat models, IF is associated with greater muscular endurance.

Weight loss with IF is associated with improved insulin sensitivity and improved diabetic retinopathy. Markers of inflammation have also been noted to reduce especially in patients with Rheumatoid arthritis.

IF and Cardiovascular disease:

IF brings about reductions in Blood pressure, reduces heart rate and increases heart rate variability. Lipid profile also improves with reductions in the levels of LDL, Triglyceride and increase in HDL values. Improved indicators of cardiac health were noted as early as 2-4 weeks of starting IF.

IF and neurological disease:

In experimental animal models of IF hadve shown delayed onset of Alzheimer’s disease and Parkinson’s disease. IF increased neuronal stress resistence by bolstering mitochondrial function and DNA repair. GABAminergic transmission is enhanced and this can prevent seizures activity. IF reduces autoimmune demyelination in mouse models of multiple sclerosis and after traumatic and ischaemic spinal cord injury and leads to improved functional outcomes. In humans, IF has shown to improve memory (verbal spatial and working memory).

IF and Cancer:

IF reduces the occurence of spontaneous cancers and also my other types of induced cancers in mouse models. Calorie restriction with IF impairs energy metabolism of cancer cells, reducing their growth and rendering them suseptible to chemotherapy. Several studies with Glioblastoma suggest that intermittent fasting can suppress tumour growth and extent survival.

Suggested regimens for daily time restricted feeding

Month 1 10 hr feeding period 5 days a week

Month 2 8 hr feeding period 5 days a week

Month 3 6 hr feedine period 5 days a week

Month 4 6 hr feeding peiiod 7 days a week

Suggested regimen for 5:2 Intermittent Fasting

Month 1 1000Kcal 1 day a week

Month 2 1000 Kcal 2 days a week

Month 3 750 Kcals 2 days a week

Month 4 500 Kcals 2 days a week

Celebrities who have used Intermittent fasting to reduce their weight.

Why do some men develop breasts and what can be done about it?

Gynaecomastia is quite a frequently encountered condition in medical practice and it refers to the presence of a palpable enlargement of the male breast. Overall the incidence of gynacomastia is increasing throughout the world across a variety of age groups for a various reasons. Some of the causes attributed are endocrine disrupting chemicals in an increasingly polluted world, obesity, anabolic steroid (androgen) abuse, widespread use of medications that cause gynaecomastia and increased prevalence of diseases that cause gynaecomastia such as testicular cancer.

Gynaecomastia is common amongst teenage boys and also in elderly people who gain weight rapidly. Gynaecomastia can occur in upto 60% of pubertal boys (usually tall or obese teenagers) under the influence of hormones and most would spontaneously subside within a year.

What are the common causes for Gynaecomastia?

Often gyanecomastia occurs when an adult puts on weight very quickly. Even in pubertal children the incidence peaks between the ages of 12-14 in response to increased and fluctuating levels of male and female hormones that are secreted by the body. Most often (70% of the times) breast size would regress within a year. So when should one seek medical help and intervention?

In a teenage boy, persistence of breast tissue above the age of 17 or a sudden increase in size with pain may necessitate a visit to the doctor’s clinic. In adults, asymmetric breast enlargement especially if located below the areola of unusal firmness/hardness with nipple changes (retraction, eczema or bleeding) should alarm the individual enough to see a doctor.

The doctor after doing a thorough examination might ask for a few tests. Screening tests may include blood tests like Liver function and kidney function tests,hormonal assays of LH, FSH, Prolactin, Free and total Testosterone, Estradiol, beta hCG and thyroid function. Other scans such as Ultrasound breast, testes, CT for chest and adrenal glands and a FNAC may also be suggested.

Treatment is usually indicated for painful large breast masses (>5cm) in size with worrying features such as nipple bleeding or discharge, eczema or enlarged lymph nodes on doctors examination.

Medical treatment with drugs such as Raloxifene, Tamoxifen and Anastrazole would help in reducing the estrogens (or theri effect) in the body. Surgery is also an option with a high success rate of complete cure (90%).

All about Vomiting – ad nauseam!

Vomiting is a process by which the body expels substances that may irritate the stomach and the intestines. This explanation is a very simplistic and our reality is that we still aren’t very sure of all the reasons and mechanisms of vomiting from the many causes.

There are many causes for vomiting. They may be classified as follows:

Gastrointestinal reasons-

Intestinal obstruction – tumours, adhesions, hernias etc

Reduced/Abnormal motility – Diabetic gastroparesis

Infection – acute peritonitis, appendicitis, gastroenteritis (bacterial and viral), food poisoning etc.

Gastric irritants -alcohol, pain killer intake, antibiotics etc

Others – pancreatitis, hepatitis, kidney stone disease, heart attacks etc

Vestibular (related to the inner ear)

Acute viral labrynthitis

Travel sickness

Meniere’s syndrome

Neurologic disease

Infections -meningitis and encephalitis

Increased pressure- tumours, strokes, intra-cranial bleeding

Migraine

Psychiatric illnesses

Others

Drugs and toxins

Chemotherapy medications

Opioid drugs

Anticonvulsants

Systemic diseases

Diabetic ketoacidosis

Uraemia (kidney failure)

Adrenal insufficiency

Parathyroid disease

Pregnancy

Mechanics of Vomiting

The process starts with increased salivation and nausea (the uncomfortable feeling of vomiting). The stomach starts contracting upwards (reverse peristalsis), the wind pipe is shut by the epiglottis reducing the chances of the vomited food from entering the lungs, the tummy muscle contract forcefully, the chest is held fixed in mid inspiration, the increased intra-abdominal pressure ejects the stomach’s contents out through the mouth and the nose.

Neural control of Vomiting

The neural pathways that bring about vomiting all lie within the brainstem. The brainstem consists of 3 areas, the midbrain, the pons and the medulla. Behind the brain stem is the cerebellum (the little brain) and above the brainstem is the Cerebrum. Between the cerebral hemispheres and the brain stem is the amygdala (which controls emotions).

There are 4 pathways to causing vomiting.

1. The stimulus from the throat (via the Glossopharyngeal Nerve) and the stimuli from the stomach and other abdominal organs (via the Vagus nerve) are carried to the Nucleus Tractus solitaries (NTS) which can not only set off the vomiting reflex but also acts by stimulating the brainstem vomiting centre. This pathway works via the serotonin (5HT3) pathway.

2. Stimuli from the inner ear and the vestibular system directly activates the Brainstem vomiting centre and brings about its effect. Histamine and muscarinic/cholinergic stimulation mediate this pathway.

3. The higher brain centres such as the Amygdala (emotion) and other centres that perceive stimuli such as pain and bad smells stimulate the brainstem vomiting centre directly to cause vomiting.

4. There exists a Blood brain barrier which protects the brain from toxins in the blood. The Chemo Receptor trigger zone is one such area that lies outside the blood brain barrier. Drugs such as opiates and chemotherapy medicines work on this area, to stimulate both the NTS and the brainstem vomiting centre to induce vomiting. These stimuli work through serotonin, NK1 and dopamine pathways.

Why should vomiting be treated promptly?

Repeated vomiting can cause dehydration, loss of stomach acid (and therefore alkalosis), loss of sodium and hyponatraemia, aspiration (when what is vomited enters the lungs) and pneumonia, rupture of the lower end of the gullet/esophagus and blood vomiting (Mallory -Weiss tears) etc.

How is vomiting treated?

Knowing which pathway is involved will suggest the best medicines to stop vomiting.

Stimuli from the pharynx (throat) stomach and other abdominal contents work through serotonin. Therefore serotonin antagonists such as Ondansetrol (Emeset), Granisetron, Dolosetron and Palonosetron will help.

Stimuli from the ear (due to vertigo, motion sickness) or from the cerebellum (due to reduced blood flow) will cause vomiting mediated via histamine receptors. This vomiting would respond well to medicines that have an antihistamine function such as Meclizine, Dimenhydrinate etc.

Stimuli from chemotherapy which stimulates the Chemoreceptor trigger zone via the Neurokinin (NK-1) receptors would respond to treatment with NK antagonists such as Aprepitant, Fosaprepitant, Rolapitant and Netupitant.

Second line antiemetics are:

1. Steroids – Dexamethasone works in ways that aren’t clear.It is definitely useful as a powerful anti-vomitng especially a second line and for vomiting after surgery.

2. Dopamine antagonists such as Prochlorperazine (Avomine) and Promethazine (Phenergan), Chlorpromazine, Haloperidol and Olanzapine (with additional serotonin blocking effects)

3. Cannabinoids also work by unknown mechanisms.

4. A combination of vitamin B6 and Doxylamine (Doxinate 24) is used for vomiting of Pregnancy.

So after reading this article and if you should have severe vomiting, you will be able to ask your doctor for better medicines for yourself!

Do you have IBS?

Irritable Bowel Syndrome is one of the common functional bowel diseases that affect us. Intestinal diseases may be classified broadly into Organic and Functional, where Organic refers to structural intestinal disease as compared to Functional disease where an identifiable structural bowel problem like an ulcer or narrowing (stricture) or bulge (diverticula of the intestine) is absent. IBS is characterised by abdominal pain and altered bowel habits (constipation or diarrhoea).

People with IBS tend to have visceral hypersensitivity i.e., increased perception of pain on intestinal distension. Studies done on IBS patients have shown increased inflammatory/ immune cells in the intestines (on biopsy) such as lymphocytes, mast cells which secrete inflammatory cytokines, histamine, serotonin and other substances that stimulate the nerves inside the bowel wall (Myenteric plexus) and cause increased cellular permeability, pain and increased contractions of the intestinal muscle leading to diarrhoea. This could be the cause for the so called post infectious IBS that is associated with bacterial, viral, protozoal and helminthic infections. There is also a theory that composition of fecal microbiota could be associated with the development of IBS. Small intestinal bacterial overgrowth (SIBO) also has an association with IBS. Studies done have shown that people with IBS have abnormal breath tests indicating bacterial overgrowth and gets better with antibiotc treatment which can reduce the bacterial population. Food allergies, carbohydrate indigestion and gluten sensitivty are also attributed as causes for IBS. Genetic causes, psychological causes such as anxiety depression phobias and somatization have also been shown to be risk factors for IBS development.

IBS is usally suspected when symptoms of abdominal pain and altered bowel habits persist for more than 3 months. The following are typical features of IBS: The symptoms could be either intermittent or continuous.

1. Abdominal pain for atleast 1 day a week. It is usually lower abdominal.

2. Changes in stool frequency – Constipation or diarrhoea

3. Changes in stool form – lumpy hard, pellet like or tooth paste like or loose and watery!

4. Change in stool passage – urgency, need to strain or having a feeling of incomplete evacuation

5. Bloating of abdomen.

6. Association with depression, anxiety, chronic stress or somatization.

What features would suggest that IBS is UNLIKELY!

1. Alarm symptoms such as alternating constipation with diarrhoea, blood in stools, nocturnal diarrhoea, weight loss and fever might indicate a more sinister pathology such as cancer or Inflammatory Bowel disease.

2. An Acute onset might suggest an infective cause for the symptoms.

Such people with the above features and those with a family history of cancer, Inflammatory Bowel disease or Coeliac disease would need other investigations such as Colonoscopy and biopsy.

IBS is classified into 4 types. IBS with diarrhoea (bowel movement > 3 /day), IBS with constipation (bowel movement < 3/week) , IBS with both diarrhoea and constipation and IBS that is not subtyped.

A complete blood count, ESR, CRP, stool complete and occult blood test, Stool calprotectin and and a sigmoidoscopy and colonoscopy may be done (for those with alarm features only) are some of the tests that may need to be done for someone suspected to have IBS.

IBS is a chronic disorder and therefore education and reassurance go a long way in helping the patient cope with the disorder. IBS is prone to recur with periodic exacerbations and remissions. Moderate exercise is believed to be helpful. Avoidance of gas causing food may also help. A diet low in FODMAPS (fermentable oligo, di, mono sacharides and polyols may be helpful. Restriction for 2-4 weeks may improve symptoms. The FODMAPs include 6 food groups:

1. Fructose – corn syrup, apple, pear, watermelon and raisins.

2. Fructans – garlic, onions, leeks, asparagus and antichokes.

3. Wheat based foods – breads, pasta, cereals, cakes.

4. Sorbitol – stone fruits

5. Raffinose – legumes, lentils, brussel sprouts, soybean and cabbage.

Many pharmacologic agents (medicines) are being used to treat IBS.

Antispasmodics such as hyoscyamine, dicyclomine and mebeverine and Probiotics are used for abdominal pain.

Loperamide can be used for diarrhoea.

Polyethylene glycol 3350 is used for constipation predominent IBS. Newer medicines such as Lubiprostone, Linaclotide, Plecanatide and Tegaserod are also used for the same condition. Antidepressants such as Tricyclics and SSRI are also useful. Rifaxamin, a non-absorbable antibiotic is used with good effect for bloating.

Cognitive behaviour therapy, yoga, relaxation and hypnotherapy is also believed to be helpful.

Why do I feel so tired, Doc?

Fatigue is not an uncommon complaint that a doctor hears at his clinic. This term however could mean many things to many people. While there are many normal causes for fatigue and tiredness, I would like to write about the abnormal (pathological, disease related) causes for tiredness that the reader needs to be aware of.

Fatigue could happen normally from doing unaccustomed severe exertion or exercise or due to inadequate rest and recovery after exertion, sleep deprivation, travel thorough different time zones (Jet lag) or due to obesity, under nutrition and severe emotional stress. You could recover from fatigue from the above causes by taking adequate rest. So why should fatigue persist even after taking enough rest and what could the reasons be for it?

Pathological fatigue has many causes. Broadly they may be grouped into the following categories.

Significant Fatigue is when fatigue persists for at least 2 weeks and can affect upto 25% of the population at some time. Chronic sleep deprivation (sleep apnoea) can also be a cause for severe fatigue.

Chronic Fatigue is when fatigue affects the person for more than 6 months.

Alarm signs in Chronic fatigue:

1. Anorexia and weight loss (>10% per 6 months)

2. Enlarged Lymph nodes.

3. Memory and concentration impairment

4. Inability to function due to myalgias, arthralgias, headaches etc.

5. Deep depression

Evaluation of complaints of Fatigue:

Treatment of Fatigue

Identification and treatment of the cause for fatigue will cure the problem most of the times`.

Interventions that may be of benefit for people with problematic fatigue are:

1. To fix lifestyle abnormalities – to regulate lifestyle, to eat, sleep on time.To exercise regularly – resistance as well as aerobic training reduce fatigue. (Graded exercise programme)

2. Use of nocturnal cPAP for those with Obstructive Sleep Apnoea

3. Medications – Melatonin or nocturnal sedatives

– Modafinil or Armodafinil

– Testosterone replacement therapy for those with deficiency

– Steroid replacement therapy for those with adrenaline insufficiency

– Correction of Vit D and other vitamin deficiencies.

4. Cognitive Behaviour therapy provided by an experienced psychologist.

A note of Long Covid Syndrome:

Covid 19 infection has been the most common cause for prolonged fatigue over the past 2 years. Long covid syndrome refers to the persistence of symptoms many weeks after the acute infection. Fatigue is a persisting symptom irrespective of the severity of the infection. In one study 92% of covid patients had fatigue 79 days after the onset of Covid infection.

Common symptoms of long covid include:

Fatigue,breathlessness, chest pain,mental fudge and cognitive abnormalities, sleeplessness, smell and taste abnormalities, headache and feverishness etc. Treatment is essentially symptomatic only.

You aren’t a bloody bugger, you are just anaemic!

I am currently reading a book called The Anarchy by William Dalrymple, a book detailing a state of anarchy existing in India in the eighteenth century which made it easy for the British East India company to defeat the ruling Kings and take over the country. Apparently at the time when Lord Cornwallis ran the EIC, Britain had lost its American colonies to the descendants of the original european settlers (and not the locals). In India, one in three British men were “cohabiting” with Indian women and it was believed that there were 11000 Anglo-Indians living in the 3 Presidency towns ( Madras, Calcutta and Bombay). Fearful of losing their Indian territories in the future to the descendants of British men, the EIC banned all Anglo-Indians “orphans” from serving in the company army (as well as in the civil and marine branches of the EIC) and from owning land thereby excluding them from most lucrative sources of employment. They were only allowed to work as pipers, drummers and farriers in the company army and were further demoted to holding minor jobs as clerks, postmen and train drivers. The Anglo- Indian community was therefore relegated to the fringes of Indian society where they developed their own unique culture and spoke English in their own unique style. My father had told me many years ago that “bloody” and “bugger” were words used primarily by the Anglo-Indian communtiy and that it subsequently become common usage. I remember using these words without knowing their meaning as a child, at home in front of my parents and never being corrected or admonished. So kindly excuse my use of those words in this article.

So, this article is written to give you more information of the common causes for anaemia, why they happen and give you some information as to what you can do about it. I write this article from my perspective and experience as a doctor practising in an urban setting in South India.

Low hemoglobin in referred to as Anaemia. Men are anaemic if their hemoglobin in less than 13.6 gm/dl (hematocrit <41%) and in women if hemoglobin is less than 12gm/dl (hematocrit <36%). Worldover, the commonest cause for anemia is Iron deficiency.

Hemoglobin serves the very important function of carrying Oxygen to all the tissues. Oxygen is picked up in the lungs and delivered to the tissues in every corner of the body. Therefore when anemic, the person may feel breathless on exertion (or even at rest when severe), tired, dizzy with chest pain, cold extremities and pallor. The person could also be absolutely asymptomatic especially if the anemia develops gradually over several months or years.

The cause of the anemia could vary according to the age at detection. In children, Nutritional Iron, B12 and folate deficiency, Hook worm infestation, Hemolysis and heriditary causes (Thalassemia or Sickle cell anemia) may occur.

In adults, Iron deficiency due to Acute or chronic blood loss (menstrual blood loss, Gastrointestinal bleeding from piles, stomach ulcers etc worsened by antiplatelet drugs such as Aspirin or Clopidogrel), Kidney failure, chronic diseases and Cancer chemotherapy.

In the elderly, anemia can be caused by Chronic diseases, Iron deficiency (from gastrointestinal blood loss), Vit B12/Folate deficiency, Chronic leukaemia and cancers, Myelodysplastic disorders and blood loss (acute from fractures after falls and chronic from intestinal bleeding).

Broadly Anaemia can be divided into the following categories:

Reduced production of blood

Deficiency Anaemia – Iron, B12 and Folate.

Bone marrow disease – Acute and Chronic leukaemia, lymphomas and other bone marrow malignancies, Aplastic anaemia, Myelodysplastic syndrome, Myelofibrosis and Infections affecting the bone marrow.

All blood cells are produced in the bone marrow and any disease that affects the bone marrow can cause anaemia.

Anaemia of Chronic disease – Chronic disease such as Inflammatory bowel disease, Rheumatoid arthritis affect the transfer of iron from the immune cells to the bone marrow.

Anaemia of Kidney failure – the kidneys produce Erythropoietin, a hormone that stimulates the bone marrow to produce blood. When this stimulus reduces due to kidney failure,anaemia ensues.

Increased Blood destruction or loss

Blood loss – acute and chronic.

Hemolytic – Heriditary (Hemoglobinopathies), Autoimmune, Enzyme defects(G6PD), MAHA

Malaria

Overactive spleen (Hypersplenism)

So how do you go about finding out the cause for your anaemia?

The following tests would be useful.

The CBC – complete blood count

Hemoglobin levels – based on the hemoglobin levels anaemia can be classifed as mild (>10gm/dl) moderate (7-10gm/dl) and severe ( <7gm/dl).

MCV – mean corpuscular volume

– A low MCV occurs frequently in Iron deficiency and a high value >100 in Vit B12 and folate deficiency.

Platelet counts – are reduced in acute infections and Vit B12 and folate deficiency and Bone marrow disease. A high platelet count is seen in Acute as well as chronic blood loss.

ESR – increases in all Anaemias.

CRP – increases in all inflammatory and infective conditions.

Reticulocyte count and index – A normal or increased Reticulocyte count and index indicates a functioning bone marrow and could indicate blood loss or hemolysis as a cause for the anaemia.

Peripheral smear – especially reported by a human rather than an automated machine will give a very valuable information regarding the cause for anaemia.

Iron study – Serum Iron, Transferrin saturation and Ferritin – Low serum iron, low transferrin saturation (low TIBC) and a low Ferritin indicate iron deficiency. A normal or high iron, normal or low saturation and a high Ferritin level would indicate Chronic infection and inflammation.

Serum LDH – lactate dehydrogenase – rises in hemolytic anaemias and other hematoloic conditions.

Stool for occult blood – positive report would indicate gastrointestinal blood loss.

Serum Vit B12 and folate levels – are reduced in Megaloblastic (macrocytic) anaemia due to B12 and folate deficiencies.

Renal function test – Urea and creatinine – Creatinine levels > 4 mg/dl may indicate a renal cause for Anaemia.

Other tests:

Haemoglobin electrophoresis – can help diagnose Thalassaemias.

Bone marrow aspiration and biopsy study – Will indicate if an underactive bone marrow is the cause for the anaemia.

Osmotic fragility – Increases in Heriditary spherocytosis.

Coombs test – is positive in Autoimmune Hemolytic anaemias.

Normal blood smear showing RBC with central pallor (1/3 diameter of the cell). The large purple cells are the white cells and the small ones (11’o clock position) are the platelets.
The smear above shows iron deficiency anemia, the central hollow is more than a 1/3rd of the whole red cell. The red cells are of smaller sizes and different shapes.
The smear above show megalobalstic (macrocytic) anemia with large red cells and hypersegmented Neutrophils in the lower centredue to Vit B12 or Folate deficiency.

Case studies: Lets have a look at a few case stories from my practice.

1. Mrs. M was a 38 yr old lady who was seen by her gynaecologist for anemia and was prescribed iron tablets as emperic treatment of Iron deficiency anemia due to menstrual blood loss.I had seen her a month later for severe abdominal pain and constipation.As her stool occult blood test returned positive, a colonscopy was done and it showed a large growth nearly occluding the rectal lumen (and she had been absolutely asymptomatic till then).She underwent surgery to relieve obstruction and later succumbed to the cancer despite best therapy.

Moral of the story- every case of suspected anaemia needs relevant investigations!

2. Mr. A was a 21 yr old man studying in Canada. He was my patient since the age of 16yr and his parents were always unhappy that he was a poor eater and liked only junk food like pizzas and bread! He was brought to my clinic by his father who was concerned that his son looked weak, the blood tests done revealed anemia which was thought to be due to iron deficiency as it was of the microcytic type.I ran a set of tests on him which showed that his iron levels were normal. A Hemoglobin electrophoresis test done revealed Thalassaemia minor. In this case giving iron tablets would have been the wrong thing to do.

Moral of the story- every case of anemia needs relevant investigations!

3. Mr.S was a 36 yr old patient of chronic deforming Rheumatoid arthritis. He gave a history of previous blood transfusions for anaemia and of regular intake of pain killing tablets for his joint pains. His Hemoglobin was 3.5gm/dl, ESR and CRP were very elevated, the iron study revealed low iron and elevated ferritin levels and the stool occult blood test was negative. He was diagnosed to have anemia of chronic disease. He was transfused to hemoglobin of 8gm and was started on DMARDS for his Rheumatoid arthritis.

Moral of the story – not every case of anemia is due to Iron deficiency.

4. Mr. H was a reformed alcoholic who came with complaints of weakness and tiredness. His examination revealed signs of chronic alcoholic liver disease with ascites (abdominal swelling due to fluid collection). Investigations revealed moderate anemia with hemoglobin of 8gm/dl, pancytopaenia (reduction of Red cells i.e., anaemia, white cells and platelets) and fecal occult blood test was positive. He was diagnosed to have anemia due to hypersplenism and due to GI blood loss. The patient was transfused to a hemoglobin of 10gm/dl, his coagulation disorder was corrected and he had a endoscopic procedure to treat his bleeding varices.

Moral of the story – your doctor can find clues to the cause of anemia. So if you are anemic, go see your doctor and get it corrected.

5. Mr. N came to see me with some dyspeptic symptoms. His hemoglobin was 8gm/dl and his MCV was 105. His peripheral smear showed macrocytic anaemia suggestive of megaloblastic anemia with hypersegmented nuclei on Neutrophils. He tested postive for anti Intrinsic factor antibodies, his vit B12 levels were very low and an endoscopy done revealed atrophic gastritis. He was diagnosed to have Pernicious anemia due to Vit B12 deficiency and was given IM injections of Vit B12 after which his hemoglobin returned to normal.

Take home message: If you are anaemic, get some tests done, see your doctor before you start giving any excuses to explain why you are anemic.

Should you buy a smart device to track your sleep?

Sleep is a recurring natural state of mind and body characterised by reduced consciousness, reduced sensory activity and perception, reduced muscle activity (increased muscle relaxation) and consequently reduced interactions with the surroundings.

Sleep is essential for all animals and is when the body builds up, restores energy and every other system (muscular, nervous, endocrine and immune systems) during this period of rest. Inadequate quantity and quality of sleep can lead to a variety of diseases including diabetes, heart disease, strokes, obesity and depression and other psychiatric disorders.

Modern living with long working hours, working through the night, travelling through various time zones, use of various electronic gadgets (Blue light emitted by mobile phones tablets and laptops supposedly inhibit the release of the sleep hormone melatonin) disrupt normal sleep and lead to typical stress related disorders.

While each person requires different amounts of sleep, on an average a 40 yr old needs 7 hr every night, 6 1/2 hrs of sleep at ages 45-60 and about 6 hrs or less at the age of 80 yrs and above.

Sleep occurs in cycles that last 90-110mins (i.e., less than 2 hr). Each cycle has 2 types of sleep, NREM (non rapid eye movement or slow wave sleep) and REM (Rapid eye movement sleep). NREM has 4 stages 1,2,3 &4). When we close our eyes to sleep , we are in stage 1 and we gradually move into the other stages as we continue to sleep. Stages 1 and 2 are the lighter planes of sleep and 3 and 4 are the deeper planes. Throughout each stage the body relaxes progressively and the EEG (brain activity) changes and slows down.

REM sleep deprivation leads to sleep that is not restful. More time is spent in stage 3-4 during the first half of the sleep period. In the second half, more REM sleep happens as shown in the diagram. As REM sleep is most restful, staying awake during this period (between midnight to 4AM) has health consequences. Younger children especially newborns spend much longer times in stage 4 sleep and REM sleep. REM sleep duration reduces with ageing to much less than the 25% enjoyed by young adults.

You may have a sleep disorder if you have trouble falling asleep when you lie down in bed, if you wake up feeling tired and if you tend to doze off during the day especially during work.I had a friend who fell asleep at the wheels of his car and had a serious accident. If these are issues for you, the question may arise if you should buy a smart device to track your sleep. Unfortunately most of these devices that are worn on the wrist are not medically validated to diagnose sleep disorders. Most of them detect body movements or in some cases the heart rate and its variability, to decide if you are asleep or awake. These devices could get fooled into believing that some insomniacs are asleep when they have their eyes closed, body relaxed and are in bed waiting to fall asleep. So while these devices may be accurate in detecting duration of sleep (based on movements etc), they can be quite inaccurate when they calculate the time spent in the different stages of sleep and also when they make assumptions about the quality of sleep. My smart device suggested that I had sleep apnoe when it detected that I woke up 20-25 times during the night. As I didnt have any symptoms of a sleep disorder, I concluded that it probably detected my movements in bed and inferred that I had woken up. The sleep specialist whom I discussed this also came to the same conclusion. On the other hand, validated sleep study devices (Polysomnography) monitor various parametes such as EEG, ECG, Muscle tone, chest and abdominal movememts, O2 saturation and limb movements to give a detailed analysis of sleep. Compared to these devices, sleep trackers are only 78% accurate in detecting sleep vs wakefulness, 38% accurate in identifying exactly how long it took to fall asleep and only about 50% accurate in detecting the various stages of sleep (including REM sleep).

So should you by a sleep tracker? I believe that anything that is measured, improves. Therefore if you aren’t sleeping well, it may be a good idea to buy a sleep tracker. Many of these devices also measure your heart rate during sleep and an increasing RHR (resting heart rate) may also be indicative on a non-restful sleep.

I have used the Samsung Galaxy watch 3 which is excellent for sleep monitoring and the apple watch which is more accurate for heart rate monitoring (especially during exercise). So go ahead and buy a smart watch that can track your sleep, focus on all the things that you need to do to stay healthy and get healthier!

Are all sore throats the same?

Pain in the throat can happen from many reasons. Although people may refer to the neck as the throat, what doctors consider as throat is the pharynx and the tonsillar areas. Lets have a look at the anatomy of the throat and then see how things change in disease.

The throat or pharynx is a muscular tube that connects the mouth and the nose to the windpipe (trachea) in the front and the food pipe (Oesophagus) behind. It is divided into 3 parts, the upper Nasopharynx (the part behind the nose), the Oropharnx (the part behind the mouth) and the Laryngopharynx (the lower most part behind the larynx (the voice box).

The throat or the Oropharynx is bordered by the palate on the top, the pharyngeal pillars (tonsillar areas) on the sides and the tongue below. This is the most important gateway into both the Respiratory as well as the Gastrointestinal tract and is therefore a site for frequent infections.

A sore throat occurs whenever there is inflammation in the throat. Inflammation could be due to infection or a non-infectious cause. Lets look at some of the common and not so common causes for a sore throat.

1. Viral Pharyngitis – the most common cause for a sore throat after streptococcal infection is a viral pharyngitis. This season, the commonest cause is the Covid 19 infection which causes severe and painful sore throat. Unlike a bacterial infection, the patient will have a runny nose, the throat will be erythematous (reddened) and would not show any pus points. Infectious mononucleosis (kissing disease)is seen in young patients who catch infection from kissing. The pain is often out of proportion to the severity of the pharyngitis on examination. This infection can be associated with a rash, enlarged lymph nodes in the neck and an enlarged liver and spleen. The blood smear study would show typical large lymphocytes (increased Lymphocyte count) The treatment is essentially symptomatic.

2. Bacterial (streptococcal pharyngitis and tonsillitis)

The throat shows small petichiae (bleeding spots) on the palate. If tonsillitis coexists, the tonsils are enlarged and show pus oozing from them and the lymph nodes in the neck are enlarged. Streptococcal infection is the commonest cause for a sore throat even more common than viruses. Recurrent streptococcal infection may predispose patients to Rheumatic fever and cardiac disease. Bacterial pharyngitis may also be caused by Neisseria gonorrhoea, Mycoplasma and chlamydia species. Antibiotics would be needed in many cases.

3. Peri-tonsillar abscess (Quinsy)- when the infection spreads through the capsule of the tonsil, pus collects outsides the tonsil and displaces the tonsil inwards, nearly occluding the oral cavity.Peritonsillar abscess must be treated with antibiotics and may need a drainage procedure to remove the pus and to hasten

4. Diphtheria is a respiratory tract infection that cause severe pharyngitis with a thick membrane over the throat. This can be dangerous if left untreated. Prompt antibiotic therapy will be needed.

5.Oral thrush is causes by yeast like fungus called candida. This is also quite common. It is seen on those on broad spectrum antibiotics, diabetes, steroid therapy, immune compromising conditions including HIV infection. The white patches can easily be dislodged showing underlying erythema (redness) and inflammation. Anti-fungal lozenges will be very effective in its treatment along with treating the cause for the infection e.g., controlling the blood sugars and stopping the antibiotics.

Non- infective causes for a Sore throat

1. Acid Reflux with pharyngitis – this is a very common cause for chronic pharyngitis. Acid reflux is a lifestyle disease caused due to an incompetence of the gastro-oesophageal valve usually seen in obese individuals who overeat.

2. Oral aphthous ulcers, Lichen planus, pemphigus and pemphigoid, Behcets syndrome and drug reactions can also give severe sore throat. Rarely cancer can be a cause for a sore throat. The photo below shows large ulcers of pemphgus.
The photo below shows a larger ulcer from cancer of the mouth.

So if your throat is sore and you have difficulty swallowing food, please consult your doctor for advice. Once the cause for the sore throat is identified, specific treatments are given to hasten recovery. Most infective sore throats respond well to antiinflammatory medicines such as Brufen. Antibiotics will be given by your doctor as necessary. Specialist consultation may also be needed.

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.