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Category : All ; Cycle : October 2014
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Oct25
ALCOHOLISM, ITS EFFECTS AND ROLE OF FAMILY PHYSICIAN
ALCOHOLISM, ITS PROBLEMS AND ROLE OF FAMILY PHYSICIAN

Dr.S.ABBAS ALI
MD, DFM, DNB (FAM.MED)
MNAMS (Family Medicine)
FCGP, MCCP (Cardiology)
PGDHSc (Ultrasonography)
PGDHSc (Echocardiogram)


Alcoholism is usually defined by the behavioral patterns and consequences of alcohol intake, not on the basis of the amount of alcohol intake. Abuse is defined by a repetitive pattern of drinking alcohol that has adverse effects on social, family, occupational, or health status. Dependence is defined by alcohol-seeking behavior, despite its adverse effects. Many alcoholics demonstrate both dependence and abuse, and dependence is considered the more serious and advanced form of alcoholism. A clinically helpful approach to diagnosis of alcohol dependence and abuse is the use of the CAGE or TWEAK questionnaire, which is recommended in all medical history-taking

CAGE Questions


Acronym Question
C Have you ever felt you ought to C ut down on your drinking?
A Have people Annoyed you by criticizing your drinking?
G Have you ever felt Guilty or bad about your drinking?
E Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?


TWEAK QUESTIONNAIRE

Acronym Questions points
T Have you an increased tolerance to alcohol 2
W Did you worry about your drinking 2
E have you ever had alcohol as an eye opener in the morning 2
A Do you ever get amnesia after drinking alcohol 2
K (C) Have you ever felt c(k)ut down on your drinking 2

A score of more than 2 suggests an alcohol problem. It may be more sensitive than the CAGE questionnaire in some populations (eg.pregnant women)
1. EPIDEMIOLOGY
World wide an estimated 2.3 million people die from alcohol related causes. This is 3.7% of all deaths. 6.1% among men and 1.1% among women. In India survey showed that around 20-30% of adult males and 5% of adult females use alcohol. While alcohol is used traditionally by men, its use by women is now on the increase. Over the past 30-40 years increasing percentages of young people have started to drink alcoholic beverages. Their alcohol consumption has increased in quantity and frequency and the age at which drinking starts has declined. This situation is disturbing because the young people concerned may run a greater risk of alcoholic problems in later life and also, in the short term because of increased rates of drunkenness and involvement in road accidents.
2. PROBLEMS OF DRINKING TOO MUCH ALCOHOL
Liver and body can usually cope with drinking a small amount of alcohol. Indeed, drinking a small amount of alcohol (1-2 units per day) may help to prevent heart disease and stroke. Heavy drinking has an increased risk of developing disturbance in function of many organs and in the long run organ damage with irreversible serious complications.

2.1. Liver problems: Drinking too much alcohol can lead to three types of liver conditions - fatty liver, hepatitis, and cirrhosis. Any, or all, of these conditions can occur at the same time in the same person.
2.1.1. Fatty liver
Drinking a large amount of alcohol, even for only a few days, can lead to a build-up of fats in the liver. This is called alcoholic fatty liver disease, and it's the first stage of ARLD. Fatty liver disease is not usually serious and rarely causes any symptoms but it is an important warning sign that you are drinking at a level harmful to your health. 90-100% of heavy drinkers have alcoholic fatty liver disease and it is reversible on abstinence of alcohol. If drinking of alcohol is continuous one in four drinkers with fatty liver disease will develop alcoholic hepatitis and one in five drinkers with fatty liver disease will develop cirrhosis.
HOW TO DIAGNOSE FATTY LIVER: Mild increase in Liver profile and increased serum triglyceride levels. Ultrasound of abdomen shows increased echogenicity of liver.
2.1.2. ALCOHOLIC HEPATITIS:
 Hepatitis means inflammation of the liver. The inflammation can range from mild to severe. Alcoholic hepatitis is an acute form of alcohol-induced liver injury that occurs with the consumption of a large quantity of alcohol over a prolonged period of time; it encompasses a spectrum of severity ranging from asymptomatic derangement of biochemistries to fulminant liver failure and death
 Mild hepatitis may not cause any symptoms. The only indication of inflammation may be an abnormal level of liver enzymes in the blood, which can be detected by a blood test. However, in some cases the hepatitis becomes persistent (chronic), which can gradually damage the liver and eventually cause cirrhosis.
 A more severe hepatitis tends to cause symptoms such as feeling sick, jaundice (yellowing of the skin, caused by a high level of bilirubin - a chemical normally metabolized in the liver), generally feeling unwell and, sometimes, pain over the liver.
 A very severe bout of alcoholic hepatitis can quickly lead to liver failure. This can cause deep jaundice, blood clotting problems, confusion, coma, and bleeding into the guts, and is often fatal.
 The main treatment for alcoholic hepatitis is to provide adequate nutrition (this sometimes involves passing liquid feeds through a tube in the stomach) and steroids.
2.1.3. CIRRHOSIS: Cirrhosis is a condition where normal liver tissue is replaced by scar tissue (fibrosis). The scarring tends to be a gradual process. The scar tissue affects the normal structure and regrowth of liver cells. Liver cells become damaged and die as scar tissue gradually develops. So, the liver gradually loses its ability to function well. The scar tissue can also affect the blood flow through the liver which can cause back pressure in the blood vessels which bring blood to the liver. About 1 in 10 heavy drinkers will eventually develop cirrhosis. It tends to occur after 10 or more years of heavy drinking. The scarring and damage of cirrhosis is usually permanent. Early cirrhosis is compensated cirrhosis. Early symptoms of liver disease can include:
• fatigue
• nausea
• vomiting
• diarrhoea
• abdominal pains
Later stage cirrhosis (decompensated cirrhosis) symptoms are more serious – They can include:
• jaundice (yellow skin)
• vomiting blood
• fatigue
• weakness, loss of appetite
• itching
• easy bruising
• swelling of the legs ankles, or abdomen (ascitis)
• liver cancer
• bleeding in the gut
• increased sensitivity to alcohol and drugs, both medical and recreational (because the liver cannot process them)
In cirrhosis, complete abstinence of alcohol is essential to prevent more serious complications of liver failure. The treatment option of cirrhosis is Liver transplantation.
2.2.GI tract and stomach; obesity (alcohol has many calories)diarrhea, gastric erosions, peptic ulcer, varices (which results in haematemesis) carcinoma, oral mucosal lesions and pancreatitis (both acute and chronic)
2.3.CENTRAL NERVOUS SYSTEM: Stroke (CVA), poor memory (Problems with thinking, memory, mood) poor cognition, faintness and light headedness, cortical atrophy, retro bulbar neuropathy, fits, falls, wide based gait, neuropathy(numbness in legs and feet) , confabulation, korsokoff psychosis, wernicke’s encephalopathy. Mental health problems, including depression and anxiety, Jealousy, temper tantrums, vagrancy, auditory hallucinations, and paranoid delusions. Unintentional injuries, suicides, homicides, total social damage which includes family disorganization, domestic violence, wife battering, crime and loss of productivity.
2.4. Heart: arrhythmias, Hypertension, cardiomyopathy, sudden death in binge drinkers (Holiday heart syndrome)
2.5. GENITOURINARY SYSTEM: Sexual difficulties such as impotence, testicular atrophy, with shrinkage of seminiferous tubules, loss of sperm cells,
2.6. HAEMOPOITIC SYSTEM: leucopenia (decreased WBC) thrombocytopenia (decreased platelets), anemia, ↑MCV, sideroblastic anemia
2.7. VITAMIN DEFICIENCIES: alcoholism associated Vitamin B complex (thiamine) and Folate deficiency,
2.8. INCREASED CANCER RISK: Cancer is the second leading cause of death in alcoholics after cardiovascular disease. Common sites include head and neck, mouth, pharynx, larynx, oesophagus, cardia of stomach, colon, breast, Liver and pancreas.
2.9. Accidents - drinking alcohol is associated with a much increased risk of accidents. In a study in Bangalore, nearly 28% of traffic injuries were found directly attributable to alcohol.
2.10. High risk sexual behavior: Sexually transmitted diseases including HIV/AIDS, Hepatitis B and C: Alcohol use is considered a risk factor for high risk sexual behavior leading to STD including HIV/AIDS, Hepatitis B & C
2.11. Infections: pneumonia and tuberculosis are more common in alcoholics
2.12. FETAL ALCOHOL SYNDROME: Damage to an unborn baby in pregnant women. The baby has low IQ, short palpabral fissure, absent philtrum and small eyes.
2.13. ALCOHOL WITHDRAWAL: It starts after 10 to 72 hours after last drink characterized hypotension (↓BP) rapid pulse, tremor, confusion, fits, hallucinations (delirium tremens) may be visual or tactile eg. Animals are crawling on the skin. The alcohol withdrawal patients should be admitted in hospital
• give IV fluids and stabilize BP & pulse
• 25%Dextrose
• Inj. Thiamine
• Chlordiazapoxide 10-50mg 6 hourly etc.,
3. MANAGEMENT
3.1. The family physician should consider every consultation is an opportunity to detect early-warning signs that prevent illness and disease. Sensible, timely and appropriate interventions can help make people aware of the potential risks they are taking. Health promotion is not simply risk avoidance, rather than active encouragement of individuals to increase control over bad habits which are detrimental to health, to attain their best possible level of well being.
3.2. Opportunistic health promotion and disease prevention is defined as “an advice made more effective by being directly linked to the content of the preceding consultation”. For example, advice to stop alcoholism is proportionately more powerful when it is linked to an episode of acute vomiting, abdominal pain etc. Prevention: prevention is always better than cure because it reduces undue suffering from diseases. Promotion of health, preservation of health and restoration of health when it is impaired. Nowadays, however, the majority of mortality and disabling illness accounted for by ischemic heart disease, stroke, cancer, and chronic lung disease. These are principally affected by life styles and habits of individuals, alcoholism, smoking, diet and exercise. Consequently the role of the physicians has become more important and he/she must communicate this information more effectively to his/her patients. Helping patients to take responsibility of their own health must be the fundamental feature of opportunistic health promotion and disease prevention
3.3. Identity high risk factors: such as smoking, tobacco chewing, high risk sexual behaviour, physical inactivity, history of premature death or CHD, stress factors, contraceptive use and failure or inability to obtain preventive health services. If found provide promotive and preventive measures.
3.4. Identify co-morbid conditions: like Diabetes, obesity, hyperlipidaemia, hypertension. If found specific intervention and necessity of treatment should be carried out to control these conditions for preventing organ damage.
3.5. If alcoholic having liver problems, alcohol is contraindicated. The other conditions where alcohol contraindicated are pregnancy, carcinoid, peptic ulcer, and serious reactions will occur with drugs (antihistamines, metronidazole)
3.6. Psychological assessment of motivation: the patient should be psychologically motivated. Treating established alcoholic may be rewarding particularly if they want to change their life style. If so family therapy, group therapy or self help may be useful in self initiated and determined alcoholic. The family members and friends should encourage the alcoholic will to quit. Give and maintain follow up and encourage.
3.7. If patient is alcoholic with no evidence of liver disease advise measures for preventing alcohol-related liver disease. The most effective way to prevent ARLD is to stop drinking alcohol, or stick to the recommended daily limits and have at least two alcohol-free days a week.
3.8. .The recommended limits of alcohol consumption are:
 Men should not regularly drink more than 3 units of alcohol a day.
 Women should not regularly drink more than 2 units a day. One unit of alcohol is 10 ml (1 cl) by volume, or 8 g by weight, of pure alcohol. For example: One unit of alcohol is about equal to:
 half a pint of ordinary strength beer or cider (3-4% alcohol by volume); or
 a small pub measure (25 ml) of spirits (40% alcohol by volume);
 A standard pub measure (50 ml) of fortified wine such as sherry or port (20% alcohol by volume).
 There are one and a half units of alcohol in a small glass (125 ml) of ordinary strength wine (12% alcohol by volume) or a standard pub measure (35 ml) of spirits (40% alcohol by volume).
 But remember, many wines and beers are stronger than the more traditional ordinary strengths. A more accurate way of calculating units is as follows. The percentage alcohol by volume (% abv) of a drink equals the number of units in o in one litre of that drink. For example:
 Strong beer at 6% abv has six units in one litre. If you drink half a litre (500 ml) - just under a pint - then you have had three units.
 Wine at 14% abv has 14 units in one litre. If you drink a quarter of a litre (250 ml) - two small glasses - then you have had three and a half units.
References
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Oct02
What is Test Tube Baby or IVF? Test Tube Baby Treatment, Success Rates and Risk involved with Ivf.
Test tube baby is another name for IVF procedure, where sperm and eggs are collected, fertilized in the laboratory and the resulting healthy embryo is then transferred into the uterus. A test tube baby is the term that refers to a child that is conceived outside the woman's body. The process is referred to as "in vitro" (outside the body) fertilization. Here eggs are removed from the mother's ovary and incubated with sperm from the father. After fertilization, the "pre-embryos “are allowed to divide 2-4 times (in a "test tube", hence the name) and then returned to the mother's uterus where they can develop normally. Through these procedures, women with otherwise untreatable infertility problems have given birth to healthy babies. It is a method of assisted reproductive technology for treatment of infertility. With egg donation and IVF, women who are past their reproductive years or menopause can still become pregnant. Today, the process of in vitro fertilization is considered common and utilized by infertile couples around the world.

Today, thanks to the efforts of British Nobel Prize winners Dr. Patrick Steptoe and biologist Robert Edwards, who pioneered the procedure with the birth of first test tube baby Louis Brown, IVF is performed successfully around the world. Now, the procedure is so common that more than 5 million around the world have conceived babies through in vitro fertilization or IVF.

When is the option for Test tube baby recommended and to whom is IVF treatment recommended?

As we all know infertility is the failure on the part of the couple to conceive after 12 months of trying without the use of contraceptives. IVF is a complex procedure involving considerable personal and financial commitment, so other treatments are usually recommended first. It is advisable that before opting for ivf, infertile couple has tried less invasive treatment options including fertility drugs to increase production of eggs or intrauterine insemination — a procedure in which sperm are placed directly in your uterus near the time of ovulation. Occasionally, IVF is offered as a primary treatment for infertility in women over age 40. IVF can also be done if you have certain health conditions.

Ivf is usually recommended to infertile couples having blocked fallopian tubes, endometriosis, ovulation disorders, ovarian failure, the male partner has low sperm count, unexplained infertility or any other reason by which the fertilization which occurs in outer part of the fallopian tubes does not take place. Advanced reproductive age also plays a major role in deciding about ivf treatment. I.V.F. can also be the treatment of last resort in the case of problems like oligospermia, major cervical mucus hostility factors and certain cases of unexplained infertility.

What is the success rate of IVF?

The success rate of pregnancy associated with this treatment ranges between 15-30%. Therefore it is also not advisable to go in for IVF treatment without trying simpler treatment options first. IVF is a complex procedure involving considerable personal and financial commitment, so other treatments are usually recommended first. The success of the ivf treatment also depends on the age of women and the quality of the eggs. One of the reasons for the success is whether donor eggs are used or mothers eggs are used?

Although IVF has a high rate of success in helping couples to become pregnant, it has some disadvantages as well, including high costs, potential risks from fertility medications and invasive procedures used, as well as an increased rate of multiple gestation (i.e., twins or triplets). There may also be an increased risk of some pregnancy complications, such as preterm birth. Ectopic pregnancies can occur after IVF, although the risk is much lower than with other fertility therapies.
Women who are considering IVF should discuss the risks, benefits, and alternatives with their healthcare provider and partner before treatment begins. In most cases, several cycles of a less expensive and less invasive infertility treatment are recommended before considering IVF.

Every year, millions of couples try to conceive a child; unfortunately, many find that they cannot. The process to find out how and why they have infertility issues can be long and arduous. Before the invention of test tube baby treatment or ivf treatment women’s with Fallopian tube blockages (approximately twenty percent of infertile women) had no hope of becoming pregnant.

A woman's age must be considered. Older women feel additional pressure as they feel their biological clocks are ticking and time is running out. However, there is no upper age limit at which IVF should not be done, - and in fact, for older women, it might represent their only chance of success. It's not really the age of the woman, which is the limiting factor - it's the quality of her eggs.

All couples who are facing infertility issues and who are thinking of pursuing ivf must consider following tips for higher results and success.

For Women

1) No smoking or alcohol use as it can result in lower pregnancy rates and a greater risk of miscarriage.
2) No more than two caffeinated beverages per day.
3) Avoid change in diet or weight loss or fad diets during IVF cycle. A healthy well balanced diet works best.
4) Refrain from intercourse three to four days prior to egg retrieval and following embryo replacement until pregnancy determination is made.
5) Normal exercise may continue unless enlargement of your ovaries produces discomfort.
6) Avoid hot tubs or saunas.

For Men

1) Drugs, alcohol, and cigarette smoking should be avoided for three months prior to treatment and at all times during the ongoing IVF treatment cycle.
2) Sitting in hot tubs and saunas is not recommended. Even a single episode in the hot tub can adversely affect sperm function. Refrain from this for at least three months prior to treatment.
3) Abstain from intercourse for at least three days, but not more than seven days prior to collection of semen for egg collection and during treatment.
4) Fever greater than 100.4o one to two months prior to IVF treatment may adversely affect sperm quality. Consult your doctor immediately.

You may adopt this lifestyle changes and live healthy life. Ivf treatment is costly affair and one should consider all efforts possible before seeking this treatment.
Facing infertility is one of the most stressful situations one may encounter, emotionally, physically and of course, financially. At Indira Infertility Clinic and Research Centre doctors are aware of it and hence they work hand-in-hand with you to make every phase of the fertility treatment from diagnosis to end of IVF treatment - as predictable and comfortable as possible. The treatment offered is at very affordable price and economical. Indira IVF believes in Supporting Your Family Building Dreams with IVF. We provide state-of-the-art IVF treatment at affordable prices in a comfortable atmosphere. All the latest reproductive techniques including IUI, IVF, ICSI, Laser Assisted Hatching, Blastocyst Transfer, Sperm & Embryo Freezing, Donor Egg IVF and Embryo Adoption are available with us under one roof.

The team of fertility specialists includes talented and aspiring Gynecologist, Sonologist, Embryologist and Clinical staff who is highly trained in all aspects of Reproductive technology. They continuously work for the improvement of the IVF treatment program as per the need of their patients. The team at INDIRA IVF with their sincere effort, dedication and professional approach has been instrumental in achieving more than 2000 IVF pregnancies all across India in just 3 years. Our IVF success rates are high and we keep patients' stress levels low. We believe that the best patient is a well informed one, and that you are the most important person in our IVF clinic.

You can visit the clinic or fix up an appointment with our infertility specialist at http://www.indiraivf.com or you can call us on 0294-2412063


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