World osteoporosis month
Osteoporosis:
Interventions to manage vertebral fractures

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist

Some important facts about osteoporosis
• Osteoporosis is a systemic skeletal disorder characterized by low bone mass, disruption of the microarchitecture of bone tissue, and compromised bone strength which leads to an increased risk for fracture.
• Bone strength is a product of both bone density and bone quality. Bone density is expressed as grams of mineral per area or volume; bone quality refers to factors such as architecture, turnover, damage accumulation (e.g., microfractures), and mineralization
• Osteoporosis is common among menopausal women but is often clinically silent until a fragility fracture occurs. Osteoporosis is also being recognized with increasing frequency in older men.
• After peak bone mass is reached, the bone remodeling process is in a state of equilibrium until menopause. Cessation of estrogen production leads to rapid bone loss of approximately 2% to 3% per year in the spine for up to 6 to 8 years, which accounts for 50% of the total spinal bone loss among normal women .This is then followed by a slower rate of bone loss (0.5%/year), which is attributed to aging.
• Even among men, it is now known that estrogen deficiency plays a big role in bone loss, perhaps an even bigger role than played by testosterone . Studies among osteoporotic males have shown a closer correlation between estradiol levels and bone mineral density (BMD) than testosterone and BMD. A finding that men with osteoporosis may have low estradiol yet normal testosterone levels further supported this correlation.
• Clinically, osteoporosis is diagnosed when bone mineral density (BMD) is reduced or when fragility fractures (ie, fractures after little or no trauma) occur. Dual-energy x-ray absorptiometry (DXA) is by far the best standardized technique and is preferred for diagnosing osteoporosis and monitoring responses to therapy. BMD assessment by DXA has been used by the World Health Organization to define osteopenia and osteoporosis
Normal BMD T-score –1

Low bone mass (osteopenia) BMD T-score < –1 and > –2.5
Osteoporosis BMD T-score –2.5

Severe osteoporosis BMD T-score –2.5 with one or more fragility fractures


• The most common misuse of the WHO criteria is applying it to nonwhite postmenopausal populations. The fracture risk/T-score relationship used for these criteria was derived solely from a database of white, postmenopausal women. Thus, the criteria cannot be taken to mean or suggest the same fracture risk when the individual being measured is male, premenopausal, or nonwhite.
• The T-scores obtained from peripheral sites do not have the same fracture implication as those obtained with central machines.
• Degenerative changes in the spine are exceedingly common among the elderly. These are seen as sclerotic changes in the facets and discs as well as osteophyte formation. They elevate BMD and may lead to falsely normal BMD and T-scores in the spine.
• Vertebrae with compression fractures are denser than normal vertebrae and would have higher T-scores. It would be a big mistake to withhold therapy for a patient who appears to have normal T-scores due to compression fractures.
The most common osteoporosis-related fractures involve the thoracic and lumbar spine, the hip, and the distal radius.

Biochemical evaluation
Successful management of osteoporosis requires a careful choice of biochemical tests to determine the presence of secondary causes of osteoporosis. At a minimum, laboratory evaluation should include a complete blood cell count, serum chemistry panel, liver function tests, and serum thyroid-stimulating hormone and calcium determinations.

Complete Blood Count

Complete blood count (CBC) tests can detect anemia, which can be seen in many secondary causes of osteoporosis; these include celiac sprue and other malabsorptive states, chronic liver disease, chronic kidney failure, metastatic bone disease, and multiple myeloma.
KFT
Renal insufficiency often leads to a deficiency in 1–25 OH vitamin D deficiency and secondary hyperparathyroidism, which must be addressed prior to initiation of osteoporosis therapy. Bisphosphonates are contraindicated when GFR falls below 30 mg/24 hours
Liver Function Tests

An alanine aminotransferase (ALT) test is the most cost-effective way to screen for liver disease among osteoporotic patients. Elevated ALT levels suggest liver dysfunction, which, regardless of the cause, increases the risk of vitamin D deficiency.

Serum calcium

Postmenopausal women as a group are commonly affected by primary hyperparathyroidism .A serum calcium determination adequately screens for this disorder


Treatment of osteoporosis

The essentials of management for most forms of osteoporosis include the following:
• Lifestyle modifications.
• Nutritional interventions.
• Pharmacologic therapies.
• Interventional procedures for vertebral fractures
Lifestyle Modifications
Safety of the patient's immediate environment to prevent falls and fractures, eliminating habits that are deleterious to skeletal integrity and that can contribute to falls

Discontinue smoking and alcohol consumption.

Weight-bearing exercise program

In patients with inflammatory diseases who are receiving long-term glucocorticoid therapy and are at risk for osteoporosis, an exercise and physical therapy program is imperative

Nutritional Interventions

Nutritional interventions for osteoporosis should assure that the diet plus supplements provide at least 1200 mg of elemental calcium per day and up to 1500 mg in high-risk patients over the age of 70 with established disease or with steroid-induced osteoporosis.

Pharmacologic Therapy
Drugs for osteoporosis can be divided into two major classes: antiresorptive and anabolic agents. Antiresorptive agents inhibit bone resorption, mainly through their action on osteoclasts, whereas anabolic agents stimulate osteoblastic differentiation and activity.



Antiresorptive Therapy

Bisphosphonates

These pyrophosphate analogues bind to hydroxyapatite crystals in the bone, are taken up by osteoclasts in the bone, and exert their action by inhibiting the mevalonate pathway, subsequently leading to inhibition of osteoclast function and increase in rates of apoptosis. Oral bioavailability is generally low, only 1% to 3%, and is greatly inhibited by food, calcium, iron supplements, and drinks. Patients must be advised to take this medication in the morning, to withhold food and drinks to ensure good absorption, and to remain upright for at least 30 minutes.
• • Bisphosphonates
Alendronate 5 mg/d or 35 mg/wk for prevention of osteoporosis; 10 mg/d or 70 mg/wk for treatment of postmenopausal, male, and glucocorticoid-induced osteoporosis

Risedronate 5 mg/d or 35 mg/wk for prevention and treatment of postmenopausal and glucocorticoid-induced osteoporosis
Ibandronate:2.5 mg /d or 150 mg/month .or 3mg iv 03 monthly

Raloxifene
Raloxifene is a selective estrogen receptor modulator, with agonistic effects on bone. The major efficacy trial for raloxifene was the Multiple Outcomes of Raloxifene Evaluation (MORE) Trial. The LS BMD increase over the 3-year study period was 2% to 3%, and vertebral fracture reduction rates in women with and without preexisting fractures were 50% and 30%, respectively.
Calcitonin
Because of its modest effect on BMD, and small fracture risk reduction, calcitonin is rarely used as first-line therapy; rather, owing to its mild analgesic effects, this drug is more commonly used now as an adjunctive therapy after an acute vertebral fracture, usually combined with a stronger antiresorptive.


Hormone Replacement Therapy
Hormone replacement therapy (HRT) was the original antiresorptive therapy used for osteoporosis. However, current controversies centered on increased breast cancer, and cardiovascular risks have resulted in a marked decline in use for osteoporosis indications.

Anabolic Therapy
Teriparatide
Synthetic human parathyroid hormone [PTH (1–34)], or teriparatide, is an anabolic agent that has been approved for postmenopausal and male osteoporosis treatment


Combination Therapy
Trials that have studied combination therapy for osteoporosis had BMD and not fracture risk reduction as the primary endpoint. Thus, although the effects appear to be additive, it is unknown whether there is indeed a greater reduction in fracture risk when two agents are combined.

Interventional procedures for vertebral fractures


Kyphophasty and Vertebroplasty


These two surgical modalities have been reported to successfully relieve pain from acute compression fractures and decrease kyphosis slightly .The procedures entail injection of polymethylmethacralate or bone cement directly into the fractured vertebra in vertebroplasty, and into a balloon within the vertebra, in kyphoplasty.


Vertebroplasty is a percutaneous procedure with a low complication rate that provides immediate and long-¬term pain relief to patients suffering from chronic ver¬tebral compression fracture pain. Vertebro¬plasty is a minimally invasive procedure that not only provides immediate relief but continued and prolonged relief that may increase the patient's daily activity level, which in turn helps provide a better quality of life. In several studies it has been shown that in more than 90% cases it provide immediate pain relief.
Some of the potential complications include leakage of the cement into the spine, surrounding structures, and vessels.

Introduction



The patient record is the principal repository for information concerning a patient's health care. It affects in some way, virtually everyone associated with providing, receiving, or in any way related to health care services. Despite the many technological advances in healthcare over the past few decades, the typical patient record in the public hospitals in India, have virtually remained unchanged. Patient record improvement could make significant contribution to improving the health care system in the public hospitals in India.


This interest in a patient care information system has basically emerged from the belief that, it would help overcome current breakdowns and inefficiencies in patient information system and that the quality of care and inefficiencies are greatly due to reliance on paper-based records. In several cases it has also been seen that, prior medical records have been almost impossible to retrieve from the pile of existing ones and examinations as well as investigations are unnecessarily repeated. This not only results in incurring unnecessary expenditure and waste of time, but also deprives the hospitals, with limited resources, to respond to everyone's health needs.

Who is to blame here? The clinicians, the hospitals lack any sort of information system to deal with this problem and the patients using the public hospitals are not literate enough to preserve all the medical reports and reproduce in their next visit.


Public hospitals in India, constitute a major portion of the health sector. They consume a major share of the health services expenditure. Government expenditure on public hospitals accounts for about one third of the health services expenditure (Mahapatra & Berman, 1994). Thus, improving efficiency in these public hospitals could free up resources, for either service expansion or improvements of quality and reliability of care. Within constrained resources, the government needs better/appropriate information systems to handle the volume of patients effectively and efficiently.



Currently, these hospitals do not use any kind of information system to assist in their daily operations, as is common in any Amercian hospitals. Hence, the best step for the introduction of information system, would be towards developing a computerized patient record system in these hospitals.


I would like to propose for a computerized patient record system for the public hospitals of India. First, I would give a brief description of the organization of the public hospitals in India. Then, I would discuss the problems that these hospitals are facing due the system of paper based records. Then, I would discuss the advantages of having a computerized patient record system. Finally, I would like to highlight the problems that one would likely face, in developing such a system in India, and overcome them. I would also like to mention that there is a private sector which is quite large. The reason I have only dealt with the public hospitals relates to the disorganized state of affairs in the public hospitals and the large volume of patients that they receive. Private hospitals usually have a comparatively manageable volume of patients and have some amount of automation in place.


But, it would be worthwhile to have an integrated approach, once some standards have been developed. I have discussed this aspects in the later part of this paper.


A. The Organization of Public Hospitals in India


Before going into further details of the need and introduction of a computerized patient record system, let me first give some light into the organizational structure of the public hospitals in India. They are basically organized in a three tier system, the tertiary level, the secondary level and the primary level.


1. Tertiary : The tertiary level hospitals are designed to provide a complete range of treatment, which include such specialities as radiotherapy, neurosurgery, thoracic surgery, plastic surgery, along with the other specialities commonly provided in all hospitals. They are usually teaching hospitals and located in the state capital as well as district headquarters.


2. Secondary : The secondary level hospitals are the intermediate level hospitals of about 100 beds, and provide medical, surgical, obstetrical, and other specialized treatments. These hospitals are otherwise referred to as the first referral hospitals, since the referrals from the primary level institutions are most likely directed to them. They represent the level of care and facility in between the primary level and the tertiary care institutions.


3. Primary : These are small local (rural/community) hospitals of 20 to 100 beds, probably undifferentiated, to provide where necessary general, medical, surgical and maternity care. They are at the lowest level in the three tier system.



The Present Scenario of Patient/Medical Records

At present, the condition of patient records system, in the public hospitals, is quite discouraging. The clinicians record patient information, diagnosis and treatments in paper, in a free style manner, which is called the "Case Sheet". There have been some attempts in the recent past to standardize the manual forms, but there is still a long way to go. The paper medical records remain the legal and official record of patient care. Although, some super-specialty hospitals have started using computer-generated information as part of the medical record, file folders full of slips of paper and massive file rooms are the still the norm in the public hospitals in India. I have listed below a few point to describe why it is essential for the hospitals, to switch from this system of paper records to an electronic one.


A. High volume

There is always overcrowding in most of these hospitals, and the utilization rate is very high. This is due to the high demand of health care services and the relative dearth of health care providers and beds compared to the size of the population. Recent studies show that, there are 6 beds for every 10,000 people. This high volume of patients means high volume of medical records. Any amount of proper filing has been unable to handle the high volume of the paper.


B. Illegibility

The information in the medical records is handwritten, especially patient's problem list, documentation of history and physical, encounter notes in outpatient records, order sheets and progress notes in inpatient records. One of the drawbacks of handwritten documentation is obviously illegibility. This is less of a problem for the clinicians, who originally penned the text, but can be extremely difficult for others, who must devote extra time to the task of reading it and may end up with not getting the information they need.


C. Non-standardization (Lack of any standard format)

When documentation is handwritten, it tends to be free form and not necessarily complete. Because medical nomenclature is not standardized, it is difficult to ensure that the user of a medical record draws the interpretation from the documentation that the author intended. Thus, this non-standardization aspect of the paper records adds confusion and may lead to lower standard of clinical care of repeated investigations.


D. Duplication of records

If a patient has to visit more than one department in the same hospital, then separate records are created for him/her in the individual departments. Medical records are typically maintained in each care setting.
This is done to avoid any chance of losing the record, because of its moving around various departments. As a result, it ends up with more paper and more filing and more duplication of laboratory investigations. This causes unnecessary costs.

Patients who obtain care in multiple hospitals, have fragmented, partial documentation of their medical history in a number of different records.


E. Delay in retrieving records

Currently, hospitals have elaborate processes in place to pull medical records and make them available to the locations where physicians and providers need the information. Due to the difficulty in locating, a lot of time is wasted and most of the times the patients end up being seen without a medical record.


F. Missing records

As a result of all of the above mentioned reasons, one often sees a high rate of missing records. One consequence of missing information is repeated diagnostic tests and procedure. Another consequence is unnecessary delay in inpatient or ambulatory care and treatment. Sometimes it may turn out too costly, and may cost patients' lives.


G. Inability of part of patients to preserve medical reports

Most of the patients visiting the public hospitals in India, are poor and usually illiterate. They cannot be expected to understand the handwritten papers and preserve them. So, it becomes difficult on the part of the providers to rely on these patients for their medical history/records. Primarily, the hospitals and the providers tend to be responsible for the medical history/records of these patients. But, the lack of any proper patient record system in these hospitals results in a lot of frustrations to everyone involved in the process.


The Need for a Computerized Patient Record System
All the points discussed above, strongly argue for the necessity of a computerized patient record system for the public hospitals in India. Clinical information systems were considered a helpful luxury a few years ago, but today they have become an urgent necessity. The health care delivery system is changing, and today's health care facilities need to share integrated patient information within their own environments as well as across providers. The real question is how are the hospitals going to benefit for this system. Apart from overcoming the various problems that have been discussed above, let me now point out the advantages that a computerized patient record system will have over a paper based one.


A. Improve efficiency

The most important function of a CPR is increased efficiency, both from the cost and the clinical care perspective. The efficiency can be increased by reducing costs and improving staff productivity, which can in turn be achieved by avoiding duplications, repetitions, delays, missing records and confusions.


B. Improve Health Care Delivery

It can lead to improved health care delivery by providing medical personnel with better data access, faster data retrieval, higher quality data and more versatility in data display/ The ease and speed of obtaining information is one obvious advantage. Some studies have found enhanced care and improved outcomes of care for patients and a reduction in medication errors with the introduction of CPR (Rogers et al., 1982, Garrett et al., 1986).


C. Quality Assurance/Quality Improvement

Automated patient records can also make quality assurance activities possible in the individual hospitals, departments. The clincial data that is captured electronically could be later used for evaluation for quality assurance, quality improvement, examinations of variations in care and studies on utilization and outcomes.


D. Measure Physician/Hospital performance

Another possible advantage of CPR is making measurable and comparable (by risk adjustment of course). This will enable the clinicians to rectify any possible problems relating to care. With the Consumer Protection Act, which started being applicable to health care since September 1995, there will be a necessity which started being applicable to health care since September 1995, there will be a necessity for hospitals, as well as the providers to have a documentation of their treatment and advice.


E. Can be used as a teaching/research tool

CPR can support health service research and accommodate future developments in health care technology, policy, research, finance etc. Health care professional schools and organizations could enhance educational programs for students and practitioners in the use of computers, CPR's, and CPR systems for patient care, education and research. The could make medical knowledge more accessible for use by practitioners when needed. CPR could also support information management and independent learning by health care students and professionals in both patient care and clinical research settings. Tools for such learning include clinical decision support systems, bibliographic and knowledge links, and statistical software.


F. Force orderliness and standardization

Studies show that the accuracy and completeness of the data in the medical records have improved after the introduction of computerized patient record system (Metzer, ..._/ Further, it is also possible to program the entry in such a manner so that it would be necessary to fill in all the required places. This would force some kind of standardization, where the integration of patient data would be possible. Many problems that providers face due to non-standardization, would be overcome by introduction of CPR.


G. Increase accountability

CPR would also make providers more responsible and accountable for their actions. I would assume that the number of adverse events linked to physician's irresponsibility would definitely come down. Increased accountability would also help the providers more efficient both from the cost as well as the clinical care perspective.


H. Managerial tool

Finally, CPR could also be used as a managerial tool to provide total, cost-effective access to more complete, accurate patient care data and to offer improved performance and enhanced functions that can be used to meet those information management challenges. They can play an important role in improving the quality of patient care and strengthening the scientific basis of clinical practice; they can also contribute to the management and moderation of the health care costs.



Areas of Caution


While introducing CPR, one has to keep in mind that merely automating the form, content, and procedures of the existing patient records will perpetuate their deficiencies and will be insufficient to meet user needs. So, an in-depth analysis and needs assessment of the potential users is necessary before the introduction of the CPR. Depending on the requirement of the users, the CPR may be designed with special features to cater to their needs. CPR should offer enhanced communications capabilities and must be able to transmit detailed records reliably across substantial distances.


If users are to derive maximum benefits from CPR system, they must fulfill four conditions. First, users must have confidence in the data which implies that the individual who collects data must be able to enter them directly into the system and that the system must be able to reliably integrate data from all sources and accurately retrieve them whenever necessary. Second, they must use the records actively in the clinical process. Third, they must understand that the record is a resource for use beyond direct patient care. Fourth, they must be proficient in the use of future computer-based record systems and the tools that such systems provide

(e.g., links to bibliographic databases or clinical decision support systems).


Further, I would recommend that before the implementation of any CPR, some activities that are very critical to CPR development, should be undertaken. They are, proper identification and understanding of the CPR design requirements, development of standards, CPR and CPR systems research and development, demonstrations of effectiveness, costs and benefits of the CPR system, coordination of resources and support for CPR development, diffusion, education and training of developers and users?


Obstacles to Overcome


A. Absence of any system of Unique ID

One major problem in the introduction of CPR in India, would be identification of patients. There is no system of social security numbers or any other identification numbers. Further, there are a few similar names that many people have. So, it would be very difficult to have a database of similar names and no other IDs. One way to overcome this problem is to have their parents as well as their village names in the database. This would differentiate the individuals with similar names. The database could be developed, having this problem in mind. Currently, the government of India is developing the system of social security identification numbers. So, this problem will be dealt with effectively.


B. Acceptability by the Providers

One major barrier to the introduction of CPR is the acceptability by the providers in the hospitals. Sometimes, there are providers who are eager to learn new things, while there are some who would object to any change in their lifestyle, especially one that would require interactions with a computer. They may feel threatened by the consequences of the CPR. Here it is crucial that, some good leader-ship figures are identified, who would become cham-pions and positive role models in the use of CPR.


C. Postal Addresses


It is very likely that many poor people do not have any postal address. They either live in temporary houses or share houses. Sometimes they would build a thatched house beside a railway station or a bus stand, then they would build a thatched house beside a railway station or a bus stand, then they would pack up and find another convenient place.

So, it is very difficult to track these people. The health care delivery system would be missing a big chunk of the population, if it does not have any system of having them in the database. Some system has to be worked out to identify these people when they come in frequently to the hospitals.



D. Multiple Languages

A big problem one faces in any part of India, is the use of multiple languages. In India, people speak several languages. Some of them are Telegu, Urdu, Hindi and English. So, which language should the

CPR sue? If it uses Telegu, then many people do not know how to read and write it. Similar is the case with the other languages. So, I feel that this may pose a major problem, unless there is a built in translator in the program. English is also a good alternative, as most PC users know English.



E. Cost Component


One important influencing factor, whether the public hospitals would adopt CPR, is the size of investment required on the part of government. Acquisition costs for CPR are substantial, but are difficult to estimate, because, the purchase of a system does not reflect the total implementation cost. It excludes the cot of training, potential losses of productivity during transition to the system and previous level of automation/computerization. One cost analysis of the implementation of CPR (ambulatory care) found that the cost per patient encounter of a computer based system was 26% greater than the direct costs associated with operation of a manual system (Koster et al., 1987).


I would urge that an international funding agency be requests to aid in this kind of an innovative approach to health care delivery.


F. Maintenance of computers in rural areas

As I have mentioned before, the primary hospitals, which are the lowest in the three tier system are located in the rural areas of India. It may be extremely difficult to automate these hospitals. Should they be excluded from the CPR system or should there be some way to deal
with these hospitals? May suggestions are to first conduct a study, where we collect data about the capacity and utilization of such hospitals. Then, it will be possible to get some idea as to how much investment is necessary to include these hospitals in the system and how much do we lose by excluding them. Any new system should not be over ambitious from the beginning.


G. Uninterrupted Power Supply

One of the minimum requirements of a CPR system is uninterrupted electrical power supply. A major problem in must of the states in India is the frequent breakdown of power supply. Most hospitals have some sorts of alternative power supply systems, to handle cases during these breakdowns. It would be advisable to, either have better Uninterrupted Power Supply (UPS) system, or upgrade the existing system, if they are good enough to support the CPR system.


H. Dearth of Trained Personnel

A CPR system would require a good number of trained personnel for development, implementation and finally maintenance of the whole system. At present, there may not be adequate professionals in this field. But, once people come to know that there are opportunities in this area, many would up to be trained in order to get employment in the hospitals. I recommend that such courses be introduced in colleges as subjects, so that there would not be any dearth of trained personnel, in a few years to come.


I. Confidentiality
The uses of confidentiality is substantial, but not a big deal as it is in the Western societies. To me, this is more of cultural issue. India is a collective society, and privacy is not so much of a big issue. There are much more grave and competing issue to be attended to than this one. This does not imply that one should not make any attempts toward protecting patients security, during the development of a CPR system. I personally feel that some standards should define the limits and scope of privacy and confidentiality for sensitive data (abortions, AIDS), psychiatric problems, drug use or alcohol problems) in clincial information of the CPR, systems. However, any amount/level of sophistication is never enough to deal with the social deviants. So, one should realize the tradeoff between efficiency, effectiveness and privacy of patients.



J. Standardization


There would be a need to develop guidelines, in order to standardize the clincial practices. AT present, there is not standardized from at or clinical guidelines that are existing to aid in the development of the CPR. Some attempts have been done by the commissionerate of Medical Services in 1989. Major steps towards standardization is essential for a successful CPR. There should be no confusion regarding what should be entered to convey what. All records need to be accurate, accessible, authenticated, organized, confidential, secure and complete.



Summary and Conclusion

The promise offered by fully computer-based patient records for improving quality of care and advancing medical knowledge is enormous. Therefore consorted efforts should be full development of computer-based records system.
One needs to recognize that considerable work
needs to be accomplished and practical difficulties
resolved before CPR become the standard mode of documenting and communicating patient information and before they are perceived and used as vial resource for improving patient care. The challenge of coordinating CPR development efforts in a pluralistic health environment, as in India, is great. Further, achieving maximum benefit from CPR systems will require that they linked to an information infrastructure (e.g. network) that allows patient data, medical knowledge, and other information to be transmitted and accessed when and where needed, subject to appropriate confidentiality and security.

The desire to improve the quality of and access to patient data should be shared by patients, practitioners, administration, researchers and policy makers in the state of India. The CPR, at present, is an essential technology for health care, to be adopted by the public hospitals in India.


The following recommendations would help in making the whole process possible.

1. The public and the private sector should collaborate and establish a committee to promote and facilitate development, implementation, and dissemination of the CPR.


2. Cost analysis studies should be conducted to understand the feasibility of a statewide COR system.


3. They should develop and promulgate uniform, state level standards to facilitate implementation of the CPR. A variety of standards need to be developed, tested, and implemented before the CPR can realize its full potential at all levels.


4. There should be a survey for the demand for such a system. The full cost of implementing and operating a CPR may be shared by those who benefit from them.


5. Health care professional schools and organizations in India, should enhance their educational programs for students and practitioners in the use of computers, CPR, and CPR systems for patient care, educational and research.


6. The committee should work out and develop a system of identification numbers for the patients, that would be used by the CPR system.
If appropriate steps are taken before the development of a computer-based patient record system, I am sure that the whole process would be a success and ease a lot of problems that clinicians currently face in public hospital settings.

Shwas (Bronchial Asthma)



Introduction


The word Shwas means “difficulty in breathing”. Normally shwas word represents to Tamak shwas described in Ayurvedic texts. The feature of this disease is very similar to the disease ‘Bronchial Asthma’ mentioned in allopathic books. It is characterized by difficulty in breathing, increased breathing rate, cough with thick sputum.

Hetu (causes) – the common causes includes


Kulaj-: family history of Tamak shwas.

Food-: excess of food items like curd, milk products, and uncooked food; drinking very cold water, cold beverages etc.

Exposure to dust, smokes, breeze, air condition.
Injury to vital organs.

Anemia, respiratory tract infections.


Classification / Types

It is divided into five types; these are Mahan, Urdhva, Chinna, Tamaka & Kshudra.

Purvaroopa (prodormal symptoms)

Cough (with or without expectoration), flatulence, constipation, discomfort in chest, are some common prodromal symtoms.



Rupa (clinical Features):

Dysnoea (aggravated in lying position and relived in sitting position), momentary comfort after expectoration


Cough with cracking sound /with or without expectoration; running nose,
Loss of taste, appetite
Perspiration on forehead, dry mouth, desire for hot comforts, darkness in front of eyes.
Fever, generalised fatigue, delusion
The condition gets worsened in rainy season, windy and cloudy atmosphere. On the contrary the patients feel fresh on bright sunny day.


Sadhya - Asadhyatva (Prognosis)

Acute attacks of tamak swasa need urgent management. Otherwise it can prove life threatening also. It is considered as Yapya (incurable but manageable, persists for a long time). The chronic disease in a thin and weak person carries a bad prognosis. The disease with latest onset and no family history can show excellent prognosis by Ayurvedic medications.



Chikitsa - treatment

Shodhan-:


Snehapan-: in this mode certain medicated ghee/ oils are advised for ingestion. Usually ghee like vasa ghrita, kantkari ghrita, bharngyadi ghrita, yashtimadhu ghrita etc are used for shodhan purpose. These are administered in an increasing dosage schedule for not more than 7 days.



Swedan-: in acute stage, lukewarm mahanarayan taila mixed with saindhav salt is used for gentle chest massage, which is followed by fomentation by vapours of dashmoola decoction. It is a very effective remedy for reliving bronchospasm. Swedan by means of dry valuka pottali, hot water bag is also useful in acute cases.



Vaman-: vaman reduces the recurrence rates of asthmatic attacks



Virechan-: it is also useful mode of purification for increasing the immunity of an individual towards allergies.



Basti-: various preparations like mahanarayan taila, yashtimadhu taila etc are administered through anal route. This helps in reducing the severity of attacks.



Shaman Chikitsa -: commonly used drugs



Churna-:

Yashtimadhu + tankan
Pushkarmoola churna
Shringyadi churna
Shatayadi Churna




Aasav-:

Kanakasav Somasav
Dashmoolarishta


Bhasma -:

Abhrak bhasma
Raupya bhasma
Shrung bhasma
Suvarna bhasma
Moti Bhasma


Raskalpa-:

Brihat Vata Chintamani Rasa
Shwas-kasa chintamani rasa
Suvarna malini vasant
Shwas kuthar rasa
Nag guti


Avaleha-:


Chyavanprashavleha
Kantkari avaleha
Vasa Avaleha
Agastiprasha
Chitrak haritaki avaleha


Miscellaneous-:


Vardhaman Pimpali
Chaushati pimpli

ABSTRACT

Ayurvedic formulation triphala was found to be effective in inhibiting γ-radiation induced damage in
microsomal lipids and plasmid pBR322 DNA. The fast reaction kinetic tools like pulse radiolysis and
stopped flow technique were used to asses its antioxidant activities and antioxidant equivalents. The
phytochemical analysis showed that triphala is rich in polyphenols (38± 3%) and tannins (35 ± 3%).
Based on these studies it is proposed that triphala is an effective antioxidant, which can act as a good
radio protector.



DETAILS

Introduction


In the recent past, there has been growing
interest in exploiting the biological activities of
different ayurvedic medicinal herbs, owing to
their natural origin, cost effectiveness and lesser
side effects ].

Triphala is one of the
ayurvedic medicinal herbal formulations
prescribed by most health care practitioners.

It isused as colon tonic, laxative, eye rejuvenator,
anti-inflammatory, anti-viral etc.

It is a composite
mixture of three medicinal herbs Amalaki
(Emblica officinalis), Haritaki (Terminalia
chebula) and Bibhitaki (Terminalia belerica).
Triphala is gentle for people of all ages, from
children to seniors and hence is recommended
for everybody [3].

Triphala has been tested as
an antioxidant and also as a radioprotector in
mice [4, 5]. In the present study, we tested the in
vitro antioxidant activity under γ-radiation
induced conditions.

In order to understand the
factors responsible for the antioxidant and radio
protection activity, free radical reactions and
phytochemical analysis of triphala were carried
out.






Experimental



Lipid peroxidation in microsomes and DNA
damage in pBR322 were carried out using 60Co
γ-source [2].

Nanosecond pulse radiolysis and stopped flow technique were used to study rates
of free radical reaction and to determine the
antioxidant equivalents. Phytochemical analysis
were carried out by using HPLC and absorption
spectrophotometry.




Results and Discussion


The aqueous extract of triphala (20 μg/ml)
inhibited γ-radiation induced lipid peroxidation in
rat liver microsomes at all the doses employed
(120 – 360 Gy) to the extent of 65 to 85%. By
using concentration profile studies (5-35 μg/ml)
at a fixed dose of 240 Gy, IC50 value of 10μg/ml
was determined.

Triphala (25-200 μg/ml) was also found to be effective (~35-75%) in inhibiting
γ-radiation induced (absorbed dose of 6 Gy)
strand breaks in plasmid pBR322 DNA



The above two studies suggest that triphala
exhibits antioxidant activity under γ-irradiation
conditions. Under these conditions, damage to
biomolecules is initiated by the free radicals
produced by the radiolysis of water. Hence it is
appropriate to study their free radical scavenging
ability.




Free radical reactions of Triphala




The radical scavenging experiments were
carried out by using fast reaction kinetic tools
like pulse radiolysis and stopped flow technique
and the reactivity of triphala towards different
radicals such as hydroxyl radicals, superoxide
radicals, DPPH and ABTS•− were determined.
Triphala was found to be an effective scavenger
of DPPH and superoxide radicals.


The reaction of ●OH with triphala, produced a
transient absorbing in the region 350 – 500 nm
with a major transient absorption peak at 350 nm
attributed to gallic acid type of radicals.



Phytochemical analysis


Phenolic acids, flavonoids and tannins are the
most commonly found polyphenolic compounds
in the plant extracts. In the present studies we
have estimated the total polyphenolic and tannin
content in triphala by using Folin- Ciocalteau
method and Folin-Denis method respectively.

It showed that triphala contains 38± 3%
polyphenols and 35 ± 3% tannins. The HPLC
analysis was carried out by using a C18 PCX
500 analytical column and mobile phase (0.05 M
HCl, 0.1 M KCl and varying the percentage of
acetonitrile from 2.5 – 32 %). The detector used
for HPLC analysis is a UV detector set at 260
nm.


It showed that triphala contains sufficient amount
of gallic acid (Figure 2), so that it can be used as
marker compound for in-vivo studies.





Conclusions



Triphala, a well known ayurvedic formulation,
exhibits antioxidant activity and radio protection
ability under in vitro conditions The polyphenolic
content in triphala confirm that the antioxidant
and radioprotecting ability of triphala arises from
the polyphenols, which reduce oxidative stress
by converting the reactive oxygen free radicals
to non-reactive products. The studies are of
great significance as the demand for herbal
products as antioxidants and radio protectors is
increasing constantly.


( SOURCE -- Founder’s Day Special Issue, 2005)

Note - The aim of this article is to increase awareness in Ayurvedic community about
wonderful uses of ayurvedic drugs , and to enhace use of evidence based medicine.

Pancha Karma: The Ayurvedic Science of Detoxification and Rejuvenation

Ayurveda, which literally means the knowledge of life is the traditional healing science of India. Viewing disease as the natural end result of living out of harmony with our environment,

Ayurveda emphasizes reestablishing harmony and balance as the means of recreating a state of optimal health in our bodies and minds. While Ayurvedic methods utilize many therapies including herbs, diet, aromatherapy, color therapy, mantras, yoga, meditation and general lifestyle counseling, the most profound of all treatments is that of Pancha Karma.


Pancha Karma is the traditional form of detoxification of the body and mind that facilitates rejuvenation. It has been utilized for thousands of years as a method of staying healthy, young and vital.


"The value of Pancha Karma is that it offers systematic treatment for dislodging and flushing toxins from every cell, using the same organs of elimination that the body naturally employs -- sweat glands, blood vessels, the urinary tract and the intestines."


Pancha Karma is unlike any other detoxification program because it is fundamentally designed to remove a different form of toxin. While many toxins exist in our environment which accumulate and harm our bodies, Ayurvedic Pancha Karma addresses a special toxin called ama which is formed within our own bodies.


Ama is the by-product of inadequate digestion. It has the qualities of stickiness and heaviness. In our bodies it clogs our systems and damages our tissues. It is among the most damaging of forces in our bodies and contributes to disease.

Here is an analogy to help you understand how ama is formed. Imagine that there is a fire inside your stomach. Think of a campfire. If the fire is weak, it cannot burn up the wood put on it. Instead, the wood smolders and begins to smoke. In the end, charred bits are left and the wood is not efficiently turned into ash.


Poor digestive fire, or digestive strength, leads to food being improperly digested. This results in gas, bloating, burning indigestion, or constipation. In addition, a residue of this poorly digested food accumulates in your digestive tract and overflows into your bodily systems. This residue is called ama.


Ayurveda links the occurrence of ama in the body and a weak digestive system to the cause of such chronic conditions such as candida, chronic fatigue syndrome, migraine headaches, chronic respiratory disease and many other conditions. The process of Pancha Karma removes ama and clears the way for the body to re-establish an internal state of balance and harmony.


Ama may be present in the body if there is a coating on the tongue. A normal tongue appears pink throughout, but as ama accumulates in the digestive system, the tongue may appear with a white, yellow, green or gray film over it. In addition, in some cases the body and breath develop a strong odor and the stool becomes dense and sinks to the bottom of the toilet. (According to Ayurveda, the normal stool should float). If you have any of these signs, Pancha Karma treatment may be indicated.


The Process of Pancha Karma


Pancha Karma therapy begins with proper preparation. This includes several days or weeks of a special diet and herbs which begin the process of loosening up the ama and bringing it back to the digestive system for elimination. While the person is eating special foods and taking special herbs, oil and heat therapies are applied. These include the deeply relaxing therapies of Shirodhara, Ayurvedic massage, and Swedana.


Shirodhara is a unique therapy where the client lies down upon a massage table with their eyes covered. Then, a specially prepared warm herbal oil is poured in a thin steady stream through a spicket directly onto the forehead and sixth chakra. This blissful therapy purifies the mind, alleviates anxiety, reduces headaches and expands awareness. Shirodhara can be administered by itself or as part of a Pancha Karma regime.


During Ayurvedic massage two practitioners perform a choreographed hand dance upon the body. Using oils blended with special herbs, this form of massage specifically loosens up the ama stored in the tissues so that it can move back to the digestive system. Not only is it cleansing, but it is deeply relaxing. Ayurvedic massage can be administered by itself or as a part of Pancha Karma.


Swedana is a full-body steam therapy. Special herbs are fused into the steam and together the heat and herbs dilate the channel systems of the body allowing the stored ama to move back into the digestive system.


Once all of the ama is back in the digestive system, the next phase is to eliminate it from the body. This is achieved by the administration of a purgative to cleanse the small intestine and herbal enemas to cleanse the colon. A special form of cleansing is applied to the sinuses called nasya. Following the application of oil and heat over the sinuses, the herbal oils are administered directly into the nasal passages. This procedure not only eliminates ama but is helpful in the treatment of chronic allergic sinusitis and sinus headaches.


Rejuvenation

With the body clear of toxins and ama, it is much like a clean slate. Now the internal energy of the body can be rebuilt. The rebuilding process strengthens the digestive system and the immune system and entails taking additional special foods and herbs. These herbs are designed to enhance the strength of immune system and are revered for extending life.


The end result of Pancha Karma is an optimally functioning digestive system and renewed internal energy. After receiving Pancha Karma the mind is light and clear, the body is pure and the energy is high. For many it is a life-changing experience.



Pancha Karma is traditionally used in the healing of many diseases. It is an intensive therapy best performed at a time when the patient has adequate time to rest. Brief Pancha Karma programs last 7 days. This is followed by a period of rejuvenation which can be done at home. Extensive programs can be designed for up to one month.