Hunger & Obesity

                                                     Hunger and Obesity

                                                  PKGhatak, MD

One cannot escape from the fact that the present generation is getting heavier and fatter, despite cable channels broadcasting continuously healthy cooking, diet, and exercise, the print media are not far behind. 

Why then is the opposite happening!

Maybe we are asking the wrong questions. We should be asking what makes us feel hungry.

Hunger is a sensation registered in the brain as a strong desire for food. As we fill up our stomachs with food and drinks, the hunger goes away and again returns after an interval.

The nerve center for hunger, the Appetite Center, is located in the Hypothalamus. The stomach and small intestine are connected to the appetite center. The hypothalamus, in turn, is connected with other parts of the brain, and the input reaches the conscious level in the cerebral cortex.

 A full stomach sends signals to the brain through the vagus nerve. The appetite shuts down.  Alcohol speeds up stomach emptying, and fat delays emptying.

  

 In starved conditions, the fat cells provide needed energy. Eating extra food makes adipocytes bulge with fat.  Leptin, a hormone, decreases appetite and increases energy expenditure (EEx).  Adipocytes also produce blood pressure regulating Angiotensinogen, a vascular protective protein called Adiponectin, a blood clotting inhibitor known as Plasminogen activator inhibitor 1, a complement called Adiposin or factor D, and cytokines - Interleukin IL6 and Tumor necrosis factor alpha. The net effect of these chemicals on the body is to help regulate BP, blood sugar, blood lipids, blood vessels’ health, healthy body weight, and a competent immune system.

The appetite center is under the influence of several hormones and chemicals. Cortisol depresses appetite. Glucagon secreted from the pancreas has a similar effect. Growth hormones and Gonadal hormones also regulate appetite.  A gut peptide, Ghrelin, is produced by the stomach, which speeds up stomach emptying. Peptide YY and cholecystokinin are produced and have a similar effect to ghrelin. 

High blood sugar and Ketones depress the appetite.

It may sound strange, but it is true that as the person gains weight, the mean energy expenditure (EEx) increases.  As EEx increases, the person feels hungry because of stimulation of the appetite center. The reverse is also true: with weight loss, the EEx falls and the appetite center is depressed.

Non-Exercise-Activity-Thermogenesis (NEAT) regulates energy expenditure of activities of daily living. The basal metabolic rate (BMR) accounts for 70% of EEx,  only 5 to 10% of EEx is required for voluntary activities, including work, exercise, etc. A person can burn at most 400 kcal/ hour by intense exercise, and marathon runners can burn 1200 kcal/hr.

To lose 1lb of flesh, one has to burn 2,500 kcal.  It is not difficult to understand why losing the extra fat by exercising is difficult.

Hypothalamus produces and releases many peptides known collectively as hypothalamic peptides; by the actions of these, it maintains a balance between appetite, fat storage, and energy expenditure. Important peptides in this group are neuropeptide Y, Agouti-related peptide, alpha melanocyte-stimulating hormone, and melanocyte-concentrating hormone. An interaction between hypothalamic peptides and neural pathways via Serotonin, Catecholamine, and endocannabinoid receptors in various target tissues is ultimately responsible for maintaining steady body weight.

Appetite supressing drugs are coming to the market in increasing numbers, but none are safe for long-term use. These drugs act directly on the appetite center by increasing the production and release of a chemical group called monoamine. The pharmacological actions of norepinephrine, serotonin, and dopamine are enhanced by monoamine. These drugs may increase the risk of heart disease and high BP, as well as insomnia and nervousness.

The newer anti diabetic II oral drug, SGTP-2, and a weekly injection of Glucagon-Like Peptide-1 Inhibitors ( GLP-1) work in different sectors of metabolism and have a different safety profile.

 Body mass index (BMI), height-weight nomograms, the thickness of skin fold of arms, and waist-hip ratio are helpful to identify obese individuals, but not all agree on a particular standard. An underwater determination of weight-volume ratio is an accurate measurement of obesity, but it is not a practical method.

 A normal BMI is 20 to 25 kg/m2. A person is considered overweight if the number is between 26 and 29, and over 30 is considered obese. An increase in the waist-hip ratio of over 0.9 in women and 1.0 in men is taken as obesity.

The cause of obesity is unknown. Several factors have been implicated: heredity, environment, cultural habits, a viral infection of the GI tract, and sleep deprivation. 

Several endocrine disorders like Cushing's syndrome, Hypothyroidism, Insulinoma, Hypogonadism and mental retardation also produce obesity.

 Obesity increases the risk of heart disease, diabetes, high cholesterol, high BP, arthritis, and disturbances in sex-hormone-related diseases.

The body’s own regulating system of appetite, energy storage, and energy expenditure must be derailed before weight gain starts. If the process is allowed to progress unchecked for years, the person will be overweight or even obese.

 

edited May 2025

 

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Hepatitis

                                                                Hepatitis

                                                     PKGhatak, MD                                                         

          

                                                 

Yellow Fever is now classified under acute viral hemorrhagic fever but it is viral hepatitis.  The methodology used in the investigation of yellow fever outbreaks opened the doors for all future studies in the epidemiology of viral hepatitis. 

In colonial America, outbreaks of Yellow Fever were frequent.  In 1904, the USA took over the construction of the Panama Canal from the French and thousands of US workers went there to work. Over 5000 workers died of yellow fever and malaria during canal construction. Carlos Findlay of Cuba theorized that man-to-man transmission of yellow fever did not occur and in 1881 he identified a mosquito - Ades egypti, which was responsible for the spread of the disease. Walter Reed confirmed Findlay’s observation and Reed’s research proved that the yellow fever virus infected jungle monkeys and the monkey acted as a natural reservoir of the virus. When men entered their domain, the mosquitoes attacked men and infected mosquitoes transmitted the yellow fever virus to men.  For his work, Carlos Findlay was nominated seven times for the Nobel Prize in Medicine; he, however, did not get the prize. Max Theiler of South Africa won the Nobel Prize in 1951 for discovering an effective vaccine.   

In present-day medical journals, you will find discussions on viral hepatitis; they are mostly on hepatitis C (HCV) and occasionally also other forms of viral hepatitis. The cable news and newspapers will whip up your anxiety, from time to time, with reports of outbreaks of a few cases of Infectious Hepatitis, also called HAV or hepatitis A virus infection. Compared with Yellow fever, Infectious Hepatitis is a relatively mild disease and fatality is rare.

The story is quite different in South Asia where Hepatitis A infection is endemic. The poorer the country, the more prevalent the disease is and the government statistics are either non-existent or simply unreliable.

Hepatitis A.
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It is transmitted from man to man by the fecal-oral route and is highly contagious.

When a person is infected with the virus, initially he has no symptoms but the virus keeps on multiplying in their body. He sheds the virus in his stool. Contaminated water and food are the primary mode of spread of hepatitis A, sexual contact and sharing needles among IV drug users also spread the disease. Even when patients recover from the infection, they would continue to shed the virus for another 2-3 weeks. In South Asian countries, the monsoon rain often inundates the cultivated fields; overflow sewer water also ends up in fields and contaminates the produce. People eating raw vegetables, shellfish, or fresh fruits are infected. The rich and affluent middle class often employ 2 -3 domestic help as cooks, kitchen help, etc., they are poor and live in appalling unsanitary conditions. They have no knowledge of fecal-oral transmission of hepatitis, and hardly ever wash their hands with soap and water after visiting toilets. This mode of spread of a disease is called the fecal-oral route of transmission. You may not know that people working in restaurants in many South Asian countries are not required to carry food-handler certificates. Consequently, you are at risk when you eat out. If you have neglected HAV vaccination, check your vaccine status before you leave home.

Infected people when recovering from HAV infection carry a lifelong immunity; others can protect themselves by taking the HAV vaccine.

Hepatitis B.
-------------

People infected with this virus carry the virus in all of their body fluids, including saliva.

Transfusion of contaminated blood or blood products, sharing infected needles and sexual intercourse are the usual modes of transmission of HBV (hepatitis B virus). Late in pregnancy, the mother may pass the virus to the unborn child and also may infect during childbirth. Breastfeeding does not add any risk.  Since mandatory screening for hepatitis was instituted in donated blood and blood products, the HBV by transfusion is nearly eliminated. All newborns are vaccinated for HBV and adults are going to be covered for HBV vaccination by the new health care bill. HBV is still a problem for HIV infected people. The new cases of HBV infection are decreasing rapidly; hopefully, it will be eliminated in the near future.

Hepatitis C.
---------------

It is a blood-borne infection like HBV; however, the virus is less virulent.
The mode of transmission is usually by sharing IV needles and transfusion of contaminated blood and blood products and by sexual contact. Transmission during the perinatal period (late pregnancy and childbirth) is very rare. Breastfeeding does not increase the risk of transmission to a child.

This disease is a major concern of the present time, not because it is a deadly disease, but because the illness is so benign initially that the infected persons may be completely symptom-free. The majority of the infected people will recover spontaneously. Only a minority will have major complications. Carriers of this virus can be identified by antibody testing and polymerase chain reaction (PCR) tests. Several years after the initial infection, patients may present with cirrhosis of the liver or cancer of the liver. The treatment of HCV is expensive, requires medication administered by injections or oral antiviral tablets, given over twelve weeks, in certain cases, liver transplant is the only option. Since HBV infection is declining, HCV infection has come more and more into focus. There is no vaccine against HCV.

Hepatitis D.
-------------

HDV is a deadly virus but it either co-infects people at the time of HBV infection or infects people who are suffering from HBV disease; by itself, it is unable to infect healthy individuals.

There is no HDV vaccine.

Hepatitis E.
--------------

This virus is a waterborne disease and spreads by contaminated drinking water. It is rarely transmitted from person to person. It infects younger adults in general, often those immune to HAV. It is suspected that pigs are the natural reservoir of this virus.

The vaccine for Hepatitis E is available only in China.

Hepatitis F.
-------------

This virus may cause hepatitis in rhesus monkeys but has not been proven to cause any human disease. This virus is delisted as a cause of human viral hepatitis.

Hepatitis G.
--------------

This is also known as GBV-C, named after G. Baker. It is an infectious virus to humans but probably does not cause human illness. It is transmitted by the oral route and sexual contacts in HIV infected people.

It is thought that co-infection with the BG-C virus may actually slow the progression of HIV infection.

Several other viruses may also damage the liver, but the liver is not their primary target, and will not be discussed here.

Hepatitis means inflammation of the liver, not necessarily infection only. Many other agents including poisons, drugs, parasites, and our own misdirected immune system may seriously damage the liver.

Let us look at this aspect a bit closely:

1. Lupus hepatitis: (SLE) For some poorly understood reasons, some individuals may start directing the body's defense system against their own normal tissues and organs. In SLE liver damage is a significant finding.

2. Poisoning: By consuming poisonous mushrooms, many people may end up in acute liver failure. Habitual drinking of African bush tea, a known hepatic poison, may lead to serious liver problems. Industrial poisoning by Carbon tetrachloride, a dry-cleaning agent, is a well-known hepatotoxin; so also, many other deadly gases are used in warfare. Suicidal attempts with ingestion of Copper Sulfate is common in some Asia countries, hepatic narcosis is not unusual in many such cases. Chronic Iron overload (in Hemochromatosis, repeated Red Cell transfusions) may lead to hepatic cirrhosis and liver cancer. A high dose of Paracetamol (Tylenol) may cause Liver failure.

3. Drug reaction: Many medications have significant adverse effects on the liver, and may produce reversible or irreversible damage to the liver. Some of the drugs are listed here.

Anti-Cholesterol: - Ezetimide, Statins.Fenofibrate, Gemfibrozil

Anti-TB: - Isoniazide, Refampin, Pyrazinamide,

Antibiotics: - Tetracyclines, Oxycyclins, Chloramphenicol, Telithromycin, Trovafloxacin, Sulfanomide, Nitrofurantoin,  

Anti-Retroviral: - Abacavir, Nevirapine, Tipranivir,

Anti-Seizure-: Carbamazipine, Valproic acid, Phenytoin, Lamotrigine, Felbamate

Vitamins: - Vitamin A, Niacin

Ant- Diabetic: - Troglitazone, Pioglitazone, Rosiglitazone

Antifungal: - Ketokenazole, Itracoazole, Voriconazole

Antidepressant: - Duloxatine, Premoline, Nefazodone

Arthritis: - Aspirin, Declofenec, Rofecoxib. Leflonamide, Bromofenac, Benoxaprofen, Methtrexate, Phenylbutazone, Parafon forte.

Anti-Parkinson: - Methyldopa, Tolcapone

Anti- Cancer: Flutamide, Interferon beta1b, Imuran, Imatinib, Isotretinoin

Anesthetic: - Halothane

Acne: - Isotretinoin

Heart: - quinidine, Amiodarone

Asthma: - Zileuton, Zafirlukast,

Alzheimer’s disease: - Tacrine

Hyperthyroid: - Propylthiouracil, Methimazole

Diuretic: - Tienic Acid.

4. Parasitic diseases: Liver flukes (schistosomiasis) infect men when they eat uncooked fish. A bite of sand fly spreads Leishmaniasis (Kalazar). It is a chronic debilitating disease with hepatic enlargement. Amoebic liver abscess by Entamoeba histolytica in tropical countries is not uncommon. Humans acquire amoebic infection via the fecal-oral route and from the gut, the amoeba travels to the liver via the portal vein. By eating improperly cooked pork, men acquire Echinococcus infection and may develop multi-loculated Hydatid cysts in the liver. Mosquitoes transmit Malaria. There are several families of malaria parasites; in some chronic stages of malaria, liver enlargement and dysfunction are common.

5. Leptospirosis: Liver necrosis is a common finding in its hepatic form. The disease spreads via the contamination of water by rats’ urine.

6. Q Fever: Drinking milk contaminated with   Rickettsia may cause serious liver damage.

7. Fungal infection: In disseminated Histoplasmosis liver damage is inevitable.

8. Bacterial infection of the liver is very unusual; however, an infection may spread to the liver from infected gallstones and bile ducts.

9. Alcohol: It is a curse of our civilization. So many people are addicted to this potent liver poison and heading for chronic liver diseases and serious health & social consequences. Alcoholics are less likely to recover when they contract other forms of hepatitis.

This is not a complete list. But if you are reading it, please pay attention and do not get into trouble.

 

edited 2020

 

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Wheezing

                                                                     Wheezing

                                                             PKGhatak, MD

Wheezing is a common symptom of asthma but asthma is not the only cause of wheezing. As more and more people are developing asthma. You need to pay attention if you begin to wheeze for the first time in your life.

What makes one wheeze?

When airways of the lungs (nose, throat, voice box, windpipe, bronchus and its smaller branches) become narrower relative to the airflow, the flow of air becomes turbulent and makes a sound. The sound then gets magnified in the chest because the air in the lungs acts as a resonator.

The airway has three layers, the innermost layer is moist and rich in blood supply, and the middle layer has smooth muscles laid down in a circular fashion and the outer layer has connective tissues.

Inflammation or infection of the airway makes the inner wall swell up making the passageway narrower; contraction of muscles of the middle layer narrows the airway. Any growth or swelling next to the outer layer of the airway can produce narrowing by compression of the airway.

When a person breathes with a narrowed airway, wheezing is heard; at the same time, the person feels it is difficult to breathe because he has to work harder to breathe. When one is exhausted from labored breathing, airflow diminishes so much that only a faint sound of airflow is hard and wheezing disappears. It is now an emergency, without medical help, life is in danger.

Asthma is an inflammatory disease of the bronchus and its branches, resulting in swelling of the inner layer, at the same time, the muscle layer contracts, making airways still narrower. There are several effective medications available to treat asthma.

What about other causes of wheezing.

When heart muscles become weak and fail to pump blood adequately through the lungs the liquid part of blood sips out from the blood vessels into the lungs, constricting the airways from outside and also swelling the inner layer making it narrower.

Any foreign body lodged in the airway, any growth or accumulated secretion in the airway can make one wheeze. In addition, there are several other diseases, not so common, involving the airway and may produce wheezing.

The common cold and hay fever in a certain group of people can produce wheezing. Newborn infants and children have narrower airways, to begin with; as a result, any viral infection can produce wheezing.

In essence: if one begins to wheeze for the first time, it must be checked out by a physician.

 

edited 2020.

 

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Sinister Headache

                                                         Sinister Headache

                                                     PKGhatak, MD

Any abnormal condition in the head and neck area may cause a headache. The cause of this type of headache is easily identifiable and effectively treated. There are, however, more serious forms of headaches. We will consider a few of them here.

 

The brain tissue itself is insensitive to pain, but its coverings (meninges) at the base of the skull are very sensitive. Arteries and veins of certain parts of the brain are also sensitive to pain. Bacterial meningitis is probably the most life threatening and very rapidly progressing infection.

An 18-year-old youngster gets up in the morning with a mild frontal headache and malaise, which he attributes to drinks he had the night before. Later in the day, he has chills and fever; the headache becomes intense and throbbing in character.  He develops nausea and vomiting. In an hour he becomes dizzy; pink colored skin rashes begin to appear over his wrists and ankles. Unless he is taken to a hospital at that moment, it may be too late to save him. This is an example of meningococcal meningitis.

Besides this bacterium, other bacteria may also cause meningitis but the progression of meningitis in those cases may not be that explosive and skin rashes do not develop.

A variety of common and not so common viruses can cause meningitis. In general, sore throat, runny nose, and cough begin first; a day or two later headaches become most troublesome and persist even after taking potent headache pills. A low-grade fever continues and a stiff neck develops. Only a spinal tap and examination of the CSF (cerebrospinal fluid) will differentiate viral meningitis from bacterial meningitis. Coxsackie, Echo, Herpes simplex, E-B virus, and Adenovirus are commonly responsible for viral meningitis. From time to time TV news and newspapers scare people with reports of West Nile virus encephalitis, Western Equine encephalitis, St. Louis encephalitis, Japanese B encephalitis, and other forms of encephalitis. Viral Encephalitis is an infection of the brain tissue and is often associated with meningitis. Depending on the type of virus, the illness may go on for days or a week before a correct diagnosis is made. A headache, fever, and neck rigidity are common symptoms; lethargy, mental confusion, and altered consciousness characterize encephalitis. Various neurological signs and seizures are common, however, most of the neurological defects will resolve with treatment over a period of time.

 

The most intense and worst type of headache is seen in subarachnoid hemorrhage. A ruptured intracranial aneurysm is often the cause. Typically, the person has an episode of a short, sudden severe headache, which may subside in time. Then the most painful, intense headache starts, followed by loss of consciousness within a short period. There may or may not be warning signs of the presence of a berry sized aneurysm at the base of the brain; pain following a rupture may be the only presentation. An immediate surgical procedure is required to save the life. 

A stroke, as a result of bleeding inside the brain tissue, may produce a severe headache because accumulated blood stretches the meninges and blood vessels; often, a headache may precede the bleed for hours or a few days, but associated paralysis is the predominant presenting symptom. A headache from stroke, as a result of thrombosis of an artery or blood clot emboli, may or may not be present.

 

A person having high Blood Pressure often complains of a dull headache over the back of the head or forehead, often the headache has a throbbing character, at times a headache is associated with dizziness. A headache subsides with the control of BP.

People fear a headache may be a sign of brain tumors but often headache is not a presenting symptom. When a headache is present, it is deep seated, dull aching and becomes worse with coughing and straining at stool.

A persistent and constant throbbing headache over one side of the temple, or in rare cases on both sides, may result from Temporal arteritis, also called Giant Cell Arteritis. The pain is located on the face, jaw, or side of the neck. The scalp becomes very painful to touch. At times, it is associated with visual impairment or the onset of sudden blindness. Urgent treatment is required when vision is affected.

 

A fall or injury to the head will cause pain and headache but if vomiting, confusion, and altered consciousness are absent and no neurological signs are present, then brain injury is unlikely. A subdural hematoma may result from a fall in old people; it could even develop several weeks later. A persistent headache may be the only symptom, later incontinence of the bladder, unsteadiness on the feet, walking difficulties, and drowsiness may develop.

Infection from nasal sinuses or inner ears may spread inside the skull to the brain tissue and may end up in an abscess formation. Persistent fever is associated with a headache and various neurological signs are present depending on the location of the abscess. Nausea, vomiting, drowsiness, mental confusion, and lethargy are common.

The 5^th cranial nerve carries sensation from the face, forehead, and anterior part of the scalp. Herpes zoster infection (commonly called shingles) at the ganglion of this nerve can cause a severe headache and pain in the affected area. At times a headache precedes the appearance of the typical vesicles on the skin. The vesicles appear in bunches like grapes. Without the presence of skin lesions, the diagnosis can be difficult. Early initiation of treatment with antiviral drugs may shorten the duration and severity of the illness. Neuralgia of the scalp and forehead from other causes often makes life miserable for the patients and may be difficult to treat effectively.

Post-spinal tap headache is another painful condition. It is localized on the back of the head, often dull and pulsatile in character. It is worse when the person gets up from the bed and assumes an upright posture and the headache is relieved on lying down. When there is a significant loss of CSF from the puncture site, the problem is a complex one, and a surgical repair of the torn dura is required to seal the leak.  

Migraine, Cluster headache, and Histamine cephalgia are also important in this group, but most people are aware of them, and they will not be highlighted here. 

 

edited 2020.

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Varicose Veins

                                                                 Varicose veins

                                                        PKGhatak, MD

Inside the veins, at certain intervals, there are valves. Valves prevent blood from moving downwards to the dependent parts of the body and legs. Valves break up the blood column in short segments, thereby lowering the pressure within the veins. Blood flows by gravity from the head and neck to the right atrium of the heart. The pressure generated by skeletal muscle contractions and smooth muscle contractions of the vein wall creates the pressure gradient that propels blood from the dependent parts of the body toward the heart. The pressure inside the veins is very low, but higher than the right atrial pressure, which is generally 1 to 3 cm of water.

You can easily see the healthy veins on the back of your hands. If you follow a long vein of your legs, you will notice small bulges along the walls. These are valves. 

When standing in one spot for long hours, blood tends to remain stagnant in the legs. The blood column exerts pressure on the valves. After many years in sedentary workers, the valves become lax and unable to hold back blood, and become incompetent. These veins become tortuous and darker in color, and the condition is called varicose veins. Often, there is also a genetic predisposition for varicosity, but the precise mode of inheritance is not known.

Incompetent veins cause fatigue of the legs and may cause a sense of fullness and pain in the legs when walking for some time. In older people, loss of muscle, the veins become easily visible, and if the valves are incompetent, the stagnant blood thins out the skin, and ulcers and clots develop.  This is called venous thrombosis. Though many other factors favor blood clotting in the leg veins but prolonged immobility in the elderly is the main cause of venous clots.

It is a good idea to remain active even if you have a job requiring standing for long hours. You must walk around every so often to help blood circulate better in your legs, thereby preventing varicose veins.

 

edited May 2025.

 

 

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Double Vision

                                                             Double Vision

                                                    PKGhatak, MD

If we cover one eye and look at an object, we see it as one. If we remove the cover and look at the same object with both eyes, we still see it as one. How is this possible?

It is the coordinated movements of eye muscles that turn the eyes in such a way that the image is formed on the corresponding points of each retina.

Six muscles move each eye in all possible directions; the muscles, in turn, are supplied by three cranial nerves. The one called the 3^rd cranial nerve supplies all but two muscles of the same side. The remaining muscles are supplied by the 4^th and the 6^th cranial nerves. The coordinated movement controller of the 3^rd, 4^th, and 6^th cranial nerves is located in the cerebral cortex of the brain, and by direct connections and relays, it makes the eyeballs move harmoniously and keeps the visual axis parallel.

In normal people, when an object is placed very close, next to the nose, both eyeballs rotate inwards, the visual axes converge, and the image appears as double.

Muscles of the eyes may be damaged in accidents and certain diseases like Myasthenia gravis and Graves' disease of the thyroid gland. The image of the involved eye may not land on the corresponding points on the retina of the normal eye. The image produced by the involved eye is called a false image and appears on the outside edge of the image produced by the normal eye. As the object is moved gradually further away from the eye, two images appear further and further apart.

Diabetes is the most common cause of damage to the cranial nerves besides injuries to the face and orbit in automobile accidents. Damage to the 6^th cranial nerve in particular and other cranial nerves may occur in situations resulting in an increase in cerebrospinal fluid pressure, as seen in head injury, intracranial bleeding, and brain and meningeal tumors. Enlarging brain aneurysms, tumors of the pituitary gland, and meningitis may damage cranial nerves. Stroke may damage nerve centers. A migraine and decreased blood flow to the brain stem can produce intermittent double vision. Multiple Sclerosis patients may present with double vision. Alcoholic encephalopathy and inflammatory polyneuritis can cause double vision. Parkinson's disease may cause double vision when objects are placed close to the eyes.

Infection of the central part of the face may spread to the brain and may cause double vision. Immunosuppressed patients, diabetics and patients taking prednisone are vulnerable to certain fungal infections of the nasal sinuses, which may spread to the brain and cranial nerves and may result in double vision.

Diseases affecting one eye, leaving the other one untouched, may cause double vision. In astigmatism, the curvature of one cornea unevenly changes and may cause double vision.. In some other conditions, corneal optical properties may change; a developing cataract of the eye lens may similarly produce double vision. Retinal diseases or growth behind the retina may distort the retina and may lead to double vision.

Double vision may be an important symptom of an underlying serious illness. It should never be neglected and should always be checked out by a doctor within a day or two.

 

edited 2

 

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A Sluggish Thyroid Gland

                                                A Sluggish Thyroid Gland

                                                 PKGhatak, MD

The Thyroid gland produces a hormone called Thyroxine. Thyroxine is essential to all living cells and must be supplied constantly just like oxygen and sugar. It controls all chemical activities of the body acting like a metabolic thermostat. When the blood levels of thyroxine fall below the normal levels, the condition is known as Hypothyroidism. It may be a temporary condition as seen in acute serious illness, prolonged malnutrition, and starvation; the thyroid function will return to normal with the reversal of the primary condition. When a disease affects the thyroid gland, hypothyroidism will persist unless proper treatment is undertaken.

The thyroid gland has the shape of a monarch butterfly with wings half open. The gland is located in the neck below Adam’s apple and in front of the windpipe. It has a very rich blood supply. The thyroxine enters directly into the blood supply. The thyroid gland is under the control of the Anterior pituitary gland, which is located inside the skull below the brain, above the roof of the nose, and between the eyes. When the Anterior pituitary senses thyroid function is falling, it sends out a chemical messenger – Thyroid Stimulating Hormone (TSH) to boost the thyroid gland activity. As production of the thyroxine increases, the anterior pituitary scales back TSH release. This process of check and balance is known as the negative feedback loop.

The main hormone Thyroxine has four Iodine atoms bound to an amino acid Tyrosine (T4). In addition, the Triiodothyronine hormone (T3), containing three atoms of iodine, is also produced by the thyroid gland in a smaller amount. Both T4 and T3 are carried in the blood bound to plasma proteins, and only a tiny amount (0.05%) remains free and is metabolically active. They are called Free T4 and Free T3 respectively. Though T3 in the blood is present in a smaller amount, it plays a dominant role. It is 3 to 5 times more active than T4; it acts faster, disappears faster and is bound loosely to plasma proteins. In the tissues, most of the T4 is converted to T3 before it acts on the cells. In the thyroid gland, 80% of thyroid hormone is T4 and the rest 20% is T3. In the blood, the T4 to T3 ratio is 40: 1.

We take in about 100 to 400 micrograms (mcg) of Iodine daily with food and drinks. The thyroid gland needs about 30 mcg of dietary iodine and the rest of the iodine is obtained by recycling the breakdown products of thyroxine. The thyroid gland takes up iodine from the blood by an active process because iodine concentration in the thyroid gland is higher than that of blood. The iodine is oxidized to iodide and then attached to the tyrosine residues of a glycoprotein. Cells of the thyroid follicle pick up iodinated glycoprotein and convert it into T4 and T3 within the follicular cells. And then release T4 and T3 in the blood when needed. Each and every one of these four steps of hormone production and subsequent release is controlled by TSH. At each stage, a specific enzyme is required for the completion of the process.

Decreased levels of circulating thyroid hormone will initiate the release of TSH from the anterior pituitary gland. TSH blood level is an accurate and sensitive test for the detection of hypofunction of the thyroid gland. TSH test has replaced most of the other tests used in earlier years. TSH is extremely useful in monitoring patients on thyroid replacement treatment and during pregnancy. A developing fetus starts making thyroxine at 18 weeks; in the second trimester, the mother’s blood supplies a good part of thyroxine to the growing child. If a mother is hypothyroid and remains untreated, the child will have a low IQ and even mental retardation.

Iodized salt, bread, milk and saltwater fish are the major sources of iodine for the population in the USA. The population of countries deficient in dietary iodine and others who are unable to metabolize iodine because of high consumption of cassava and turnips in their diet suffers from chronic iodine shortage. As a consequence, the thyroid gland enlarges. Many people present with an enlarged gland (goiter), and this condition is called Endemic Goiter. They may or may not show signs of hypothyroidism. But left untreated, most of them will have some complications in the long run. The treatment of endemic goiter is to supply Iodized salt or other forms of iodine in the diet.

Congenital deficiency of enzymes responsible for iodine transport or its incorporation into the glycoprotein and subsequent production of thyroxine may result in congenital hypothyroidism. These cases are rare. In still rare instances, a child may be born without a thyroid gland. Often the disorder is not detected at birth because a mother has supplied thyroxine during pregnancy and by breastfeeding. A child presents with an enlarged thyroid gland, at times the gland may have grown ten times the normal size. Such a Cretin child, as it is called, has a puffy face, enlarged tongue, and low forehead, increased hair, umbilical hernia and sluggish response to stimuli. Various neurological deficits, from deafness to paraplegia may be present. If treatment is delayed then mental retardation, deafness, muteness, stunted growth may be permanent.

The signs and symptoms of hypothyroidism are variable depending upon the severity and duration of the condition. Patients may complain of tiredness, fatigue, and weight gain, depression, falling asleep at inappropriate times and constipation. In some cases, muscle pain, pain in joints and effusion of the knees are present. Cold sensitivity, deafness, a decrease in taste and smell sensations may be present. A large tongue, non-pitting edema, puffy and watery eyes, menstrual disturbances in the female, thinning of hair and loss of the outer half of eyebrows, coarse skin, carpal tunnel syndrome may be present on examination. In some cases, fluid in the pericardial sac, pleural cavities, and ascites may be present. Patients may have slow mentation, confusion, and somnolence. The term Myxedema is used in the hypothyroid patient when weight gain, non-pitting edema, low serum sodium and fluid overload are present. Various psychiatric symptoms from disorientation, hallucination, paranoia, and psychosis in myxedema are commonly referred to as myxedema madness. In severe cases, a coma may result. When a patient presents with a myxedema coma, the chance of survival is very poor.

In a given patient, the precise cause of hypofunction of the thyroid gland may remain unknown. Viral infections either directly or by inducing an autoimmune response may damage the thyroid gland. Lymphocytic infiltration of the thyroid gland and subsequent hypofunction, known by Hashimoto thyroiditis, is well known. Infectious mononucleosis may damage the thyroid gland. Radiation to the neck, chest, and shoulder can damage the thyroid gland and result in decreased function. People with hepatitis C infection may develop autoimmune thyroiditis. Drugs used in the treatment of seizures like Dilantin, and Phenobarbital, can lower T4 levels. Other drugs like Lithium and Amiodarone, Phenylbutazone, Sulfonamides, Interferon alpha, and beta have significant adverse effects on thyroid function. Cancer, Sarcoidosis, and thyroid surgery, and previous treatment with radioactive iodine may damage part or whole of the thyroid gland. TSH may be elevated in autoimmune diseases, acute psychiatric illnesses and in the elderly. Many drugs used in the treatment of various diseases may cause hypothyroidism or drugs may interfere with T4, T3, and TSH tests. One should be careful in interpreting those test results correctly.
In certain conditions of the Anterior Pituitary, less than the normal amount of TSH is secreted, this results in decreased production of thyroxine. This condition is called Secondary Hypothyroidism.

The treatment of Hypothyroidism consists of: -
1. To supply thyroid hormone in the form of oral tablets.
2. Proper follow up with the adjustment of thyroid dose over the lifetime of a patient.
One tablet a day dose is inexpensive and effective. Iron and calcium tablets taken with thyroid medication interfere with the absorption of thyroid hormone. An antacid containing aluminum hydroxide, soy milk, proton-pump-inhibitor and many other agents also interfere with thyroid hormone absorption. It is recommended that thyroid tablets should be taken without other medications. The bioavailability of T4 varies from brand to brand. It is better to stay with one name brand or one manufacturer of a generic thyroid drug.
The results of hormone replacement therapy are excellent. Only in far advanced cases and in myxedema coma the results are not good.

 

 

 

revised 2020

Human Hair

                                                                    HUMAN HAIR

                                                            PKGhatak, MD

The hair is an appendage of the skin. The entire skin surface is covered with hair except on the palms of hands and soles of feet. Human hair is subdivided into two categories.

1. Terminal Hair. The coarser hairs that are present on the scalp, eyebrows, eyelashes, nostrils, under the armpits, pubic area, and in men mustaches and beards.

2. Body Hair. The finer hair covers the rest of the body.

Each hair has a bulbous end called a hair Follicle located in the deep layers of skin. It is supplied with nerve fibers and blood vessels. The part of the hair that remains underneath the superficial layer of skin (epidermis) is called the Root of the hair. The part of the hair on the top of the skin is called the Shaft. The cells of the hair follicles are responsible for the growth and maintenance of hair.

Under the microscope, the hair has loosely packed cells in the center called the Core. The core is surrounded by several layers of densely packed cells containing pigments, and a protein called Keratin; the outer layer of hair is made up of a single layer of cells called Cuticle.

The hair is surprisingly strong for its size. 100 strands of hair can support 20 lbs. of weight without breaking. Hair is wettable, soaks up water about a third of its weight. With air sacs in the core and water retaining property, the hair protects the head against strong sun and chill winds.

There is a small gland underneath the skin at the point where the hair emerges from the skin. It secretes a tiny amount of oil and the oil keeps hair shiny and silky looking. This oil coats all surfaces of straight hair evenly; in persons with wavy or kinky hairs the oil cannot get to the entire shaft uniformly and these types of hair look dry and disorderly.

The body hairs grow slowly, whereas scalp hairs grow about 1 inch in 3 months. The rate of growth is slower in older people and fastest in adolescence. Growth takes place at the root of the hair, and as hair grows it sprouts out of the skin surface. Each individual hair has its own life cycle; independent of its neighbors. It decides when to grow, when to rest and when to die and fall off. And then it begins to grow again and the cycle continues. Because we lose so few hairs at a time that we do not notice the hair loss. Hair on the scalp grows to shoulder length in 3 years and reaches waist length in 5 years. Generally, after 6 years, growth stops and hair rests for a period of time, and at the end of 6 to 7 years it dies and falls off. During its lifetime, a hair may grow 5 feet in length if not trimmed. In the Guinness Book of Records, you may find evidence of longer hair. Body hair has a shorter life and growth remains limited.

The keratin of hair gives hair its flexibility and strength. It is made of amino acids, of which Cystine has a disulfide bond. This disulfide bond gives keratin its special properties. When hairs are treated with alkaline agents, this disulfide bond is weakened and curly hairs could be strengthened or straight hair may be given a curly shape. Then an acidic agent is applied to neutralize alkali and to make the changes last longer. The color of hair is due to the presence of a pigment called Melanin produced at the root of the hair by cells called Melanocytes. Two types of melanin are produced by these cells. Long arms of these cells deposit the pigments in rows, like a string of pearls, in the cortex cells of the hair. One color is black and the other is red. By the various combinations of these two pigments, hairs get various shades of black, brown, yellow and red. The gray color of hair is due to the presence of only a few melanin pigments, non-pigmented hair looks yellowish due to the color of keratin.

The terminal hair depends on Androgen for its regulation of longitudinal growth, thickness, and vigor, whereas Estrogen slows the growth rate but prolongs the growth period. The thyroid hormone maintains its health. Body hair depends mostly on thyroid hormone for its health and growth. Zinc and B vitamins, particularly pantothenic acid, are required for the nutrition of hair. Steroid hormones may slow or weaken the roots of hairs when used for a prolonged period. Certain chemicals like arsenic are taken up by the hair and remain unchanged in hair for years even after burials. Drugs used in cancer treatment may arrest the growth of all fast-growing cells of the roots of hair all at the same time, making hairs fall off in 2 to 3 weeks. But after completion of treatment, the hair will grow back. Thallium used in cardiac stress laboratories may cause hair to fall for the same reason. Many other drugs may influence hair one way or the other.

The roots of the hair are the living part of the hair. The shaft of hair is a dead tissue. The DNA of hair cells can help identify an individual.

In hair, we admire the texture, wave, color, and silkiness - all about a dead tissue and the living part is unseen and remains buried under the skin.

 

 

revised 2020

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Blood Sugar

                                                                     Blood sugar

                                                            PKGhatak, MD

We need energy at all times, just to stay alive and a higher rate of energy supply when we are engaged in activities. The lowest rate of energy requirement for an average person is 70 Kilocalories/hr. (Kcal). This is also called the Basic Metabolic Rate (BMR). The actual BMR varies according to height, weight, gender, age and ethnicity of the person and on the climate conditions.

The sugar that circulates in our blood is Glucose; table sugar is sucrose, made up of one molecule each of glucose and fructose; milk sugar is lactose, a combination of glucose and galactose and fruits contain fructose. All sugars belong to a group called carbohydrates; also present in this group are - starch, dextrin, corn syrup, potatoes, wheat, cereal and rice. The body, for the most part, must break down starch and other sugars into glucose before turning glucose into energy. The human body is unable to break down cellulose, the most abundant carbohydrate in nature, the main constituent of trees and other vegetation. Cellulose provides the bulk of our daily meals.

As we eat food, it gets mixed with saliva. Saliva contains an enzyme called Amylase and it begins to break down carbohydrates. The process continues in the stomach and in the upper small intestine where more amylase comes from the pancreas. As glucose is generated from other sugars and the breakdown of starch, it is picked up by the cells of the small intestine and then transported to the liver via blood. Any excess amount of glucose in the liver is converted into a complex glucose structure called Glycogen (commonly known as animal starch). The liver can easily turn glycogen into glucose and release it in circulation whenever there is a need. The muscles of our body store Glycogen as fuel for work.

Every living cell of the body has a chemical factory called Mitochondria. It is loaded with enzymes, catalysts, and a high-energy fuel packet called Adenosine Tri Phosphate (ATP). A chemical process called the Tricarboxylic acid cycle, better known as the Krebs cycle, is the main energy producing process in the body. We can view it as a furnace having three entry gates; one for the sugars, the other one for amino acids (derived from breakdown of proteins), and the third one for fatty acids (comes from fat). The products coming out of the Kerbs cycles are heat, ATPs, and other intermediate products. These intermediate products are in turn synthesized into fat, proteins, hormones, and other essential chemicals in the liver and other specific organs. Outside the mitochondria but within the cells, there is another process where glucose is directly converted into energy through a chemical pathway known as Hexose monophosphate shunt.

You must have known a friend or relative who would not add a grain of sugar in his coffee but at the same time drink two glasses of wine and finish half a bottle of ketchup over two hot dogs. They tend not to remember wine and prepared food containing carbohydrates. Yes, wine and drinks containing alcohol are carbohydrates. We eat about 300gm of carbohydrates on an average day; we need a minimum of 150gm of carbohydrates daily in order to keep the chemical fire going in the body. When the minimum amount of carbohydrates is not present in the diet, the Krebs cycle will generate acetone from partially utilized amino acids and fatty acids. The human body cannot break acetone further. It is an acidic substance. It makes the cells sick and the kidneys work extra hard to eliminate acids. The appetite is lost and respiration becomes hurried. Over a period of time, the person loses weight. That is the basis of a high protein, low carbohydrate diet. It works for a short period, but it is a different story a year or two later.

You must have noticed that in order to utilize sugar it must enter the cells first and then find its way to the mitochondria. In nature, nothing is left to a chance. The cell walls have pores, gates, binding sites, messengers, and controllers. Of these factors, Insulin is the most important member for glucose utilization. It is a hormone produced in the pancreas by Beta cells. If insulin is absent in the body or produced in less than normal amounts, or the insulin is biochemically defective, or antibodies against insulin, making Insulin less effective. This will raise blood sugar levels in the blood. When the blood level exceeds the normal range, the condition is called Diabetes.

Normal blood sugar in the fasting state is less than 100 mg /100ml. When it exceeds 180 mg the sugar begins to show up in the urine. After a meal, depending upon the amount of carbohydrate ingested, the blood sugar may be anywhere from 100 to 180 mg/100 ml in normal individuals; in diabetics, it may be 200 mg or higher. In rare circumstances, the sugar may reach 1000 to 1200 mg /100ml.

The blood sugar may fall from having too much insulin in the body, from an insulin-producing tumor or insulin administered inappropriately, or, in starvation or in conditions preventing a person from swallowing. When the level falls below 60 mg, the person feels hungry, jittery, and tense and begins to sweat; when the level falls below 30 mg, the person becomes confused and may behave in bizarre ways. In extreme cases of low sugar (hypoglycemia) unconsciousness, coma and death may follow.

Another hormone called Glucagon is produced by the alpha cells of the pancreas. Glucagon breaks down liver Glycogen into blood sugar and raises sugar levels.  Steroid hormones and adrenaline from adrenal glands are released in response to hypoglycemia and counteract some of these symptoms.

 

Normal blood sugar in an individual requires a balance between several hormones, insulin, food and a healthy gastrointestinal tract. In a diabetic individual, in addition to these, the level of physical activity is important also.

 

edited 2020. 

 

 

Calcium and Bone

                                                    Calcium and Bone

                                               PKGhatak, MD

There is so much information and misinformation about Calcium and a bone disease called Osteoporosis that if by some misfortune you are diagnosed with this condition you will not know how to cope. Of course, you will follow your doctor’s advice but does your doctor really believe taking a calcium supplement and commonly prescribed medications will actually reverse the disease?

 

Here is the answer.

The rate of bone growth is highest in the teenage years. Outdoor games, physical activities and enough milk and cheese in food help to lay down a solid foundation for a healthy bone structure. The absence of any of two essentials, - vigorous physical activities and adequate calcium with vitamin D in the diet, will produce a weaker foundation and bones will be susceptible to osteoporosis if your adult life is like that of an average person.

The inner structure of the bone is called the matrix. It is like a mesh, made up of protein, on which calcium is laid down by a type of bone cell called Osteoblast. Like the rest of the body, bone is a living tissue. It undergoes wear and tear and rebuilding and remodeling. Calcium needs to bind onto protein scaffolding to remain in place and provide strength and stability to the bone. Once we cross the early 20s, we are not really growing, we are just maintaining our structure. 

There is an intricate relationship between the health of bones and hormones, namely growth hormone, sex hormones, and thyroid hormone and corticosteroid hormones. In addition, a calcium regulating hormone called Parathormone plays an important role in removing calcium from bones and helps to remodel. Vitamin D and Parathormone work in opposite ways in this regard. The acid produced in the stomach, a healthy small bowel and normal kidneys are closely linked in regulating calcium like a well-choreographed soccer game as if calcium is the ball, the bone matrix the playing field, vitamin D the referee, thyroid hormone and parathormone are line judges, other hormones the coaches and team officials.

 

All these are nice to know now but it is too late to reverse the osteoporotic bones to normal healthy bones. The clock cannot be turned back; the sticking part is the protein matrix. Once it is finished laying the foundation, it is done, only the female sex hormone, estrogen, helps restore its vigor to the extent that new calcium will bind to it.

 

Regular physical exercise, a well-balanced meal with adequate calcium and vitamin D, will go a long way to keep your bones in shape as long as you maintain your interest in exercise. Just because calcium and vitamin D help to restore calcium in the blood, it does not mean taking mega doses of these will undo the damage in osteoporosis, in fact, may damage your kidneys. Common antacids and other stronger, longer acting acid suppressing drugs prevent calcium absorption even when an adequate amount of calcium is present in the food. Soft drinks and excess alcohol interfere with calcium absorption. Certain drugs, used in the treatment of epilepsy, diabetes, and rheumatoid arthritis, etc., weaken bones.

Medications prescribed for the treatment of osteoporosis have significant adverse side effects. You have to question your doctor or the pharmacist before starting medication.

Preventing osteoporosis is a job that must start in childhood. Osteoporosis is a chronic disabling condition and is preventable.

 

edited 2020.

Know your Blood Pressure

                                                 Know your Blood Pressure

                                                 PKGhatak, MD

If you have normal blood pressure and you are middle-aged or older, you have a good chance of living well beyond the lifespan of an average person. It is therefore important to know your blood pressure. You should have your Blood Pressure (BP) checked whenever you visit your doctor or a pharmacy. If your BP is normal, then check it again in a year or two. BP tends to go up with increasing age, so you do not want to be surprised at a later date when someone tells you –“your BP is high.”

A BP of 110/ 70 mmHg is considered normal pressure irrespective of age – children and pregnant women excluded. Most medical practitioners will call you Hypertensive if your BP is 140/ 90. By the time the pressure rises from 110 / 70 to 140 / 90, many adverse things have taken place in the arteries and the wall of the heart. These changes are still reversible but require lifelong commitments to diet, exercise, and lifestyle changes. It is so much better not to have a high BP than to deal with the consequences of hypertension.

The heart is a muscular organ and functions as a circulatory pump. As the blood is pushed out of the heart in the main vessels (Aorta) the pressure of outgoing blood must overcome the resistance of the empty blood vessels in order to flow forward. That pressure at the point of the onward journey of the blood is the first number of the BP reading, say 110 mmHg of a BP of 110 / 70. It is called Systolic BP. The elasticity of the wall of the aorta helps to accommodate blood and generates a wave that spreads along the rest of the vessels (Arteries). That wave felt at the wrist is the Pulse. The blood follows the pulse wave in its outward journey. As soon as the heart stops pumping blood, the pressure begins to fall. That point on the scale of the decreasing pressure, determined by listening over the artery, is known as the Diastolic BP, here 70 mmHg of a BP of 110 / 70.

A healthy heart beats 72 times every minute. So, each heartbeat lasts only 0.08 seconds (60/70 =.08). Of the 0.08 seconds, the heart pumps 0.03 seconds and relaxes and receives blood from the rest of the body for 0.05 seconds. As a result, the BP fluctuates up and down 72 times a minute as the heart pumps and relaxes. This is the reason two numbers are given in a BP reading; one at the point of maximum pressure called the Systolic BP and the other as the resting pressure known as the Diastolic BP.

Often you wondered which of the two numbers is more important. The systolic BP is a measure of the pumping function of the heart. A failing heart is unable to raise systolic BP, as seen in heart failure and in shock. Diastolic BP is the resistance generated by the walls of the blood vessels. As the elasticity of the blood vessels decreases with advancing age and from the hardening of arteries (atherosclerosis) the diastolic BP rises. To pump blood out into circulation, the heart must overcome the resistive pressure by increasing its systolic BP. That produces a strain on the muscles of the heart wall and in the course of time, the muscles thicken and use up more oxygen to do the same work. You must be aware that coronary blood vessels supply the heart muscles with blood, oxygen, and other nutrients. These coronary vessels are pinched as the heart wall thickens and ultimately damages the coronary blood vessels. So, both numbers are important.

Any stress or anxiety can raise the BP but these are temporary causes. Even if one has persistent stress, the BP should not be allowed to reach 140 / 90.
Kidney diseases and hormonal imbalances can cause hypertension. The exact cause of hypertension remains unknown in the vast majority of cases. In medicine, if the cause of a disease is unknown it is called Essential and hence elevated BP is called Essential Hypertension. 

Blood Pressure measuring instruments are simple machines. A cuff, made of non-stretchable linen that goes around the arm, has a smaller rectangular rubber bag inside with two tubes attached to it. The end of the short tube is attached to a pressure gauge. The longer tube has a rubber bulb at the end. The rubber bulb has a one-way valve at one end and a release valve near the other end. The cuffs come as small, standard and large sizes. It is important to wrap the cuff around the arm of the person suitable for his size and to place the rubber bag squarely over the artery of the arm. One should easily find the artery by feeling the pulse on the inner side of the arm just above the elbow joint.
The person having his BP taken may be seated or lying on the examination table. The arm of the person should be brought to the level of his heart and kept there. The cuff is then wrapped correctly around the arm, the examiner should feel the pulse with his fingers placed over an artery at the elbow joint. Then squeeze the bulb and raise the pressure to 200 mm Hg. The examiner should note that the pulse is obliterated at this point; if not, he should raise the pressure further and make sure the pulse is cut off. Then release the cuff pressure slowly, turning the release valve. As the pressure is lowered, the pulse will return and the pressure is read off the pressure gauge. That pressure is systolic pressure. At this point release the pressure completely. And then repeat the process; this time, however, he should place the Bell End of the stethoscope over the artery at the elbow joint and listen for sounds. When the pressure is high enough to cut off the pulse, there should be no sound. A" thud" like sound will return as the pressure is lowered. The pressure reading obtained by listening should be almost the same as obtained by feeling a pulse, if not, the reading detected by the pulse is the correct systolic pressure.
The diastolic pressure is detected by sounds only. As the pressure is lowered by turning the release valve, the sound at the elbow becomes louder and louder, then suddenly sounds become muffled and then disappear completely. The point at which the sound becomes inaudible is the diastolic pressure. There are cases where sound continues to be heard even with pressure at zero, in such cases, the point where sounds transition from audible to muffled is noted. This is the diastolic BP
Measuring BP appears a simple task, but like many other situations, an accurate reading depends upon the experience of the person.
A careful doctor will take your BP on both left and right arms, and then ask you to stand up and record BP again. There are various reasons for that. Abnormalities of the aorta, effects of certain medications and disease processes can cause alteration of the BP from one side to the other or by a change of posture.
If your primary reason for going to a doctor is checking your BP and the doctor is not checking your pressure himself and delegated that task to his newly hired office assistant, then you are not getting your money’s worth. You may as well buy a digital-readout BP instrument and begin monitoring your own pressure at home. However, you must know these BP instruments are not as accurate as the one described above. But once you have found out how good or bad your instrument is, then you can easily correct the instrument readings.

 

revised 2020.