Sunday, 17 April 2016

Best Kidney Transplant Hospitals in India

Kidney Transplant Surgery:-

With the advent of technology and continuous developments in the health sector, Kidney Transplant, which was considered to be an impossible treatment, has become as common and easy as treating any other organ of the body. Kidney Transplant basically aims at replacing the inefficient, unhealthy kidney with the healthy one.

Generally, only one kidney is replaced, but if the patient is lucky enough, he may get both of his kidneys replaced, if he gets a donor who is ready to donate away both of his kidneys. A liver transplant is carried out in the lower abdomen in the front side of the human body.
Kidney Transplant Hospital
Kidney Transplant



The advancement in technology has made Kidney Transplants risk free with negligible surgery failure rate. Also, the non-requirement of frequent dialysis has made renal transplants cost effective and also less burdensome.

When Does The Need For Kidney Transplant Surgery Arise:-

There exist many possibilities and many primary stages of disorders where one may require a Kidney Transplant in India . A few have been listed below.

Hemolytic Uremic Syndrome (which is generally rare)
Lupus
Polycystic Kidney Disorder
Repeated Urinary Infections
Kidney Inflammation
Failure of Kidneys (Often Caused By Diabetes)
Obstructions


However, it may be noted that Kidney Transplant Surgery may not always be the most reliable solution and that here may exist other favorable alternatives.

Transplant In India
                Kidney Transplant in India


Unsuitable Donors For The Kidney Transplant Procedure:-

It is one of the most crucial part of the surgery where the medical history of the donor should be thoroughly checked and studied before accepting any organ as a donation, in the first place. Donors with a poor medical history, especially those affected by heart disorders, cancer, respiratory problems, and other major disorders should be mandatorily rejected.

Procedure:-

The Kidney Transplant Surgery is considered one of the lengthiest procedures as it involves a standardized three step procedure which has to be looked with utmost care as it involves blocking of blood vessels, lot of bleeding, and infections.

Pre-Operating Procedure:-

Pre-Operating Procedure is nothing but all the regulations and a few crucial tests and some indispensable analysis carried out before the ultimate Kidney Transplant Procedure to make sure the patient is ready for the comprehensive surgery. A few crucial tests focus on the general health issues and also focuses on the mental stability of the patient. It is important to carry out these run reports as it determines the irregularities in blood pressure. A comprehensive blood test also reveals whether the donor is a perfect match for the patient.

Transplant Hospitals
Kidney Transplant Hospitals


Kidney Transplant Surgery Procedure:-

The Best Kidney Transplant Hospital in India and Procedure is like any other operation procedure the only difference being that it is highly supervised under a team of professional experts. The surgery site is always prim and proper, bacteria free, and completely clean.

The donor’s kidney is also inspected before the pre operation procedure and it is made sure that the donor’s right kidney is transplanted to the patient’s left side to ensure easy association with the body and ease in performing surgery.

Post Operation Procedure:-

As the surgery is a very comprehensive surgery, post operation procedure is very essential for a patient. Post Operation Procedure includes a regular watch of a trained nurse where the patient is under observation on a 24*7 basis to avoid any infections and it also ensures complete safety of the patient.

A catheter is attached for urine removal which is also kept under complete observation to make key analysis and perform some vital tests which help in carefully understanding the state of a person’s health.

Kidney Transplant Procedure because of its highly complex procedure, it is important to make sure to keep the patient under observation even after he has been discharged completely from hospital as any smallest of problematic situation arising after the treatment should be notified to the doctor immediately which when ignored may lead to frequent dialysis and other renal issues.

 Transplant Hospitals
Hospitals in India

Wednesday, 13 April 2016

Hip Replacement Surgery in India

HIP ARTHROSCOPY

Hip arthroscopy is related to orthopedics department of surgical procedures where the main focus is the hip joint. To know the dynamics and functioning of a joint arthroscopy procedure comes to the rescue. Arthroscopy has helped doctors in understanding, diagnosing and treating any joint related problems. .
 Hip replacement surgery
              Hip replacement surgery in India


Anatomical Understanding:-

Before learning about the surgical procedure, it is important to know the functioning and characteristics of the Hip Joint. The hip joint is said to have looked like a ball and socket, where the ball is the upper end of the femur; they are also commonly known as the femoral head. The socket comprises of the acetabulum and a part of the pelvis bone. The articular cartilage of acetabular fossa is a smooth slippery tissue that connects the femoral head to the pelvis. This tissue can withstand a great deal of pressure when compared to the other cartilages.

Outline of the procedure:-

Joint replacement surgery in India procedure includes a minute camera, which also goes by the terms arthroscope, is gently placed in the hip joint. This camera acts like an eye for the doctors by displaying the interior happenings on the monitor. These processes are preferred when minute surgical instruments are to be guided down.

the procedure includes a minute camera, which also goes by the terms arthroscope, is gently placed in the hip joint. This camera acts like an eye for the doctors by displaying the interior happenings on the monitor. These processes are preferred when minute surgical instruments are to be guided down.
 Hospital in India
                           Orthopedic hospital in India


Pre- Surgical guidelines:-

The patient is examined physically to evaluate the health condition. This is done to identify any problem that might conspire against the procedure of the surgery. Later another evaluation is carried out by a team of anesthesia. Generally, the patient is given general anesthesia where the patient falls asleep over the surgical procedure; other times they are addressed with a regional anesthesia such as epidural to numb the surgical area alone.

In Good Hands, our surgeons make sure that the patient is very well aware of the procedure they are going to undergo. The patients are also given a set of guidelines and parameters to follow before and after the surgery. We are very particular about our patient's needs and make sure that they are comfortable as long as they stay in our good hands.
 Joint replacement surgery
                Joint replacement surgery in India


Procedure
The procedure commences with the leg being put in traction, this is done as it helps the surgeon to insert the necessary instrument down.
The next step is to drill/ puncture a small hole, say the size of a pepper or a buttonhole size. The hole is drilled in the hip.
The arthroscope is sent down the drilled hole and the image is caught on the monitor. This helps the surgeon in guiding the instrument without causing any internal bleeding.
Later small incisions are made separately to insert other instruments.
The most common procedures are repairing the cartilage or removal of the inflamed synovial tissue.

The total time taken for the surgery depends on the procedure carried out.


Post- surgery:-

For  Hip replacement surgery in India patient, the arthroscopy process for hip joint is similar to the process carried out for an outpatient. That is, they do not need to stay in the hospital. Although, if there are any special medical conditions present, stay in the hospital is required.

Complications and problems :-

Complications due to hip arthroscopies are rare and aren’t that common. They do have the normal risks such as rupture of the vessel or a nerve, around the surrounding of the joint or the joint itself. Due to traction was done, it may cause stretch of the nerves and may result in numbness. Other minute risks are blood clots or perhaps an infection.

Recovery:-

After performing the surgery, the patient is taken to the recovery room for about an hour with a support of a walker.

Restoration and Rehabilitation:-

These plans are laid out by the surgeons based on the procedures conducted for the surgery. It is important for the patient to take up physical therapy for achieving better and faster recovery. At In Good Hands we make sure that the movements and the pace of the patient are restored to how it was initial.
Orthopedic Treatments
                  Orthopedic Treatments in India


Wednesday, 6 April 2016

Best liver Transplant surgeon in India

Liver Transplant Surgery
Liver Anatomy:-
A liver is the largest organ of our body. It is found at the right side of the abdomen, intestines, kidney, above the stomach and beneath the diaphragm.  It is found in dark reddish brown color and appears like a cone. Its weight is around three pounds.
liver
Liver Cancer
At any given point of time, about 13% or around one pint of blood supply in the body is held by the liver. Two lobes, made of thousands of lobules, exist in the liver. They are connected to larger ducts, through smaller ducts to finally form the big hepatic duct, which is helpful for the transportation of the bile towards the gallbladder.

Liver conducts many significant functions in the body, like:

Regulation of the blood clot
Clears  the blood from poisonous substances like drug
Regulation of blood clot
Converting of the food to energy

What is Liver Transplant Surgery?

A liver transplant is a surgery to replace a damaged liver of a patient with a healthy liver from another person who is healthy. The new liver can either be from a living donor or from a dead person. But the main criterion for the transplant is that the liver must be matching to the liver of the person receiving it; that is the patient. This kind of transplant is called the liver transplantation. A liver can be transplanted as a whole of the entire organ or just a section or part of it.
liver transplant surgeons
Liver Transplant Surgeons 

The donor, who donates the liver, can continue with the rest of his/her life healthy without any side effect cause of the donation of part of the liver. This is because the section of the liver that is donated can be regenerated or grown within a few weeks in the body of the donor. As the liver is the only organ in humans that can be regenerated by itself in the body.
Need for Liver Transplantation Procedure
liver transplant doctors
Liver Cancer Hospital in India

The patients, who are suffering from ESLD or End-Stage Liver Disease, a liver sickness or dysfunction, which is a very serious life-threatening disease, require this procedure of liver transplantation. Cirrhosis is one of the examples of such a severe liver disease. This long-lived disease is caused because of the liver being covered by a fiber-like tissue that prevents poisonous substances to be vomited out from the liver. There are many other such diseases, for which this liver transplantation procedure is required, but not limited them. Below are a few of them:


o Liver Cancers – Primary tumors in the liver, and not yet spread to the external parts of the liver.
o Metabolic Disease – This is a condition, caused from the chemical activity, caused by the liver in the cells.
o Biliary Atresia – This condition occurs from either absence of the bile ducts or abnormal development of the same.
o Autoimmune Hepatitis – Damage and destruction of the liver because of the chronic inflammation caused by the liver.
o Acute Hepatic Necrosis – This condition is caused because the tissue in the liver dies.

Risks Associated With the Liver Transplantation

Some of the complications caused during this procedure are:
Block of bile duct
Bile Leakage
Blood vessels blocked in the newly transplanted liver
Infection
No function of the new liver

The immune system of the body refuses the foreign tissues or substances, naturally and so the new liver too. So, the immune system is deluded to not to attack the newly transplanted liver.
Contradictions for this procedure, which are not just limited to, are:

Serious liver disease persisting, even after the transplantation
Difficult treatment of current or recurring infection
Other medical conditions, like sever cardiac problem, which could not tolerate the hard surgical procedure
Treatment regimen non compliance
Metastatic cancer, spread around the source location
Alcohol consumption

Before the Liver Transplantation Procedure

To get the liver transplantation done from a deceased donor, the patient is kept in the waiting list in UNOS or United Network for Organ Sharing and then extensive and varied testing are conducted before the surgery.

A team consisting of transplant surgeon, hepatologist, nurses, psychologist and social worker with optional dietitian, anesthesiologist conduct the evaluation process to decide the eligibility for the transplant procedure.
liver disease treatment
Before- After Liver Transplant


Factors necessary for the evaluation of the transplant process to list the patient in UNOS, have the following, however not limited to,

Urgency – based on the critical condition of the patient
Blood Tests – to assess matching potential of the donor liver with the liver of the patient
Diagnostic Tests – to assess the liver and overall status of health of the patient.
Psychological and social evaluation – it includes assessing the stress, family support, financial condition, etc., which influence the final outcome of the transplantation.

Liver Transplantation Procedure

After removing your cloths you have to wear a gown
You need to lie on the table.
Excessive hair is removed at the site of surgery
It starts with IV or intravenous line on the hand. Heart and blood pressure monitoring catheter are inserted to the wrist and neck. Additional catheters may be inserted at subclavian areas.
After sedation, a tube is inserted into the lungs to control breathing through a ventilator.
A catheter is arranged to drain urine
A slant incision is done under the ribs.
The diseased liver is separated from the structure and surrounding organs to remove and the veins and arteries are clamped to control the flow of blood to the liver
Donor liver is taken and connected to the blood vessels of the patient, and the blood flow is        established.
Bile ducts are connected
Incision is closed
To control swelling  drain may be needed to place in the site of incision
Dressing is done

The Best Liver Transplant Surgeon in India has highest success rates. Best liver transplant hospitals in India along with the best liver transplant surgeons in India have experience of performing hundreds of successful liver transplantation surgeries.
liver transplantation
Liver Transplant Procedure

Best Heart Transplant Hospitals in India

Heart Transplant Surgery
A surgical procedure that is undertaken to fix a damaged or to remove a diseased heart is known as a heart transplant. This is then replaced by the heart that is got from a donor who is considered to be brain dead and one who is put on a life support. Before starting the transplant, it is compulsorily a necessity that the heart tissue of the donor matches the recipient in order to avoid the complications that might arise out of the mismatch of tissues. In some cases, the heart from the donor will be rejected by the recipient if there happens to be a mismatch.

heart transplantation
Heart Transplant


Heart transplant surgery need:-

In Good Hands offers the surgery for Best Heart Transplant Hospitals in India for people with some heart conditions that might include,

·         Onset of a heart failure and no form of medication or surgery can fix the problem.
·         Occurrence of heart beat pattern that is out of ordinary and threatening to life.
·         Angina in its severe form that does not have a cure in the existing surgeries and medications.
·         Heart defects in children right from their birth that cannot be fixed by normal surgery.
Though heart transplant serves as a better option in many cases, the procedure is restricted and not everyone can undergo it. The list of people who are restricted from the procedure include,
·         Malnourished people.
·         Patients who are above 55 years of age.
·         Person who had a previous case of stroke.
·         Patients who have been infected by HIV.
·         People who are suffering from cases of cancer.
·         People showing active hepatitis infection.
·         Diabetic people and others who are insulin dependent.
·         People who have no family support.
·         Patients who have serious cases of pulmonary hypertension.
·         People who have been found to have cases of drug, alcohol abuses and who are chain smokers.

Procedure:-

The transplant begins with the administration of general anaesthetics to the patient and making an incision over the breastbone. The heart has to be stopped initially by using a solution and then a bypass machine is connected to it which in turn helps to circulate the blood by serving as the oxygen supplier. The recipient’s body is fit with the donor’s heart after removing the damaged heart and the bypass machine is stopped. Blood circulation once again takes its normal route after the heart is started. 
aortic valve replacement
Heart Transplant in India


InGoodHand promises a safe transplant surgery and research indicates that India has had many successful heart transplant surgeries over the years.
One form of the heart transplant is the heterotopic transplant in which the new heart is placed right above the damaged heart without removing it. After this procedure, the patient is fit with tubes in order to regain back the full capacity of the heart and the lungs.

Associated risks:-

These are general risks that one might face when they undergo any sort of surgery or transplant. Major risks arise out of the anaesthesia that is used and this does not pertain to jus t the heart transplant. A risk arises out of a series of factors and one cannot point it towards the surgery or the anaesthetics used alone. Several risks that follow the surgery include,
·         General infection or bleeding due to surgery.
heart transplant surgery
Heart Transplant Hospital


·         Trouble with breathing from the anaesthetics used.
·         Medications that are given to avoid rejection may affect other organs other than the heart.
·         Rejection of the donor’s heart can lead to the abnormal heart beat and other forms of coronary diseases.
·         Reactions the medicines in the anaesthesia can have with the organs.
·         Reduction in the calcium and increase in the cholesterol after the administration of the drugs during surgery.

·         Onset of blood clots and bleeding after the surgery.

Protocol after the transplant:-

After the transplant surgery is over, the patient is kept in the intensive care unit for 24-48 hours following which he has to stay at the hospital for nearly 21 days or even just a week depending on his condition after the surgery. The patient is advised to be careful for the first one year after the surgery is over and it is really critical for him to have regular checkups and follow ups with the doctor to be sure that no sort of infection starts to grow in the new heart.
cardiologist in india
Heart Transplant in India


Cost of Heart Transplant in India

InGoodHand gives an approximate estimate for the surgery which includes the series of tests that needs to be done before and after the surgery, nurses assistantship, medicines, room services and in some cases fare for the pickup and drop from the airport. The estimate is provided for a duration of 24 hours after the medical records are submitted.


Skin Cancer Treatment in India

What is Skin Cancer?

Skin cancer, the most common type of cancer, is an abnormal growth of skin cells on the surface that results in a tumor. Skin cancer is the caused mainly by the exposure of harmful ultraviolet radiations or carcinogenic substances which cause mutations in DNA resulting in the formation of malignant tumors. Genetic factors can also be responsible. Most cases of skin cancer, if detected at early stages, can easily be cured by surgery methods. Late diagnosis can cause cancer to pass to other organs, thus posing a major threat to the body.
skin cancer symptoms
Skin Cancer



There are generally three types of skin cancer; Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma. While Basal Cell Carcinoma and Squamous Cell Carcinoma are most commonly occurring and less threatening, melanoma is the most dangerous variety of skin cancer.

Skin Cancer Symptoms :- 

The symptoms of skin cancer depend upon the type of skin cancer. Each class is recognized by a different set of symptoms. It is often painless.
Basal Cell Carcinoma is the most prevalent type and occurs in the lower part of the epidermis. It appears on the skin with a lot of exposure to sun and UV rays. It can appear as:
·         Reddish patch on the skin that won’t heal.
·         A sore that bleeds and returns time and again.
·         A pimple that won’t clear.
·         A flat hard sunken growth, usually white or yellow in color.
Squamous Cell Carcinoma occurs in squamous cells that form the surface of the skin. It is more common in immunosuppressed people and is detected if there is:
·         A wart-like growth on the skin.
·         A red patch that tends to bleed.
·         Scaly patch on the skin.
Melanoma usually looks like a mole. Its symptoms are as follow:
·         A mole that bleeds.
·         A dark spot on skin growing quickly into a mole.
·         A spot on skin with pain, itch or bleeding.
skin cancer symptoms
Skin Cancer Symptoms Pictures and Signs



Treatment depends upon various factors like type of cancer, the location of cancer, an age of a patient, and stage of cancer whether it is primary or reoccurrence. Surgery is the most commonly opted treatment. There are some other standard treatments as well.

Surgery:-

It is the most common treatment in which the affected area is removed by surgical procedure. The tumor cells are excavated out in the surgery. Some neighboring healthy cells are also removed in the procedure to avoid of developing the tumor in future. Different types of cancer involve different sets of surgical procedures.
Skin Cancer Surgery
Skin Cancer Surgery


Mohs Micrographic Surgery:-

This method is used for hard to reach areas or tumors with poorly defined clinical borders. In this method, the entire tumor is removed at once and then small tiny parts around the tumor are microscopically delineated until it is completely removed. This method has the highest cure rate of all methods.

Electrocautery and Cutterage:-

It is the most widely used method in which curette, sharp spoon-shaped tool, is used to remove the tumor. An electric-desiccation is performed on the affected area i.e. passing current through cells in the affected area which destroys the bleeding and damages the remaining cancer cells.

Radiotherapy:-

It is mainly applied in the case of primary lesions requiring difficult or extensive surgery. It is of two types; inner radiation and external radiation. In the case of skin cancer, oncologists prefer to use the external method in which the radiation is directed from an outer source to treat the affected organs. It is also given after the surgery to prevent cancer from coming back.

Cryosurgery:-

This method is used for the cells which are precancerous or in the case of debilitated patients with medical conditions. Use of liquid nitrogen is made to freeze the affected are and the skin blisters away, leaving a pale scar.

Chemotherapy:-

This method is used for removal of precancerous cells present on the outer layer of the skin. Use of creams and lotions is made to destroy the cancerous cells and to prevent them from growing any further. It is also used for malignant melanoma in which tumor keeps growing back but confines to one area.
Skin Cancer Hospital
Skin Cancer Hospital 


Photodynamic therapy (PDT):-

This is the relatively new type of treatment as an alternative to surgery. It makes use of a drug with photosensitizers which make skin sensitive to light. So when the affected area is exposed to special kind of light, the cancerous cells in the region are destroyed. This method is generally used for basal cell carcinoma and is not suitable for deeper skin cancer. The appearance of the skin after treatment is better than that after the surgery.

Cost of the Skin Cancer Treatment:-

The cost of the treatment depends upon the treatment, initial investigations and specialist screenings. We also provide with other facilities like stay arrangement for the patient and assistant, medical supplies and other consumables.
Skin Cancer Hospital
Skin Cancer Hospital In India


For complete information about exact cost of the treatment, send us your medical reports with your queries at our e-mail ID. We will respond you back in 24 hours with complete information about the treatment package after examining your medical reports with finest team of doctors in the best hospitals.


We here, at InGoodHand, provide you with all the assistance during the treatment including medical visa, airfare booking, airport pick and drop service, and hotel stay. With us at your service, you can completely rely on us and have a speedy recovery without all the other tensions.

Tuesday, 5 April 2016

Best Hospital for Lung cancer Treatment in india

What is Lung Cancer?

Lung cancer, also considered as carcinoma of the lung, is basically a lung tumor featured by unrestricted cell growth in the tissues of the lung. This tumor is known as malignant and cancerous. With an average survival rate of near about two to four months after analysis without any treatment, lung cancer spreads violently. Lung cancer prognosis stage one is very crucial. It grows so rapidly and frequently at the crucial time of analysis that procedures such as radiation therapy and surgical removals are less effective at this point of lung cancer.
lung
Lung Cancer


The probability of survival for at least five years becomes 75% in the early phase of cancers which can be removed surgically. However, malignant lung cancer can be recognized as the main approach towards the procedures like chemotherapy and radiation therapy.  There are two types of lung cancer namely, small cell lung cancer and non-small cell lung cancer.

  • Non-small cell lung cancer: In this, the phase of the tumor at the time of analysis is the most eminent lung cancer prognosis factor.
  • Small cell lung cancer: These can be removed surgically unlike non-small which is treated which different therapies. However, outcomes of non-small are poor in general.
Chief cause of lung cancer:-

Smoking is one of the leading reasons behind the causes of lung cancers. It also hampers in between and interferes with the efficacy of the treatment of this disease. Thus, smoking can be proven as a very dangerous act and hence should be avoided.


Lung cancer symptoms:-

  • Chest pain.
  • Shortness of breath.
  • Cough.
  • Fatigue.
  • Lose of appetite.
  • Coughing up blood.
  • Coughing up phlegm.
Where can it be treated?

India is considered to be one of the best places which offer Best Hospital for Lung Cancer Treatment in India. This is due to the availability of the cancer hospitals with plenty of expertise doctors and surgeons for the treatment of all kinds of lung cancer. In Good, Hands is one of those. On visiting In Good Hands, one may find the best team of cancer specialists who will treat lung cancer with the most advanced technology.

lung cancer treatments
Lung Cancer Treatments

How can it be treated?:-

Surgery is the most basic approach for the treatment of lung cancer which basically eliminates the adjacent tissues and tumor during the time of an operation. Other surgical methods include:
·         Lobectomy: It is the crucial type of lung cancer surgery in which one lobe of a lung is removed. It is the most practiced and successful surgery.
·         Segmentectomy: It is that process of surgery in which a portion of cancerous organ of lungs is removed.
·         Pneumonectomy: It can be used for some forms of lung cancer. In this, the entire lung is removed from the body of the patient suffering from lung cancer.

       Different   therapies: - Best Lung Cancer Treatment in India

lung cancer treatment
Lung Cancer Treatment in India
  • Chemotherapy: Many of the medical oncologists will suggest chemotherapy prior to surgery so that the tumor shrinks in dimensions. This makes surgery easier which thereby increases the success rates as well. Chemotherapy may also be suggested to follow the surgery so as to prevent any further growth of lung cancer cells. Chemotherapy sessions are known to be very effective in killing the malignant cells. However, patients may face giddiness, nausea, extreme fatigue, and hair loss after these sessions.

  • Radiation Therapy: It aids in killing the harmful cells of lung cancer. It takes a couple of weeks or so to treat the lung cancer with the radiation therapy. The type of radiation and the dosage varies with the species of the lung cancer. In this, rays directly hit the affected area in the lung and damage the cells, hence preventing the growth of the cancer cells. This is a very effective treatment in treating lung cancer.
      Things to keep in mind:-

lung cancer hospital
Lung Cancer Hospital In India
  • Lung cancer, no doubt, is a very dangerous fatal disease. It may lead to death if certain precautions are not taken during its early stages. The treatment of lung cancer should be accomplished within a particular span of time so as to minimize the chances of death.
  • Proper prognosis must be undertaken as early as the disease has been detected. The risk factor can be easily reduced if proper treatment and guidance are there.
  • The growth of lung cancer is detected by analyzing the aspect of staging. The ideal treatment for lung cancer depends upon the phase of the disease. Clinical staging procedure is a necessary and is an effective way of determining the phase. So this procedure must be taken into consideration before starting any other treatment therapy. This procedure is dependent on the consequences of the medical tests like MRI, CT scan, chest X-ray, PET scan, biopsies and some physical tests. Lung cancer survival rate is extremely low.

People usually become hopeless after knowing that they are suffering from lung cancer. They start blaming themselves but clinical researchers tell that only smoking is not the factor which causes lung cancer. Air pollution is also one of the leading factors which may cause lung cancer. So, going to the places where air pollution is in huge amount should also be avoided along with the excessive smoking