ALLERGY
Item
- Title
- ALLERGY
- extracted text
-
RF_DIS_10_SUDHA
Terfed
a specific
peripherally-acting
antihistamine
CNS H] receptor
ontihish
[inic effect
no impaired
performance
impaired
performance
peripheral H)
receptor
peripheral H]
receptor
antihistaminic
effect
antihistaminic
effect
alpha adrenergic
blocking
effect
CONVENTIONAL
anticholinergic
effect
ANTHSTAMNt
locol anaesthetic effect
TERFED
Terfenadine (Terfed) is a new,
selective histamine H]-receptor
antagonist devoid of sedative
properties associated with
antihistamine therapy. Clinically,
terfenadine (Terfed) is effective
against perennial allergic rhinitis,
acute seasonal allergic rhinitis,
and allergic skin conditions, while
being devoid of CNS effects
including sedation, psychomotor
impairment or interaction with
diazepam or alcohol.
Terfenadine (Terfed) is an
antihistamine with a completely
different and novel profile from
the "classical antihistamines" and
as such should prove to have
significant clinical advantages for
the symptomatic treatment of
histamine-associated disorders.
Quick relief of allergic symptoms
"Jh® antihistaminic effect of terfenadine
(I erfed) becomes evident within 2 hours
and several studies have demonstrated
that terfenadine (Terfed) 60 mg
histamine-induced wheal response in
man and this suppression lasts for at
least 12 hours."
suppresses nearly 100% of the
Drugs 29, 1985, p 39
Inhibition of wheal area
Inhibition of IgE-levels
Free from sedative side-effects
"A battery of sophisticated studies of
central nervous system function in man,
including electroencephalogram (EEG)
analyses in several laboratories confirm
the numerous clinical reports that
terfenadine (Terfed) is devoid of the
sedating action characteristic of other
antihistamines. No basis has been
uncovered for concern about inadvertent
overdosage or the operation of
machinery while under antihistaminic
treatment with terfenadine (Terfed)."
Low brain concentrations
Devoid of sedation
Arzneim.-Forsch. Drug Res., 32(11) No. 9a, 1982, p 1193
the quicker acting
|(?WM non-sedating antihistamine
Acute allergic rhinitis
Chlorpheniramine
Placebo
% of patients achieving satisfactory or complete relief of symptoms
Nasal Symptoms
Oj
“In the patient with acute allergic rhinitis,
terfenadine (Terfed) may well be the
primary drug of choice for relief of
symptoms, such as itchy and watery eyes,
itchy palate, itchy and runny nose, and
sneezing by acting as an antagonist of
histamine in such reactions."
Perennial rhinitis
"Efficacy of terfenadine (Terfed) has
been estimated from a global
appreciation and the evolution of 11
symptoms, and tolerance on the
frequency of diurnal sleepiness. The
results showed a very good efficacy of
terfenadine (Terfed) and the absence of
a depressant effect."
Arzneim.-Forsch. Drug Res.., 32(11), No 9a, 1982, p 1205
Arzneim.- Forsch. Drug Res., 32(11), No 9a, 193?, P 1206
Urticaria and eczema
"Terfenadine (Terfed), at a dosage of
60 mg twice daily for upto 2 weeks has
been shown to be comparable to other
antihistamines or superior to placebo in
achieving relief of symptoms in skin
diseases due to histamine release,
including primarily urticaria and
eczema."
Drugs 29, 1985, p 50
Chronic pruritus
"Terfenadine (Terfed) was significantly
(P<0.05) more effective than
chlorpheniramine and placebo in the
treatment of chronic pruritus of liver
disease."
Drugs 29, 1985, p 50
Chronic idiopathic
urticaria
"Terfenadine (Terfed) can be considered
an acceptable first-line non-sedative
antihistamine in the treatment of CIU
(chronic idiopathic urticaria)."
Br. J. Clin. Pharmac., 20, 1985, p 641
Terfed
■■ TERFENADINE
the quicker acting
non-sedating antihistamine
0)
Kapod reBoef aod
compBete pmtectioiro
Couwemeinit iwo daoBy dosage
S-ree from
sedative
effects
No potentiation of
the sedative effects of
afcohoB or daazepam
For the use only of c Registered Medical Practitioner or a Hospital or a Laboratory
Terfed
■■ TERFENADINE
the quicker acting
non-sedating antihistamine
Allergic Conjunctivitis
Urticaria
Perennial &
Contact Dermatitis Common Cold
Seasonal Allergic
Bronchial Asthma
Eczemas
Rhinitis
Vasomotor Rhinitis
Prescribing Information
Description
Warnings/ Precautions
Terfed is a selective Hj-histamine
receptor antagonist. Chemically it
is«-]4-(l, 1 -dimethylethyl) Phenyl]
-4-(hydroxydiphenyi methyl)
-1-piperidinebutanol.
Although incidence of adverse
effects associated with use of
Terfed is less, the potential for
typical adverse effects induced by
antihistamines should be
considered during Terfed therapy.
Chemical Structure
Composition
Terfed Tablets
Each uncoated tablet contains:
Terfenadine DSP................... 60mg
Terfed Suspension
Each 5 ml contains:
Terfenadine USP................... 30mg
indications
Terfed is indicated for the relief of
symptoms associated with
perennial and seasonal allergic
rhinitis and vasomotor rhinitis, and
in urticaria, contact dermatitis, and
eczemas.
Terfed is also indicated in other
histamine-mediated disorders such
as allergic conjunctivitis,common
cold and bronchial asthma.
Consideration should be given to
potential anticholinergic (drying)
effects in patients with lower
airway disease, including asthma.
Patients receiving Terfed therapy
should be instructed to take the
drug only as needed and not to
exceed prescribed dose.
Pregnancy and Lactation: There
are no adequate and controlled
studies to date using Terfed in
pregnant women and lactating
mothers. Hence the drug should
be used in this group of patients
only when the potential benefits
justify the possible risks. Women
of childbearing age must be
questioned about pregnancy prior
to Terfed therapy.
Most common adverse effects
(5-16%) include sedation,
dizziness, nervousness and
weakness.
Other reactions (5-8%) include
abdominal distress, nausea,
vomiting and change in bowel
habits.
Rarely (1%) dryness of mouth,
nose, throat and skin eruptions
have been observed.
Mild to moderate increases in
serum aminotransferase
concentrations have been
reported.
Dosage and Administration
Adults and Children above 12
years of age: 60 mg twice daily
or 120 mg once daily
Children:
6-12 years: 30 mg twice daily
3-5 years: 15 mg twice daily
Presentation
Drug Interactions
There are currently no known drug
interactions associated with the
use of Terfed.
Contraindications
Adverse Reactions
Terfed is contraindicated in
patients with a known
hypersensitivity to the drug.
Adverse reactions to Terfed occur
relatively infrequently and are
transient and mild in severity.
Terfed Tablets
Strip of 10 tablets
Terfed Suspension
Bottle of 50 ml
Ciplax
Cipla Ltd.
Bombay Central Bombay 400 008
JM- io-i
ISSN NO 0970-471)
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Vol 2
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AUGUST 1989
HEALTH ACTION
health
action
CONTENTS
• UNDERSTANDING ALLERGY
A HAFA MONTHLY PUBLICATION
DR DM PRAKASH...............................
5
EDITOR
• SKIN ALLERGIES
Dr CM Francis
7
DR SC RAJENDRAN......... .................
EXECUTIVE EDITOR
Ms Patricia Palaparti
• URTICARIA
DR KR ANTONY.......... . ............... .... 11
LITERARY CONSULTANT
Rev GT Vadakel
• LEARN TO LIVE WITH ALLERGY
SR PLACIDA...................................... 1 2
SUB-EDITOR
Ms Manjiri Saraph
BUSINESS CONSULTANT
• THERAPY OF ECZEMA
Mr Jose K Chomkara
UR YOGESH S MARFATIA............ .
13
CULATION MANAGER
S
M Leo Raj
DELHI OFFICE:
Catholic Hospital Association oflndia
CBCI Centre, Ashok Place
Goldkhanha, NEW DELHI-110 001
EDITORIAL BOARD
□r Anthony KR
Mr Augustine J Veliath
Fr Edwin MJ
□r Louisa Emanuel
Dr Prem Pais
Dr Ravi Narayan
Mr Suresh Maximus
EDITORIAL ADVISORY
COMMITTEE
Mr Alok Mukopadhyay
Dr Daleep S Mukarji
Fr George Lobo sj
Mr George Joseph
r George PO
r Jose Vincent
Dr Paul Neelamkavil
Sr (Dr) Placida
Dr Samir Chauduri
Dr Thomas MJ
O
Printed and published by Ms Patricia
Palaparti for and on behalf of Health
Accessories for All (HAFA) at Pragati Art
Printers, Red Hills, Hyderabad
Editorial and Administrative Offices:
HEALTH ACTION
PB 2153
Gunrock Enclave
Secunderabad 500 003
Tel 848293 848457 841610
Cover Artwork
K Balu
• BRONCHIAL ASTHMA
DR SANDHYA NANJUNDIAH.......... 17
• ALLERGY AND THE EYE
DR RAM S MIRLAY........................... 21
O ALLERGY IN ENT
DR KEVIN PEREIRA........ .................. 23
• THE WHITE SPOT PREJUDICE
DR CH RAJASEKHAR...................... 29
• GLOBAL ERADICATION:
THE UNREALISTIC GOAL..... 31
o MEDITATION IN MEDICINE
DR B BHARGAVA ............................. 33
O "A SIP THAT SAVES LIFE...!"
A REPORT............................... 37
• DO YOU KNOW?
DR PAUL NEELAMKAVIL.................. 39
0 JOURNAL SCAN .................. 40
• TRAINING FOR COMMUNITY
HEALTH CARE: A, MEDICAL
COLLEGE EXPERIENCE
DARAS AMAR..................... .............41
Articles and statements in this publication
do not necessarily reflect the policies and
views of HAFA
• BASIC HEALTH COMMUNITIES
FR EDWIN MJ.................................... 43
• HEALTH OF PEOPLE IS WEALTH
OF NATION
DR JACOB CHERIAN ................... 45
Subscription: Annual individual: Rs
50
Annual Institution:
Rs
80
Life Membership:
Rs 1000
Foreign Annual:
US $ 50
Foreign Life:
US $ 500
Correction: The reference list on
page 48 in July 1989 issue is in
connection with the article that ends
on page 25.
HEALTH ACTION AUGUST19B9 • 1
HEALTH ACTION
The Editor speaks —
J"Vbout 30°/o of all people are
allergic to one thing or another. The
substances which cause allergy
(allergies) are all around us: pollens (a
notorious one is parthenium), dust in
the house, bee sting, white of eggs,
cosmetics, detergents, food substan
ces and many others.
Allergy has been known from
ancient times. In the ninth century
AD, Abu Ah-Razi had described "rase
fever" — allergic manifestation in
many people when the rases
bloomed in Spring. But it is in recent
times that allergy has received
attention.
Allergy is based on immunological
process. Dur bodies produce
antibodies against foreign substan
ces. This reaction is useful in
infections, giving protection against
invading organisms. Allergy is due to
an over-reaction. Antibodies form
when the person comes into contact
with the allergens the first time
itself. The first phase sensitises the
person to the foreign substance. At
the second contact with the same
allergen, symptoms of allergy occur.
Allergic reactions may be slow or
immediate in onset. The consequen
ces may be mild or severe — rashes,
eczemas, asthma, hay fever, itching,
fall in blood pressure, shock and may
even lead to death. Allergic reactions
are caused by the release of various
chemicals. If the reaction occurs in
the lower respiratory tract, narrow
ing of air ways, wheezing and
shortness of breath (characteristics
of bronchial asthma) occurs; in the
nose and sinuses, it can cause
sneezing, running of the nose and
nasal obstruction (allergic rhinitis); if
in the skin, urticaria and itching.
The management of allergy is not
easy. Many persons are forced to
Change their jobs and environment.
Discovering what causes allergy is
very difficult. There are some testing
From the Director’s Desk —
Fram a situation like mine it
becomes rather difficult to write on a
subject like allergies. I am sure there
aren't many people who have not
become victims of this mysterious
illness — an illness for which a
Complete cure is yet to be found. This
only shows that medical science
cannot find answers to everything
though it may like to make tall claims
in this connection. Many are the
ways one could look at the whole
question of allergy. Let me explain
how I would like to look at it. The
effects of allergy are on two levels, ie
the individual person and society
itself. For an individual, it is the story
of untold misery and suffering for a
long period for no fault of the
suffering person. Fault may lie on his
genetic make up or the environment
in which he lives and in both he has no
say and the person is just a victim. At
2 • HEALTH ACTION AUGUST 1989
the society level it is a very complex
problem to which the answer is not
forthcoming. Many are the factors
that affect society at large and a
diagnostic process with the help of all
possible gadgets available in the
medical field cannot at times find the
root causes of allergy. What is more
needed and useful would be a
process Of social diagnosis to find out
the link between allergies on the one
hand and the socio, economic
political, religious, cultural dimen
sions on the other.
The memories of the man made
tragedies of Bhopal, Chernobyl etc
are still fresh in our minds. Whatever
the Union Carbide and their
sympathisers in our country nw
say. their responsibility for this great
human tragedy cannot be explained
away by any standards. The effects
procedures to find out the cause but
they are difficult and time consuming.
Because histamine is one of the
most important mediators of allergic
reactions, antihistamines are used’
they are not successful in all cases'
Steroids are prescribed but the need
for prolonged treatment leads to
adverse side-effects. Desensitisa
tion is another process which can be
tried. This process requires repeated
exposures to the allergens over a
long period of time. It is to be hoped
that current research into t1 p>
causation and better understanding
of allergy will enable us to better
management of allergy.
□r CM Francis
Editor
of this tragedy on thousands of
survivers and the dear one’s of the
thousands who died, for years to
come will testify to the whole world
the unforgivable negligence on the
part of all concerned with regard tc^
this tragedy.
Allergy needs to be looked into the
socio-economic, political dimensions.
Though our attempt in this issue
primarily is to look at allergies in the
clinical and allied aspect, there is a
need to dig deeper and look at it from
different angles, covering wide
issues. Many allergies are a by
product of industrialisation and its ill
effects, especially high profit making
at any cost, is the primary concernof
the industry. Here human beings gat
perhaps the lowest priority. Any
attempted exercise of a political wil
by any section of the people against
such a situation may not find its way
ahead in the given circumstances.
Seepage3
• In Health Action issue of June
1989, the article 'Diabetes —
Today's Scenario, mentions incorrect
values of Blood sugar to diagnose
one as Diabetic. By any criteria
the values shown are not correct.
Most of the pioneer refer the values
laid down by WHO 1980 or by
National Diabetes Data group 1979.
I am quoting here the criterias of
WHO for diagnosis of Diabetes
Mellitus Venous capill. Venous
The diagnostic values in Pregnancy
plasma are different and all pregnant women
Fasting — 120 mg°/o — 120 mg — must be examined between 24-28
140 mg°/o
week of pregnancy for Diabetes. The
criteria
of O'Sullivan and Mahan
P P after 2 hours — 180 mg —200 are useful.
^g°/o — 280 mg°fo
Dr HS Bajpai MD
If symptoms of Diabetes are
Pilibhit
present then Random venous
plasma value of 200 mg°/o or more or
o I receive your copy of Health
fasting value of 140 mg°/o is found.
Action regularly. I endorse your view
In absence of symptoms of
diabetes atleast one additional
abnormal blood Glucose value is
needed to confirm the clinical
diagnosis, eg. 1 hour post glucose
value of 200 mg°/a during first test
or an elevated 2 hour or fasting
Glucose on subsequent occasion.
The important G T T Means a
fasting B Glucose value of 120
[venous) 140 venus plasma S. PP
(2 hr) Glucose and 75 Gm or 1.75
Gm/ng) between 120 — 180 mg°/o
..(venous)/140 — 200 mg°/o (Venous
"plasma)
Almost similar values are prescri
bed by National Diabetic Data GkP.
from page 2
If we are serious about the
prevention and effective control of
allergies, we need to ask a few
honest questions of ourselves: What
about our industrial policy? Does it
give priority to people or to
machinaries and fat profits? What
about our licencing policy for new
industries? Why are they allowing
factories to come up in the middle of
residential areas? Is there a huddling
together of factories in the same
cities again for better profit margin
whereby forcing people to leave their
pathic point of view. There is
difference between Allopathic and
Homoeopathic point of view only in the
way of treatment. We individualise
each and every case and prescribe
medicine only on the totality of
symptoms of the patient: subjective
and objective symptoms; mental and
physical symptoms of the patient as
a whole. We have no standard
medicine for the disease. We have
medicine for the patient who is
suffering from the disease say
Diabetese Mellitus. Whereas in
Allopathy there are standard
medicines for the Disease. They
diagnose the disease and have the
medicine.
The above article does not reflect
Homoeopathic point of view. This
type of article only reflects that you
want to present wholistic view of the
disease and the treatment available,
of mutural concern, mutual sharing but in a biased manner. Your title
and mutual respect for each other is is on the Allopathic side. It should be
the only way by which we can develop balanced. The article should be
a system for health action. I also written by some eminent person of
endorse your wholistic approach to the system having full command on
health. We need a deeper the system. For this purpose you
analysis of our food habits, living should inform the person sufficiently
style, environment, customs and in advance so that he may spare
cultures, our standard of knowledge some of his time for the service of
and economic standard etc. etc.
the mankind. I appreciate your
I like to draw your attention to the difficulties, you may be facing for the
article, "Homoeopathic view on original articles from the eminent
Diabetes" by Dr B S Manjunath in persons. They have no time for the
your June 1989 issue. I would like to purpose where there is no money.
submit that so far as the diagnosis,
Dr Kursija SC
causation, prognosis, and complica
Ashok Vihar, Delhi
tion etc. are concerned, there is no
difference in Allopathic and Homoeo
homes in search of jobs ata very high
cost affecting their kith and kin very
badly? What about safety measures
at these factories? Do we realise
that pollution and pesticides are two
of the major threats to healthy
human life today? What is our policy
on these? What about the policy on
waste disposal? Many of our rivers are
polluted leading thereby a threat to all
kinds of life. Ho do we look at these
situations? These are but a few —
there are many more questions that
defy answers. Yet, however unplea
sant they are, they need to be asked
and proper answers found. Allergies
cause misery to many. Will the
society exercise its political will to
reduce allergies and thereby mise
ries, or will the greedy continue to
inflict and increase miseries after
miseries to many more? Else, do we
change the universal strategy of
'Health For AH by 2000 AD to
Allergy For All even before
2000 AD?'
Fr John Vattamattom svd
Managing Director
HEALTH ACTION AUGUST 1989 • 3
HEALTH - A SOCIAL JUSTICE ISSUE
HAVE YOU ANY ANSWERS ?
The man tied up and dumped on the
footboard of the cycle rickshaw is an alleged
criminal, being shifted from Barh, a
subdivisional town near Patna to the Patna
Medical College for treatment.
The Illustrated Weekly of India, in its issue
of July 2-B, 19B9 used these pictures in the
editor's page in place of their usual
recommendations. The pertinent question
raised was will some civil rights body take up
this case? Or will we all remain as callous as
usual waiting for someone else to act ?
HEALTH ACTION brings you a reprint of these photographs seeking your active involvement in this social justice
issue. Naked, tortured and trussed up like an animal being carted to the slaughter house — this is a brother — a
fellow human. With brotherhood as the acknowledged norm and with the ultimate fatherhood of God are we not
made in His image? Even animal lovers weep at the sight of sheep carried to slaughter. Should we not then be moreconcerned when man turns against man? Turn not your hearts or emotions away — send us your answers? Where are we
heading?
M LEO RAJ
COVER STORY
ALLERGIES
Understanding Allergy
Dr Dm Prakash Consulting Physician
I
n 1902, two French Scientists
injected pigeons with a small amount
of extract from the tentacles of a
sea creature. Nothing happened. A
week later, they repeated the
procedure in the same way, and
igetched, in surprise as the pigeons
"veloped severe reactions. The
pigeons had somehow become
sensitive to the formerly harmless
substance. The scientists had
discovered Allergy.
The word allergy itself was coined
by Von Pinquet, a pediatrician. He
meant by this term, altered
reactivity, i.e., the phenomenon in
i which a generally harmless sub
stance causes certain harmful
effects in a small proportion of the
population. In the decades that
followed the initial experiments, we
have understood a great deal more
about the mechanisms and manifes
tations of allergic diseases. Allergy
' affects millions of people all over the
! world. It is estimated that almost 1
^percent of the general population
^suffer from some form of allergy
| during their lifetime. Ironically, allergy.
i results from disordered working of
the immune system. This system is a
complex one which exists in man to
protect him from infections.
The Immune System:
Allergy occurs because of an error
in education. Normally, the human
body learns to defend itself against
invading organisms such as microbes
and remembering the nature of
I these enemies. Medical science has
taken advantage of this by way of
vaccinations against many common
infectious agents. These vaccina
tions give rise to immunity. Allergic
reactions occur when the immune
system mistakenly learns to recog
nise innocent and innocuous foreign
substances as potentially harmful.
These
substances
are
called
Allergens. Among the common
allergens are pollens, molds, animal
danders, house dust, and dust mite.
Certain foods can cause allergies.
We can come into contact with
allergens in different ways: by
inhalation, by skin contact, or by
ingestion. Allergic reactions can
often get aggravated by climatic
changes.
FI& I.
TW£
AttfllGic
fiLAcrioN
the mast cells contain chemicals
known as mediators, which when
released into the tissues can cause
the familiar manifestations of allergy
such as sneezing, stuffy nose,
wheezing, urticaria, etc.
Any organ system can be involved
in the allergic process; those most
commonly involved are the skin, the
lungs, the nose and the gastro
intestinal tract. Skin manifestations
of allergy. are eczema, urticaria,
intense itching on the skin, contact
dermatitis and some drug reactions.
Allergic rhinitis refers to the
common stuffy nose, sneezing,
watery nose etc which affects large
number of people. Bronchial asthma
has allergic component in certain
proportion of asthmatics and these
persons suffer as a consequence.
Food allergy can cause symptoms
such as colic, diarrhoea and vomiting.
Some children suffer from allergic
eye trouble and need attention.
A component of the immune
system which plays a central role in
allergy is the Antibody, a 'scout'
molecule whose function is to identify
foreign invaders so that the defence
system can be activated with speed.
These antibodies are produced by a
class of the white blood cells called
the B Lymphocytes;these B cells are
in turn regulated by other cells, the T
Lymphocytes. Central to the theme
of allergy is the over production of
antibodies called Immunoglobulin E
(Ig E) antibodies. Because of some
genetic factor, allergic people
produce large amounts of IgE
antibodies to commonly encountered
allergens and over a period of time
become clinically allergic. In an
allergic person, the specific IgE
molecules to a particular allergen get
attached to cells called Mast Cells:
HEALTH ACTION AUGUST 1989 « 5
COVER STORY
ALLERGIES •
cades of research. The fundamental
In rhinitis, (inflammation of the
mechanism of allergy is still not
Clinicians take detailed history to mucus membrane of the nose) known. Why an individual becomes
antihistamines
and
decongestant
pinpoint the possible allergens.
sensitive to some allergens and not
Circumstantial evidence often points nasal drops are used commonly. In
to others is not clear. Research is
the way. Allergy skin tests are recent years, antihistamines have
going on in an intensive fashion to
been
available
which
do
not
cause
performed to detect the presence of
unravel the basis of allergy, and it is
allergy. Essentially, skin tests are drowsiness, a major side effect of
hoped that in the near future, break
carried out to detect the presence of many antihistamine drugs. Use of a
throughs may be occurring which
drug
called
Disodium
Cromoglycate,
IgE antibodies in the person’s
will have important beneficial effects
system to specific allergies. In prick in the form of nasal spray or drops, is
tests, a small amount of the allergen also very useful in controlling rhinitis. for the millions of sufferers from
is placed on the surface of the skin More recently, a medication which is allergies.
(forearm or back] and the skin topically active called Beclomethapricked lightly with a fine needle. In sone has been used with success in
about 15 minutes, a y/heal cases of allergic rhinitis. This is a
(temporary red or pale raised area of locally acting steroid, devoid of
the skin) and f/arewill form at the site systemic side effects of cortisone
IX NATIONAL CONGRESS
if the person is allergic and has medications.
RESPIRATORY DISEASES
abundant IgE antibody to that
In bronchial asthma, antihis
particular allergen. In the case of tamines have hardly any role. The
17th to 20th DECEMBER, 1989
foods, elimination and rechallenge medications used in asthma are
testing is often used.
bronchodilators, both oral and inhaled.
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These afford symptomatic relief.
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For details contact:
Beclomethasone are of great use in
many asthmatics. Antihistamines
Dr. C. Srinivasa Rao,
and local steroid creams are useful in
Organising Secretary,
dermatologic allergic diseases.
Diagnosis
Hyposensitisation
Ffft
2
ALlZKL'I
SkiN
TEST
Allergy can also be detected by
analysing the serum of the patient
with a test known as Radioallergosorbent Test (RAST) in which
isotopic method is used for
quantification of the IgE antibody.
These are expensive and are not yet
available for common allergens in our
country.
Treatment
Clearly, the most obvious way to
eliminate allergy is to totally avoid
exposure to the allergen: getting rid
of a cat (dander allergy), avoiding
foods to which one is allergic, etc. But
there are a number of allergens like
dust, dust-mite, pollens and molds
which are unavoidable. In such
instances, medications have to be
employed to reduce the effects of
allergic reactions on various organ
systems.
6 • HEALTH ACTION AUGUST 1983
This procedure refers to an
attempt at reducing the severity of
allergy, with reference to rhinitis and
asthma; after detection of airborne
allergens which are thought to be the
major allergens, injections of very
gradually increasing concentrations
of allergens are administered over a
prolonged period. These injections
cause increasing production of
protective' antibodies (specific IgE
and IgM) which act as 'blocking'
antibodies and reduce the effects of
allergen entry on subsequent
exposures. Further, the treatment
makes the tissues more resistant to
release chemical mediators which
bring about the clinical manifesta
tions. It is also noted that over a
period of time, this treatment helps
by lessening the production of
specific IgE antibodies. Hyposensi
tisation has no role in food allergy. It
is useful in insect venom allergy,
which can be serious and occasionally
life-threatening.
Unanswered Questions
Major questions remain to be
answered adequately, despite de
IX National Congress on
Respiratory Diseases,
3-4-760, Barkatpura,
Hyderabad- 500 027, INDIA.
Phone Nos (0842) 63791 (Office) and
61438 (Res)
Wanted
Pharmacist posting for a D Pharm
holder, registered in Maharashtra
Pharmacy Council.
Contact;
Miss Annakutty CC
Chowttukunnel
Kudayathoor P O
Thodupuzha (via) Idikki Dt
Kerala 685 590
COVER STORY
ALLERGIES
Skin Allergies
®
Dr S C Rajendran MBBS, DVD MD
S3 efinition of Allergy:
When a substance, not harmful in
itself, causes an immune reaction
which causes nothing but misery.
There are various types of skin
l^ergies. The common ones we come
across in day-to-day life are:
1 Urticarias & angioedemas
2 Eczemas, atopic dermatitis
3 Drug allergies
4 Allergic contact Dermatitis
5 Allergy due to insect bites
immunological and nonimmunological
path ways. The commonest stimuli
are:1
Physical stimuli
Traumatically induced, most com
monly Dermographism (a condition in
which pressure orfriction on the skin
gives rise to a transient raised,
usually reddish mark so that a word
traced on the skin becomes visible);
3
5
Plants & insects
Plants like mettles cause histamine
release and urticaria by a direct
effect on mast cells. An immediate
reaction to insect stings is also
caused by histamine liberation to
insect proteins in the venom.
Inhalant allergens
Sometimes
symptoms;
can
provide
skin
Urticaria (Nettle rash or hives)
It is a raised erythematous
(reddish) skin lesion that is markedly
pruritic (itchy), tends to be
evanescent in any one location and
generally worsens by scratching.
3
Contact allergens
Minute skin trauma and direct
allergen contact (lying on a grass
lawn, playing with a dog) can induce
contact urticaria;
Leeches and jelly fish induce urticaria
by toxins.
6
4
Food and food additives
Are common causes of urticaria
especially sea food, fish, berries, egg,
nuts and chocolates. It is often IgE
mediated reaction, histamine releas
ing agents, eg: straw berries,
Urticaria has been called a vexing
problem in terms of etiology,
mechanism involved and clinical
management. The vexing problem
remains for the clinician.
Urticaria is caused by release of
histamine from the mast cells and
causes itching
and increased
vascular permeability (having pores
or openings that permit liquid or
gases to pass through). Histamine is
the principal mediator of urticaria,
although other mediators may
ho i»
e results from
iuli acting via
/
/..
tomatoes, white of egg and free
histamine food (eg: tuna fish,
mackarel, old cheese) can some
times be implicated. Food dyes and
preservatives such as Tartrazine
and Benzoate derivatives can induce
urticaria.
---------------------<
c
Parasites
Itch and urticaria are frequent
symptoms of worm infestations,
associated with IgE antibodies to
parasitic antigen.
7
Drugs
Many drugs produce allergies.
Penicillins commonly produce a
anaphylactic (immediate) allergic
reaction. Aspirin and Indomethacin
employ nonimmune mechanism
involving arachidonic acid metabo
lism. Many therapeutic and diagnos
tic agents can release histamine by
direct action on mast cells, eg:
Morphine, codeine, polymysin, tubocurarine and radio-contrast media.
HEALTH ACTION AUGUST 1989 »
COVER STORY
8
t
ALLERGIES
Infections
Rarely urticarias may be due to
exposure to light, called 'Solar'
Urticaria depending upon the wave
length of light that induces urticarial
lessions.
of histamine even if histamine
release continue. Numerous anti
histamines are available, some with
multiple drug effects. The main side
effect sedation which limits its
usage.
Corticosteroids such as oral
prednisolone may be necessary in
management of urticaria; because of
their potential long term side effects
they should be used chronically only
after a demonstrated failure of high
dosage of antihistamines and
sympathetomimetic drugs. Short
term prednisolone has limited side
effects and is often useful in treating
urticaria not responsive to antihi
stamines and ephedrine.
12
Atopic Dermatitis
Acute viral infections are occasio
nally associated with urticaria.
9
Autoimmune diseases
Vasculities (inflammation of a blood
or nymph vessel) in Systemic lupus
erythematos can present with
urticaria like eruption.
10
Malignant disease
Lymphomas and other tumours can
be associated with itching and
urticarial eruptions.
11
Solar urticaria
Cholinergic urticaria
Sometimes urticaria can be induced
after heat exposure or sweating (hot
bath, vigorous exercise, fever 8.
anxiety).
Treatment
It is largely a disease of children. It
is chronic, relapsing, characterised
by extreme itching and persistent
scratching. Initially the lesion is
exudative, ultimately becoming dry
and lichenified. (skin becomes
hardened and leathery). The disease
usually starts in infants or children
with a family history of atopic
dermatitis, allergic rhinitis and/or
asthma.
Urticaria commonly affects about
20% of population at sometime in
their life.
□rug therapy is the main form of
treatment for urticaria and angioedema (an allergic skin disease
characterised by patches of a
disorder characterised by skin
inflammation) circumscribed swelling
involving the skin, its subcutaneous
layers, the mucous membranes, and
sometimes the viscera. For most
urticaria patients 3 types of drugs
are used to obtain symptomatic
control:- 1) Sympathetomimetic
agents 2) antihistamines 3) cortico
steroids.
Notably epinephrine (basic sympa
thomimetic harmone that is the
principal blood — raising harmone
Most patients (about 75%)
(adrenaline) & ephedrine (used for develop IgE antibody to common
relief or hay fever, asthma, E’nasal environmental allergens. These pati
congestion) have alpha-agonist ents have increased blood eosinophil
properties that cause vasoconstric count and increased serum IgE
tion (narrowing of the lumen of blood levels. The disease affects 5% of the
vessels) in superficial cutaneous and population and its importance lies in
mucosal surfaces directly opposing its long term morbidity.
the effects of histamine on these end
It usually starts on cheeks and
organs.
spreads to the trunk and flexural
Antihistamines (H1 blockers) are surface of arms and legs. Papules,
used in most cases of urticaria. They vesicles and exudation predominate
are competitive inhibitors of hista Itching is intense and the infant is
mine, reducing the end organ effect unhappy.
8 • HEALTH ACTION AUGUST 1989
In children, lesions are localised to
the flexor surfaces. The skin
becomes lichenified, fissured and
excoriated (chaffing of the skin) due
to scratching. The course is chronic
and recurrent, with bacterial skin
infection as frequent cause of
exacerbation. The disease continues
into adult life in 25% cases.
Diagnosis is based on history and
physical examination. In a typical
case, it can be supported by
•laboratory tests.
Treatment
Wollen clothes and frequent use of
soap water increase itching and
therefore should be avoided. Scratch
ing at night can be reduced by giviA)
infants cotton mitten and children a
sedative antihistamine; daily use of
moisturisers is needed.
Currently the most successful
agents are topical corticosteroids,
but the usefulness is limited by the
local adverse effects. The low
potency local hydrocortisone is used
for maintenance therapy and
occasional use in sensitive areas.
Tar preparations have an anti
inflammatory activity without the
risk of long term side effects, and can
be used.
Pertly Precise:
Luxury: Something you don’t
need and can't do without.
Spinach: An expensive source
of sand.
Auctioneer: The man who
proclaims with a hammer that
he has picked a pocket with
his tongue.
Hard times: A season during
which it is very difficult to
borrow money to buy things
you don't need.
Grandparent: Something so
simple a child can operate it.
COVER STORY
Drug eruptions
Systemically administered drugs
can produce a number of morphologi
cally distinct cutaneous symptoms
which include well defined, variable,
temporal relationship with the
ingestion of drugs. Macular .maculo
papular lesions and urticaria are the
most common undesirable effects
caused by drugs. Usually these
symptoms are not serious and
disappear spontaneously within a
few days or weeks. However, the
potential for a severe complication is
there so that even mild cases
deserve full attention.
Eruptions caused by a sensitivity
faction to a given drug are not
limited to one type of lesion and can
reveal a great variability. One group
of patients may respond to a drug
with papular eruption, while the other
groups with a morbiliform (resembl
ing the eruption of measles) rash.
The nature of eruption by itself does
not permit the identification of the
offending medication.
□rug eruption can consist of
pinhead in an erythematous (reddish)
area or it can be a raised flat reddish
papule. It can sometimes present like
Rubella (German measles) called
Rubiliform eruption.
Along with these eruptions they
will have a few important accompany
ing signs which are important to
differentiate from other viral infecJtions like (1) pruritis (itching) (2) fever
(drugs like cephalosporins, nitrofuran
toins, salicylates, phenobarbitone) (3)
eosinophilia, i.e. eosinophil count
more than 400/cmm (4) transient
lymphadenopathy (enlarged lymph
nodes) caused by phenylbutazone or
oxyphenbutazone. In practice the
above mentioned eruptions are seen
most frequently after administration
of penicillin, ampicillin, sulfonomides
and antiepileptic drugs.
On occasions they may be severe
and even life-threatening . drug
eruptions, eg: Exfoliative (the peeling
of the horny layer of the skin)
dermatitis, Steven Johnson Syn
drome (a severe and sometimes
fatal form of erythema), Toxic
epidermo-necrolysis (a skin disorder
charactered by widespread ery
thema). Further, an innocent looking
eruption may progress to more
disturbing one if the cause is not
recognised and the drug is continued.
Unfortunately the appearance of
drug eruption is not characteristic
enough to implicate the drug as the
most likely cause. However, some
eruptions are characteristic enough
to suggest a drug etiology, eg. Fixed
□rug Eruption most often caused by
phenophthalein, sulfonamides, tetracyclins. Here the term fixed refers to
the recurrance of eruption at the
same site, each time the offending
drug is administered. The characte
ristic lesion is well delineated oval or
round, of size from few mm to few
cm. Edema appears initially followed
by erythema and darkness to
produce black or brown lesion.
Mucous membrane involvement
particularly of oral mucous and penis
have occasionally been observed.
Rarely drug eruptions can get
aggravated due to sunlight or,
artificial light (tube light). The
eruption is limited to areas which are
exposed to light eg: face, V-area of
the neck, dorsum of hands. The
condition is called photo-sensitivity
reaction. The drugs responsible for
this are phenothiazines, sulfona
mides, diuretics and oral antidiabetic
agents.
Treatment
In most cases of macular and
maculopapular drug eruptions with
out extracutaneous symptoms,
there is no need for systemic or local
treatment.
In severe cases of drug reaction
the offending drug should be stopped
immediately. An antihistamine is
more than enough to control pruritis.
Systemic corticosteroid therapy
may be indicated if there are
pronounced extracutaneous symp
toms like drug fever, arthralgia or
severe cutaneous manifestations
like exfoliation Steven Johnson
syndrome and Toxic Epidermonecrolysis.
Treatment is usually not required
in the cases of fixed drug eruption,
because most are mild and not
associated with significant symp
toms, but the drug will have to be
ALLERGIES
discontinued. However, topical or
systemic corticosteroids are requi
red for more severe reactions.
Allergic contact dermatitis
A skin condition commonly seen is
allergic contact dermatitis. With
new chemical sensitizers being
introduced into our environment,
undoubtedly we will be seeing more
instances of this disease. Contact
dermatitis is the most common
occupational disease and is of
tremendous importance to both
individual and society. Diagnosing
allergic contact dermatitis, especially
eliciting the cause requires all the
patience, thoroughness and acumen
of the physician.
Contact allergens almost invaria
bly are small molecular substances
that reach the skin upon contact
with the environment. Because of
their small size they penetrate the
skin barrier, which is relatively
impermeable under normal circum
stances to large molecules and
reach the lining layers of the skin. In
order to induce contact allergy these
substances must be presented by
antigen-presenting cells, principally
epidermal Langhans cells, to T
lymphocytes in an immunologically
effective processed form. The
effector cells, which mediate allergic
contact hypersensitivity are descen
dents of these T lymphocytes.
The common contact allergies can
occur in day-to-day life due to plants,
vegetables, fruits, wearing apparels,
We know him
AH through the football
game, on every single play, the
loyal rooter had cheered his
team to victory. Hoarser and
hoarser he grew, until finally
he whispered to the man
beside him, What d'ya
know — I've lost my voice'.
'Don’t worry’, was the tart
reply, ‘you 'll find it in my left
ear'.
HEALTH ACTION AUGUST 1989 • 9
COVER STORY
ALLERGIES
jewellary, cosmetics, drugs used for
topical use and industrial agents. The
person may present with clinical
features consisting of scaling,
vescicles, papulovescicles, and exuda
tion (oozing out) at the site of contact
agent. The manifestation generally
starts within 24 hours, but in milder
cases, they may be delayed for 2-3
days or even longer. Contact
dermatitis continues to worsen so
long as the contact with the antigen
continues, but once further exposure
to antigen stops, it tends to subside
even without any treatment. The
diagnosis of contact dermatitis can
be confirmed by clinical correlation
with an accurate history that the
exposure to the agent leads to
recurrence of the dermatitis and
preventing further exposure leads to
regression. The cause of the contact
dermatitis can be easily confirmed by
patch test.
Partheneum is a common cause in
contact dermatitis. Usually it takes
some time (even many years) for a
person to develop allergy after
coming in contact with partheneum.
One of the major symptoms
associated with partheneum skin
allergy is itching, and skin eruptions.
Other substances include hairdye,
ornaments (nickel) shoes (leather)
and bindi in women, which commonly
cause contact allergic dermatitis.
Treatment
Avoidance of offending agent is the
mainstay of treatment. A mild
tropical steroid is helpful to alleviate
symptoms.
Allergies to insect bites
Insect bites as the cause of allergy
was suspected centuries ago. It is
usually seen in children commonly
due to bites of flees, bedbugs,
mosquitoes and dog louse. The
eruptions consist of wheal or a firm
papule and rarely bullae (a large
vesicle or blister) especially on
exposed parts, .with itching. It is due
to hypersensitivity reactions to
insect antigens. The attack may
persist for 3-4 years perenneally or
recur seasonally.
Management consists of use of
insect repellants and use of topical
corticosteroids.
■
10 • HEALTH ACTION AUGUST 1909
Christian Medical
Association of India
PO Box 24 Nagpur MS 440 001
Third National Paramedical Conference
Theme: Health - A Social Justice Issue-Role of Paramedicals
Date: 10th Oct to 12th Oct 1989
Venue: New MLA Hostel, Nagpur MS. Tel: 31521
Eligibility:
All paramedical workers serving in
voluntary/private/ government institutions.
mission/
Registration fee Rs. 50/- (non-refundable)
Conference fee Rs. 200/Total
Rs. 250/-
Late fee Rs. 50/- after 15th Sep. 89.
Registration and payment must reach CMAI by 15th
Sept. 1989.
For further details contact: The Paramedical Secretary
CMAI PB No. 24
Nagpur M.S. 440 001
I S H A
Indian Society of Health Administrators
First National Seminar on
Leadership For Health Care
August 21-26 1989 Bangalore
in collaboration with
Christian Medical Association of India
Eligibility:
Higher level administrators of programmer, hospitals,
departments, administrators of private and social
service organisations, medical and allied health
personnel training institutions and State and District
level administrators.
Venue:
Institution of Engineers
No 3 Ambedkar Veedhi Bangalore 560 001
Fee:
Non-members
Members of CMAI & ISHA
1000/-
rs. gOo/-
Participation Certificates will be awarded.
Last Date of Reservation: August 10,1989
For further details contact:
Hony Executive Director
Indian Society of Health Administrators
104 (15/37) Cambridge Road Cross
Ulsoor Bangalore 560 008
COVER STORY
ALLERGIES
Urticaria
Dr K R Antony MBBS DCH DTCH (Liverpool)
During this summer season a
number of children were brought to
me by anxious mothers with the
complaints of itching all over the
child’s body.
A child playing and walking around
formally in the house suddenly
mecomes irritable, cranky and starts
scratching his body all over. Patchy
areas of skin surface swell up with
reddish edges and pale centre. The
face is flushed. Older children will say
that a feeling of warmth spreads all
over the body. Some may double up
with abdominal pain. By the time they
decide to go to a doctor everything
disappears to the great surprise of
the worried parents. But this doesn’t
last long. There can be many
recurrences of these transient
symptoms. Well, this is Urticaria.
What causes Urticaria?
A number of children brought to
me last summer had Pyoderma or
boils on the legs, hands and scalp as
the primary foci of infection. This
bacterial infection sensitizes the
body to show an allergic reaction.
Staphylococci and Streptococci are
common bacteria that cause
Pyoderma and when Pyoderma is left
untreated or partially treated, many
get urticaria. Bacterial infections of
throat, (Pharyngitis, tonsillitis) tooth,
middle ear etc, also precipitate an
urticarial attack.
Many viral infections also give rise
to secondary urticaria and this may
be seasonal.
When we take a detailed history of
these cases very often the patient
comes out with the fact that he had
taken some new drugs which he is
not familiar with. Many drugs,
vaccines, toxoids and hormone
preparations precipitate urticaria in
the susceptibles.
Another cause of urticaria that
can be diagnosed by history, is food
allergy. Some unfamiliar food that
has been consumed within a day or
two will give rise to generalised
itching, abdominal cramps and loose
stools. Notorious for this phenomena
are eggs, wheat, chocolate, prawns,
crabs, nuts, cocoa and some food
dyes and additives.
An intelligent mother can always
arrive at this diagnosis by sheer
common sense and will tell the
doctor that everytime a particular
food was given the child had this
problem. The role of the doctor here
is to reconfirm the diagnosis and
emphasize on elimination of such
foods for quite sometime. It is often
noticed that a boy who is allergic to a
particular type of meat, say beef,
after 2 to 3 years when he again
consumes beef this urticarial
phenomena does not occur. By some
unknown reason that allergic
process ceases to occur.
Some children develop urticaria on
going to store rooms, unused rooms,
lofts where a lot of allergic dust and
molds are present. Some sprays and
inhalants also cause urticaria. During
certain seasons when children play in
the garden they develop urticaria and
the cause may be due to certain
pollens from seasonal flowers. Some
variety of trees in the forests cause
severe oozing dermatitis and allergic
rashes which require prompt
medical treatment.
Insect bites, especially mosqui
toes, fleas, mites cause multiple
small raised rashes which persist for
many days and can get secondarily
infected by bacteria when the
patient scratches. Doctors call it
Papular urticaria.
Physical factors like cold, heat,
pressure etc also cause urticaria.
Flora is a staff nurse who worked
with me. But she gets severe rashes
on having a cold shower bath or going
in an autorickshaw or moped, when
the wind is very chilly — This is cold
urticaria.
One important cause of urticaria
among rural children is Intestinal
parasites. Round worms, pin worms
S. hook worms are the common
important parasites that cause
urticaria, if not treated on time.
Management of Urticaria:
Management of urticaria can be
made easier with the cooperation of
parents who are aware. Parents will
know better than the doctor which
are the foods to be avoided, places to
be stayed away from and plants and
flowers to exclude from the garden.
It is the responsibility of the parent
to warn the doctor about the drugs
which the child is allergic to. Mothers
should take extra care and see that
the child is not bitten by troublesome
insects by use of mosquito nets,
insect repellants etc.
Physical factors which cause
urticaria should be avoided as far as
possible in homes, schools and
playgrounds. The Doctor will help you
to diagnose whether a bacterial or
viral infection is the cause of
urticaria and if required how to treat
it.
The Doctor might also ask for a
stool examination to see whether
See page 25
HEALTH ACTION AUGUST 1989 • 11
COVER STORY
®
ALLERGIES
Learn to live with Allergy
■w
The term allergy includes all types
of reactions of hypersensitiveness.
Allergies represent the abnormal
reaction of an individual to the foods
he eats, the air he breathes or the
substances he touches. Allergy is
the body's response to the presence
of same aggravating agent called an
allergen. These allergens are all
arountfus. Fur, pollen, dust, etc. are
examples of allergens. When the
individuals inhale these allergens,
the body induces the production of
certain substances called antibodies.
Antibodies are formed when germs
invade the body or any foreign
proteins introduced into the tissues.
They are part of the body’s natural
immunity system. Antigen is a
substance that stimulates the
production of antibodies, common
antigens are, viruses, bacteria,
pollen dust, fur, etc.
Antigen and antibodies when they
unite in specific organs like skin,
nose, lungs etc. the body's defense
mechanism overreacts — as a result
certain chemical substances such
as histamine and serotonin are
released. These chemicals are
responsible for the allergic manifesta
tions of dermatitis, hay fever and
asthma respectively. In an allergic
reaction histamines escape from the
body cells, producing inflammation
and irritation also cause a flow of
mucus in the lungs and nasal
passages, resembling like a person
having a very bad cold.
Potentially every individual can
become allergic. In fact 12 to 14
percent of the population of India
suffer from mild to severe allergies.
Heredity as well as psychological
state of the individual may play an
important role in allergic disorders.
Allergies that occur in any period of
life may depend on where one lives
how much of it one is exposed to and
for how long.
Allergens that cause hypersensi
tiveness in certain individuals are
quite harmless to non-allergic
people. There are many allergens and
their responses also vary. Some
allergens such as pollens, dust,
vapours, tobacco smoke, strong
odours of perfume etc. enter the body
after being inhaled. Certain germs
invade a person’s tissue, some food
provoke an allergic response which
include wheat, milk, fruits, chocolate,
eggs, pork and fish. There are certain
allergens such as poison ivy, dyes,
metals, plastics, furs, leathers,
rubber products, cosmetics and
chemicals response through a mere
contact with the skin or mucous
membrane of a sensitive person.
Physical agents such as heat, cold,
light and pressure may cause an
allergic response. Hay fever begins
with intense itching of the nose and
throat, tears gather in the eyes and
watery discharge from the nose
which is accompanied by violent
sneezing, headache, irritability, sleep
lessness and gastric upsets.
_________________________
12 • HEALTH ACTION AUGUST 1989
There are many ways to prevent
the allergic symptoms. The general
health and resistance power of the
body should be built up to establish
immunity. Prevent the allergens to
which a person is sensitive from
entering his body. The persons who
are suffering from Hay fever, should
stay indoors or stay away from the
locality; avoid drug or food from diet
persons who are allergic to drug or
food. Take organic, untreated
unprocessed food by which you can
eliminate pesticides, various sprays,
other poisons that may cause allergy
in persons. A person can be relieved
of the allergy by desensitization
treatment. The use of anti-histamine
drugs found relief in some cases of
allergy but it may not be successful in
all cases. The use of steroid harmones
derived from the cortex of the
adrenal gland may provide some help
in cases of serious allergic reactions.
The consumption of the alkalineforming foods is essential for those
suffering from allergies. Allergic
persons should be excluded from
their diet, today's processed foods
loaded with numerous chemicals
which cause powerful reactions.
Relaxation, exercise, meditation etc
will reduce or remove stress
element that is present in allergic
conditions. The best way to
overcome allergies is to strengthen
the overall physical resistance power
of the body.
0
COVER STORY
ALLERGIES
Sites: Cheecks are the commonest
u Therapy of Eczema
Dr Yogesh S Marfatia
The word Eczema is derived from
Atopic Dermatitis (Atopic eczema)
the Greek word "efcze/h"meaning “to
boil out” or “to effervesce".
It is a pruritic papulovesicular
process. Its acute phase is
Associated with redness and
swelling which in its chronic phase,
while retaining some of its papulovesi
cular features, is dominated by
thickening lichenification (meaning
accentuation of normal skin mark
ings, so that affected skin surface
resembles tree bark or leather).
Atopy is a genetically determined
disorder in which there is an
increased liability to form IgE (reagin)
antibodies and an increased suscepti
bility to certain diseases, especially
asthma, hay fever , and atopic
dermatitis, in which such antibodies
may play some role. Atopic
dermatitis is the characteristic
clinical type of dermatitis usually
associated with atopy. It may be
divided into 3 stages:
1 Infantile, occurring from 2 months
to 2 years of age.
Classification of Eczema
2 Childhood, from 2 to 10 years.
Exogenous (Exterior)
3 Adolescent and’adult stage.
1 Irritant dermatitis
The main symptom is severe
2 Allergic Contact dermatitis
itching. It is said that in atopic
3 infective dermatitis
4 Photo-allergic Contact dermatitis dermatitis, it is "an itch that rashes
5 Eczematous polymorphic light rather than a rash that itches". This
is a chronic fluctuating condition.
eruption
6 Eczematous dermatophytosis
1 Infantile Eczema (Infantile Atopic
7 Dermatophytide
Dermatitis):
Age of onset is between 2 and 6
months in majority of cases. Onset
Endogenous (Interior)
before 2 months is exceptional
1 Atopic
because coordinated scratching
2 Asteatotic (Xerotic)
does not occur before this time.
3 Nummular
Gravitational
Pompholyx
Eczema accounts for a very large
proportion of all skin diseases. Out of
100 patients with skin diseases, 20
to 30 suffer from one or other form
of eczema.
4
5
Endogenous Eczemas
The term endogenous eczema
implies that the cause or origin of the
eczematous condition is not due to
external environmental factors but
mediated by processes originating
within the body.
The most important example is
‘Atopic dermatitis’.
site; scalp, neck, forehead, wrist and
extremities may be involved.
Moist type is very common. In dry
type, there is an excessive dryness
and xerosis that predisposes to
eczematization. Popliteal (and or of
relating to the back part of the leg
behind the knee joint) and fossae are
commonly involved (antecubital area
of the right arm).
Exacerbations are observed after
vaccination, teething, respiratory
infections and emotional upsets.
Food may sometimes play role in
early infantile eczema. Common
offending substances are egg white,
wheat, milk and orange. Less than
half the cases clear up by the age of
1 El months and in remainder the
pattern changes into that of the
childhood phase.
2
Childhood eczema:
Classic locations are the antecubital
and popliteal spaces, the wrists,
eyelids, face and neck. The constant
feature is pruritus leading to
scratching of skin which in turn
results in thickening and lichenifica
tion of skin. The condition is less
acute and less exudative but more
chronic and more dry type. There is
an increase in sensitization to wool,
cat's hair, dog’s hair and pollens.
3
Adult phase:
The picture is essentially similar to
•that in later childhood with severe
itching and lichenification especially
of the flexures (anatomical turn, bend
or fold) and hands. Housewives with
hand eczema are frequently atopic
individuals. Itching usually occurs in
paroxysms and is typically absent in
between emotional upsets. Sweat
retention makes it worse. A
characteristic psychosomatic rela
tionship is present in many atopies.
HEALTH ACTION AUGUST 1989 • 13
COVER STORY
ALLERGIES
The other triggering factors may be
skin dryness, wool irritation, clothing
and perhaps food. Atopic dermatitis
becomes less severe as the patient
grows older and is rare after middle
age.
usually on lower part of legs and the
patients are commonly middle aged
or elderly females. The eczema is
usually accompanied by varicose
veins, oedema, purpura, (patches of
purplish discoloration) hyperpigmen
tation and ulcers.
Points to remember for diagnosis:
1 History of severe itching followed Exogenous eczemas
by appearance of dermatitis in
preferred locations, family history of
asthma, hay fever or eczema.
Contact Dermatitis:
Generally there are. two types of
2 Asteatotic eczema/Xerotic eczema/ dermatitis caused by substances
Winter itch:
coming in contact with the skin.
Seen typically in elderly in winter. 1 Irritant dermatitis is due to a nonMost frequently it occurs on the allergic inflammatory reaction of the
extremities, especially on the shins skin resulting from exposure to an
of elderly. Here, the skin is irritating substance. This may be the
dehydrated and shows redness, dry result of an acute toxic insult to the
scaling and fine crackling.
skin, as with accidental exposure to
3 Nummular eczema/Discoid eczema: acids, alkalis etc, or due to repeated
It is characterised by a single, non and cumulative damage from more
specific morphological feature, the marginal irritants, both physical and
coin shaped or discoid configuration chemical. No previous exposure is
of plaques of eczema.
necessary.
Sites preferred are dorsa (upper
surface) of hands, extensor surfaces
of extremities, buttocks, breasts and
nipples. Changes of acute as well as
chronic eczema are seen. Pruritis is
usually severe and of paroxysmal
compulsive quality. Emotional stress
is usually present.
4
Gravitational eczema
This occurs secondary to venous
hypertension and an increased
perfusion of tissues. The eczema
develops suddenly or insidiously,
14 • HEALTH ACTION AUGUST 1989
Occupations with a high risk of
cumulative irritant dermatitis are
housework, catering, cleaning, nurs
ing, building construction, hair
dressing, gardening and horticulture,
engineering, motor mechanics.
2
Allergic contact dermatitis:
It is due to allergic sensitization to
various substances that produces
inflammatory reaction in those and
only those, who have acquired
hypersensitivity to the allergens as a
result of previous exposure to it. It
results from a specific acquired
hypersensitivity of the delayed type
which is also known . as ‘Cellmediated-immunity’. Persons map,
be exposed to allergens for yeare<finally developing hypersensitivity.
Occasionally dermatitis may be
induced upon a sensitised area of
skin when the allergen is taken
internally,
eg.
Antihistammics,
sulfonamide.
Common Irritants:
Frequent Sensitizers:
Alkalis such as soaps, detergents,
bleaches, ammonia preparations,
drain pipe cleaners, toilet cleansers.
acids like
Chlorine, Iodine, Bromine,
Fluorine
Insecticide dust and gases, hydro
carbons.
Parophenylenediamine, hair dye,
rubber,
Photodeveloper,
Nickel
(Coins, Keys, artificial Jewellery,
wrist watch, earrings). In fact, we are
constantly exposed to nickel and
nickel dermatitis is a frequent
occurrence, especially among women
due to presence of nickel in clothing
accessories (hooks, snaps). Rubber
compounds — eg. Rubber gloves,
girdles, garters, panties, diapers,'
sheets, condoms, elastics, boots.
□ichromates — in cement, dyes,
paints, shoe leather. Mercury
bichloride present in mercurial
remedies eg., mercurochrome and
ammoniated mercury. Mercapto
benzothiazole present in rubber
products. Terpentine Oil present in
paints, thinners, waxes, varnishes,
formaldehyde solution used in
preparing fabrics.
Pretty Dry
A visitor to New Mexico
was talking on a sun-browned
native, and commented on the
lack of rain. ‘Doesn’t it ever
rain here?’he asked. The
native thought a moment and
said, ‘Mister, do you
remember the story of Noah
and the Ark, and how it rained
forty days and forty nights?
‘Sure I do,’said the tourist.
'Well', drawled the native, 'we
got a half inch that time'.
Other Sensitizers:
Plants, trees, grasses, flowers,
vegetables like onion, garlic and fruits
like citrous fruits, weeds, etc.
Textile and clothing — Dyes and
finishes of fabrics cause dermatitis.
Dermatitis is seen in areas of
sweating and friction.
COVER STORY
Shoe dermatitis — dichromate rub
ber, dyes.
Metals like Cobalt (It is combined
with nickel as a contaminant)
Arsenic (present in dyes).
Cosmetics:
— Antiperspirants and deodorants.
— Hair dyes, bleaches, sprays,
depilatories.
— Nail Polish, Nailpolish remover
— Lipsticks
— Eye make ups
— Sunscreens
— Depigmentmg creams
— Mouth Washes and dentrifrices
Perfumes
Applied medicaments — Penicillin,
Streptomycin
— Sulphonamides, Neomycin, Furacin, Mercurial Compound
— Antihistamine cream
— Local anaesthetic
— Vehicles like lanolin
— Preservatives like panbens/ethyl
enediamine.
ALLERGIES
basal portion of epidermis and even
Topical Therapy — Principles
the dermis of subcutaneous tissues,
may be easily accessible to
Agent
Acute Subacute Chronic
substances applied to the surface.
Lower parts of legs in older persons
1 Wet dressings
++
± .
—
are susceptible to allergic contact
2 Creams, lotions
+
±
dermatitis due to age related
—
+
++
structural changes in skin. A 3 Paste
chemical that has been shown to 4 Emollients
—
±
+
have a low sensitising index on
5 Corticosteroids
—
++
+
hundreds of normal skins may show a
—
+
++
higher incidence when used on 6 Tar, ichthammol
patients with acute dermatitis.
7 Polythelene
The failure to recognize irritant or
occlusion
—
+
++
sensitization reactions from applied
8 Intralesional
—
±
++
medication is an extremely common
++
+
+
error in the management of 9 Sedation, rest
dermatitis.
10 Psychotherapy
+
±
++
Management of eczema
11 Rehabilitation
—
±
+
Accurate diagnosis and full
assessment of aetiological factors
are of prime importance. Properly
excellent. It is antiseptic also. Just
elicited history helps a lot in
1 to 2 crystals in a bowl of warm
diagnosis.
water may be sufficient. Its major
advantage is that it is cheap but it
History:
causes staining and sometimes
1 Household remedies modify clini
irritation.
cal features.
2 Use of over-the-counter medici — Aqueous cream and zinc cream
Factors affecting eczema:
are soothing and valuable.
nal products containing salicylic
In any dermatitis that persists for
acid in high concentration. Vigo — Moderate potency steroid, steroid
2 or 3 weeks, certain secondary
rous rubbing of such medica
+ antibacterial combination (in
factors become operative. They are:
ments leads to chronic dermatitis.
non-greasy base). Avoid ointments
1 Itching:
which have greasy base. Oral
3 Occupation in detail.
The effects of excoriation and other
sedative/hypnotic agent may be
means used to relieve itching are 4 Hobbies such as painting, garden
given if needed.
ing, etc.
important in all types of dermatitis
—
Extensive eczema may require
5
History
of
atopic
tendency
is
very
and these may vary from simple
treatment with systemic steroid/
important.
rubbing of skin to extreme trauma
anti-bacteria I/a ntihistammic
produced in many ways. In addition to
Avoid contact with known
agents.
mechanical injury, dermatitis is
irritant/ sensitizer.
Subacute eczema — If acute
frequently subjected to the irritant
□ rug therapy:
eczema fails to clear in'3-4 weeks,
and sensitizing effects of topical
Systemic —
carefully seek for perpetuating
medication and hot water.
Steroids,
factors, like exposure to sensitizer.
2 Secondary Infection:
Antibiotics
— Intolerance to treatment.
In an area of skin affected by
Antihistaminics
— Inadequate or improper treat
persistant dermatitis, normal bacte
ment.
rial flora is displaced by coagulase
Topical —
positive S aureus, betahemolytic
— Use of domestic remedies instead
Plain Steroid
streptococci, pseudomonas and
of proper treatment.
Combination
other bacteria. Fungal infection is
— Continuous severe itching after
others.
common, as are viral diseases such
starting treatment may be due to
as herpes simplex.
continuous emotional stress.
Principles
of
treatment:
3 Secondary Contact Dermatitis from
In
such cases of subacute eczema,
Acute eczema
applied medication:
local application of Cream/oint+
Topical
application
should
be
During an attack of acute dermatitis,
ment/ paste/lchthamol/tar/salicybland, i.e. without medication.
the skin is highly vulnerable. The
lic acid'may help.
+
Wet
dressing
in
the
form
of
Pot
stratum corneum which acts as
assium Permanganate Soaks is
protective barrier is lost and the
See page 97
HEALTH ACTION AUGUST 1989 • 15
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COVER STORY
ALLERGIES !
Bronchial Asthma
Dr Sandhya Nanjundiah Chest Physician
^Bronchial asthma is a common
disease, and causes considerable
suffering. It is estimated that
between 2 to 5 percent of the
population suffers from asthma. In
_zjr country, social stigma is
Wtached to the diagnosis of asthma,
and asthma tends to get under
diagnosed. Other terms like allergic
bronchitis, wheezy bronchitis, allergic
bronchospasm etc are used by
clinicians as an acceptable substi
tute for asthma. When diagnosed
promptly and treated optimally,
asthma is a manageable disorder.
What is asthma?
The essential feature of asthma is
episodic difficulty in breathing,
generally associated with wheezing
and cough. The main defect in
■asthma is episodes of narrowing of
the airways which causes the
symptoms. The airways in an
asthmatic are very irritable and go
into spasm at the slightest
.^stimulation,
be it mechanical,
chemical or otherwise. These stimuli
cause airway norrowing through the
nervous mechanism as well as by
liberation of chemicals called media
tors. Histamine, serotonin, leucotrienes and other chemicals are
powerful agents capable of causing
spasm of the smooth muscle in the
bronchioles. Other factors which
cause narrowing of the bronchi and
bronchioles are oedema (swelling) of
the mucous membranes as well as
the accumulation of the bronchial
secretions in the interior of the
airways.
Clinical features of asthma:
Most commonly, patients with
asthma complain of breathlessness,
cough, wheezing and chest tightness
as well as choking. Cough is usual and
moderate amounts of sputum are
produced. The sputum is thick and
sticky, and if yellow, suggests
bacterial infection. The symptoms of
asthma are worse at night, and
physical exertion worsens it. Broadly
speaking asthma can be seasonal,
restricted to certain months of the
year, or perennial. In the former type,
allergic factors due to seasonal
pollens and molds etc can be
suspected. In allergic subjects, other
features of allergy like nasal
symptoms (rhinitis), skin lesions and
eye manifestations can be present.
Examination of the patient while he
is well may not reveal any signs. In
mild asthma, signs of airway
narrowing in the form of rhonchi (high
sounds due to air movement in
bronchi) may be heard. During acute
attacks of asthma, the patient is in
distress, with marked difficulty in
breathing, wheezing sounds and
excessive contraction of the neck
and abdominal muscles. The pulse
rate increases, along with the blood
pressure.
Objective measurement of the
degree of airways obstruction can be
made with a spirometer, which
measures the volume of air exhaled
as well as the flow rate. A simpler
device called the peak flow meter is
often used to quickly assess the
degree of severity of asthma.
Severe asthma is associated with
reduction in blood levels of oxygen
and may be life threatening, unless
promptly treated. Such cases need
hospitalisation
Treatment of asthma:
The treatment of asthma is
generally with three classes of drugs:
1) Theophyllin 2) Beta agonists, and
3) Corticosteroids.
1. Theophyllin: Theophyllin prepara
tions are widely used in both chronic
asthma and in acute exacerbations.
Theophyllin acts by relaxation of the
airway smooth muscle as well as by
reducing the fatigue of respiratory
muscles. In acute situations it is
used intravenously, while in more
HEALTH ACTION AUGUST 1909 • 17
MU
COVER STORY
ALLERGIES
stable and chronic asthma oral
preparations are employed. Oral
preparations are available as short
as well as long acting ones and the
dosage has to be individualised. In
centres where serum theophylhn
level can be assessed, a level of
between 10 and 20 microgrammes
per ml has been established to be the
safe range.
2) Beta agonists: A variety of beta
stimulant drugs are available. They
act by causing stimulation of smooth
muscle receptors which in turn leads
to relaxation of the airway narrowing.
Mucus clearance is also facilitated.
These drugs are available in oral,
injectable as well as aerosol forms.
Salbutamol, terbutaline and orciprenaline are some of the beta agonists
in common use. These can be used
along with theophyllin as synergistic
combinations.
What happens in the Air passages during
Asthma
SMOOTH MUSCH CtU W TH I W»U Of UO HUtfUt AWO MSMWM Of HlKVf I HOUKS O* STIMULATWI
VAGAL
hJERVE
ENDING
CMfLINERGUC
RECEPTOR
RESULTING
CONTRACTION
5l*icfTH
ADRfNE^Gl£
k’GCGPToA
IN
Cz) RNP
RESULTING in
RELAXATION
/xdrgng/?#/^__
N£Av£ GNftiNC, U
1 GUANOSINE MONOPHOSPHATE 2 ADENOSINE MONOPHOSPHATE
Beta agonists are increasingly
being used in the inhaled form in
asthma. There are advantages in this
method, in that only very small doses
have to be used and as the drug is
directly delivered in the airways, no
side effects occur. Beta agonists
can also be administered by
nebulisers in addition to the metered
dose devices.
3. Corticosteroids: These are potent
agents which are very useful in
asthma. They act by reducing the
inflammation in the airways and by
other means. Steroids are valuable
and lifesaving in acute severe
asthma. In chronic asthma, the long
term use of steroids is associated
with many systemic side effects like
18 • HEALTH ACTION AUGUST 1989
Each Air passage, whether small
or large has got an innermost layer of
cells called "Mucosa". Surrounding
this there is a layer of loose
connective tissue. The outer most
layer consists of circular, smooth
muscle fibres. These smooth muscle
fibres are innervated by two different
types of nerve endings called 'VAGAL
and ADRENERGIC types which have
opposing types of effect on
stimulation. See Fig.
The 'VAGUS' nerve on stimulation
stimulates a particular type of
receptor on the smooth muscle cells
called 'CHOLINERGIC RECEPTOR'.
This produces a raise in the cellular
level of 'GUANOSINE MONOPHOS
PHATE' (GMP) resulting in contrac
tion of that cell. This contraction in
turn reduces the inside diameter and
produces narrowing of the air
passage.
The opposite • takes place on
stimulation of the 'ADRENERGIC
NERVE ENDING'. The corresponding
'ADRENERGIC RECEPTOR' when
stimulated increases the level of
cylie 'ADENOSING MONOPHOS
PHATE’ (AMP). But unlike GMP when
the level of cychc-AMP increases the
smooth muscle relaxes and the
inside diameter of air passage also
increases.
Apart from this action of the
nerve-endings on the smooth
muscles, there are other immunolo
gical mechanisms that also operate
on triggering off an asthmatic attack.
A number of chemical mediators
released from a sensitised cell called
'Mast' Cells bring about a number of
changes on the lining "Mucosal" cells
of the air passages. There is swelling
(oedema) and inflammation of the-'/
lining mucous membrane. There is an
increase in the permeability of the
blood vessels on the wall of the air
passages. This increased vascular
permeability of the vessels leads to
the leakage of inflammatory blood
cells. These Cellular debris and
mucus secreted together clog the
already narrowed air passages. This
reduces the ventilating capacity of
the lungs. So, pure oxygen does not
enter the blood from the air
passages and carbon dioxide in the
blood does not get cleared. The
patient feels suffocated and the
muscles of the chest wall have to
make extra effort to tide over the
obstruction.
COVER STORY
ALLERGIES
acts by minimising the release of
chemical mediators and has to be
used on a regular basis as a
prophylactic medication. It has no
role in acute episodes of asthma.
This drug is particularly of use in
young asthmatics to prevent
exercise-induced asthma, which
interferes with physical activities.
Another newer addition to the
asthma therapeutics is inhaled
Ipratromium bromide (not yet
available 'in India), which acts by
atropine-like action.
Hyposensitisation:
Allergy
Normal Bronchus
is
a
A Cross-Section of a Normal and Constricted
Bronchial Tube
high blood pressure, peptic ulcers,
diabetes and weight gain. A
significant development in steroid
use in asthma has been the principle
of low dose alternate day regimen
which allows many steroid dependant
asthmatics to be managed with
minimal side effects. Another
landmark has been the introdution of
inhaled steroids (Beclomethasone
dipropionate,
Flunisolide
and
Budesonide) which act topically and
can be used for long periods with
hardly any side effects.
Parents please note:
recurrent wheezing recognised as
asthma.
Seventy five percent of asthmatic
children will have their first attack
before four to five years of age (pre
school age group).
Problematic children who will be
affected severely, will hpve three
Twenty percent of all children will
wheeze at one time or the other
during early childhood. Do not get
worried as it may be an isolated
episode. Please don’t label this child
as an asthmatic.
Only 5°/o of children will have
desensitisation
4. Other drugs: Disodium cromogly
cate is another drug which has found
a place in chronic asthma. This drug
procedure in which gradually increas
ing doses of allergens are injected
over a period of time, to induce
tolerance in the individual. This works
in allergic asthma to some extent,
and is more indicated in a small
number of allergens which cause
allergic rhinitis.
factors such as:
® A family history of asthma
• Starting to wheez before the first
birthday
® Other allergic manifestations
such as allergic skin disorder
(Atopic dermatitis), Allergic rhini
tis etc.
HEALTH ACTION AUGUST 1989• 19
COVER STORY
ALLERGIES
Preventive Aspects of Asthma
Some factors in the precipitation
of Asthma
Measures taken to minimize dust
in the atmosphere help. Asthmatics
should avoid dusty trades or
1 Environmental:Co\d air and changes
in climate can trigger off asthmatic occupations which contain one or
more substances that may potentia
attacks. Fumes, dust, dust mite,
pollens, danders [minute scales from lly aggravate asthma. Even the
feathers or animal skin that may rooms must be maintained dust free
cause allergy) precipitates asthma in by measures such as:
subjects who have increased — Daily wet mopping or vacuuming
etc
antibody, IgE. Sudden increase in
atmosphere pollution and tobacco — Minimize the use of carpets and
stuffed
furniture
and
wall
smoke could also worsen asthma.
hangings.
2 Heredity: It is known that subjects
with strong family history of allergy — If they are so precious.clean them
and asthma are more likely to suffer
periodically without fail
from asthma than persons with no — Rooms should be well ventilated
such family history.
— It is better for asthmatics to avoid
3 Psychological factors: Emotional
pets and fur coats
upsets are important precipitators — Walls should be cleaned to
of wheezing in many children. Studies
minimize fungal growth
have shown that suggestion techni
ques can induce resistance of the — Children should be discouraged
from going to storerooms and
airways.
attics which are usually dusty
4 Endocrine factors; Increased level of
Thyroid Hormone (Thyrotoxic causes) — Asthmatics should avoid tobacco
smoking and should not encourage
increases the severity of asthma.
others to smoke in their presence
Perimenstrua!
exacerbation
of
Physiotherapy and breathing exer
asthma in the premenopausal period
cises are helpful. Swimming is a
is observed.
5 l//ruses;This is the most important recommended exercise for wheeinfectious provocator of asthma. zers. Steam inhalation and postural
drainage of sputum helps clear the
Viral agents are foundair passages.
o to stimulate the receptors of
Avoidance of stressful situations
Vagus Nerve in the airways.
and emotional support to the person
• impairs the response of the
will allay many attacks. Behavioural
system to Beta adrenergic hor
problems Of the child must be taken
mones and histamines.
care of by experts. Psycho-social
Respiratory Syncitial Virus (RSV) evaluation of the patient helps the
and Parainfluenza viruses remain physician to give adequate support
attackers on infants whereas on to the family members.
older children Rhinoviruses are the
main culprits (25°/o asthmatics).
Influenza A Virus and Enteroviruses
are also isolated less often.
Dangerous Dan Microbe
6 Exercise: Physical exertion is a well
A bunch of germs were
known factor in the cause of asthma
hitting it up in the bronchia/
and exercise testing has an
saloon; two bugs in the edge
established place in the assessment
of the larynx were jazzing a
of asthmatics. Exercise induced
ragtime tune. Back in the
asthma worsens by
teeth, in a solo game, sat
o cold
dangerous Ack-kerchoo; and
• mouth breathing
watching his pulse was his
7 Aspirin: Intolerance to aspirin
light of love, the lady whd's
manifests as asthma more often in
known as Flu.
adults than in children.
20 • HEALTH ACTION AUGUST 1989
Classification of
Childhood Asthmatics
McNicol & Williams in their study
among Melbourne School children
graded asthmatic children into four
categories (Paediatric Clinics of
North America 1975 — Paediatric
Allergy)
Grade A: Subclinical Asthma:
Children who started wheezing
after the age of three and stopped
before eight. Total attacks less than
five.
Grade B: Mild to moderate episodic
asthma:
Asthmatic attacks for four to fiveyears with three to four attacks peJJ1
year and the illness going into
spontaneous remission by the age of
ten or twelve. It is characterised by
the absence of airway obstruction in
between attacks.
Seventy five percent of the total
asthmatic children seen belong to
Grade A & B.
Grade C: Moderately severe asthma:
Onset before two years, attacks
are generally severe and prolonged.
Many have persistent airway
obstruction
between
attacks.
Asthma continues even after
fourteen years into later life.
Grade D: Severe Asthma:
About only 3°/o of the total
asthmatic children belong to this
class. Even within a period of three >
months they can have as many as
ten attacks. Episodes are severe and
prolonged. Remission seldom lasts
for more than a few weeks.
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Catholic Hospitals who are interes
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this Project may contact:
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CREST
14 High Street
Bangalore 560 005
Tel: 577 547
COVER STORY
ALLERGIES
Allergy and the Eye
Dr Ram S Mir lay DOMS MS Consulting Ophthalmologist
\A/
e have all seen people rubbing
their eyes which look watery and red.
Such eyes, accompanied by itching,
occur in many diseases of the eye.
One of the common conditions is
Allergic conjunctivitis. This is called
■^/ernal Catarrh, Spring Catarrh and
also by other less common names.
Allergic conjunctivitis has a
tendency to occur more often ih the
spring and summer. It however, does
occur in other seasons also, and
cases can be found throughout the
year. An unusual aspect of this
disease is that children are affected
more often than adults. Generally
both eyes are affected, though not
always, simultaneously.
Eyes become red, start to water
and feel uncomfortable and itchy.
These symptoms occur in a number
of diseases. For instance, seasonal
epidemic viral conjunctivitis presents
similar symptoms, although the
exudate that collects in the corners
of the eye is more abundant in this
condition compared to allergic
conjunctivitis. In allergy, the eye
discharge is watery, and often 'ropy'
strands of mucus may appear.
How do doctors diagnose allergy of
the eye? Examination of the eye,
detailed history of the patient, and
confirmation of the diagnosis by a
few simple tests forms the basis of
diagnosis. Generally, it is easy to
recognise allergic conjunctivitis. The
eye is pink in colour, often in certain
regions of the sclera (the white of the
eye). The conjunctival membrane
looks velvety and raised. Sometimes
this swelling gives rise to a
'cobblestone' appearance. Some
times there is severe itching. The
eyes are rubbed frequently, a habit
that unfortunately adversely affects
the eye. Another point that is
eyebrow
upper eyelid
eye lashes
conjunctiva
cornea
optic nerve
iris
lens
lower eyelid
retina
characteristic is that the eyelashes
are not stuck together, unlike in
other conditions. Allergic conjunctivi
tis often occurs along with other
'allergic markers’ such as rhinitis
urticaria, or bronchial asthma.
The basis of allergy of the eye is
becoming more clearly understood in
recent years. Certain particles in the
atmosphere such as pollens, dust,
fungal spores etc are capable of
causing allergic reaction in the eye.
These, called allergens, evoke a
specific immune reaction and cause
allergic conjunctivitis.
A clinical aspect which is notable in
cases of ocular allergy is that when
the patient moves to an area free of
the offending allergens, he feels
better; this aspect can be elicited by
careful history-taking. Likewise,
when the subject returns to the area
of original residence, the symptoms
promptly reccur.
After the diagnosis of allergy is
suspected on clinical grounds, it can
be confirmed by examination of the
secretions from the eye as well as
conjunctival scrapings for cells called
eosinophils; these cells are found in
abundance in tissues wherein allergic
reactions are occurring. The pre
sence of allergy to a particular
allergen can be established by allergy
testing. In this test, a small amount
of dilute solution of the allergen is
placed on the skin and the skin
pricked with a fine needle; a wheal
(temporary red or pale raised area of
the skin) at the site of test denotes
allergy. Occasionally, a dilute solution
of the allergen can be directly
instilled into the eye and the reaction
noted. These tests help in arriving at
the cause of the airborne allergy.
After adequate diagnosis, treat
ment of allergic conjunctivitis is
usually with medications instilled into
the eye; these drops are intended to
reduce the severity of the allergic
reaction. Two types of drops are in
common use. Steroid eye drops and
ointments are very effective in
controlling the symptoms of allergy.
But long term use of these drops can
be associated with serious side
effects. Two of the side effects of
importance are Glaucoma (increase
in the tension of the eyeball leading to
blindness if unchecked) and forma
tion of lens opacity or cataract. The
latter impairs vision and may need
surgical removal. Hence it is very
important to use the steroid
HEALTH ACTION AUGUST 1939 • 21
COVER STORY
ALLERGIES
medications with great caution and
only under the strict supervision of
the treating doctor.
Another medication is Disodium
cromoglycate, which is a medication
which has no side effects. It also
reduces the intensity of the allergic
reaction in the eye, and can be used
on a long term basis. The use of oral
antihistamine tablets and syrups can
be helpful in alleviating the suffering
of the patient by reducing itching.
The symptomatic therapies noted
above are able to keep the disease
under control and the patient
comfortable. But they are not
curative. In recent years, immuno
therapy or desensitisation has been
used in cases of eye allergy. In this
therapy, the most important aller
gens are detected by careful allergy
testing. A vaccine is prepared from
the allergens and the patient
receives this vaccine in gradually
increasing doses over a protracted
period of time. The body makes
prescribed, and totally avoiding selfmedication goes a long way in
reducing chances of side effects
caused by medications.
Conjunctival allergy is the com
monest form of allergy of the eye.
However, other tissues of the eye
Are there any precautions one can like choroid (a vascular membrane
take to avoid allergic conjunctivitis? containing large branched pigment
There are some methods by which cells that lies between the retina and
we can reduce the suffering caused the sclera of the eye), sclera and
by it.
even the. retina can be affected by
1 Wearing of protective goggles various forms of allergy and immune
while outdoors and travelling minimi disorders.
ses the exposure of the eyes to
Medical research progresses to
offending particles. This is more find ways and means of combating
important in the case of two-wheeler ocular allergy and in the near future,
riders.
one can hope for treatments which, A
2 Minimising dust at home by would be safe and effective. V
frequent vacuuming, wet-mopping Meanwhile it is important to treat
etc will reduce the density of dust these conditions with caution and
and consequently the allergy.
meticulous attention. Use of syste
3 Avoidance of rubbing of the eyes mic and topical medications combiwill be of great help in reducing the . ned with immunotherapy can afford
chances of damage to the cornea.
much needed relief to sufferers of
4 Use of medications only as ocular allergy.
antibodies to the allergens and the
subject feels better due to the
reduction of the allergy. The effects
of the therapy are longer lasting and
the patient has to use less doses of
oral and eye medications.
For the first time in India
Training Courses
Health Care without
Doctors and Drugs
at
Adhyatma Sadhana Kendra
November 2-8, 1989 New Delhi 110 030
August 11 - 18, 1989
Course Content
Yoga, Meditation, Herbal Kitchen Gardens and
Solar Therapy.
Course Fee — Rs. 300 (includes board & lodge
(for Students and Unemployed Rs. 200)
Contact:
JOINT ASSISTANCE CENTRE
4-65, South Extn. 1, New Delhi-110 049
22 • HEALTH ACTION AUGUST 1989
Troubles
I’ve got a heap of troubles,
and I've got to work them out.
But I look around and see
there's troubles all about. And
when / see my troubles, /just
look up and grin, and count all
the troubles that I ain't in.
No easy
There is so much good in
the worst of us, and so much
bad in the best of us, that it’s
hard to tell which one of us
ought to reform the rest of
us.
— Jenkin Lloyd Jones
The only thing that hurts
more than paying an income
tax is not having to pay an
income tax.
Lord Thomas R Dowar
COVER STORY
ALLERGIES
Allergy in E.N.T.
Dr Kevin Pereira MBBS DLO MS
“T
I he vaccinated person behaves
in a different manner from him who
has not previously been in contact
with such an agent. Yet he is
insensitive to it. His power to react
has undergone a change. For this
^concept of changed reactivity I
Wropose the term ALLERGY....” Von
Pisquet 1906.
Allergy is the specifically altered
state of the host after contact with a
specific allergen. This contact with hypersensitive to a greater number
the allergen can have the clinical of allergens than those of late onset.
consequences of immunity, which
The major immunoglobulin class
protects from tissue
damage,
responsible for the anaphylactic
hypersensitivity which is tissue
reactions in man is IgE which is
damaging, or of both in the same
produced in large amounts by allergic
host.
individuals when exposed to common
The allergic manifestations in the allergens. IgE attaches firmly to the
field of Ear, Nose and Throat cell membranes, thus sensitizing the
diseases may be nasal, otological or cell. Union of allergens with IgE in its
bronchial. The nasal conditions are cell bound state triggers a series of
common.
events which result in mast cell
Nasal:
degranulation and the consequent
Rhinitis is clinically identified by the symptoms.
symptoms of sneezing, running nose Pre-disposing factors:
f and blocked nasal airway. If there is
The airway of subjects with allergic
evidence of a tissue damaging rhinitis is seen often to be
allergic hypersensitivity process as hyperreactive to a series of non
the cause of symptoms, the rhinitis specific stimuli which include room
may be called as allergic. Features air temperature, humidity and
typical of a patient with symptoms pollution. Cold air inhalation stimu
arising from allergic hypersensitivity lates nasal glands and reduces nasal
are
a a history of symptoms after
exposure to a particular sub
stance or season.
b a family history of such hyper
sensitiveness, and
c skin prick test positive for one or
more of the common allergens.
The age of onset symptoms can be
a guide to the degree of atopy. The
proportion of positive skin prick tests
is greater in those developing
symptoms later. An individual with an
earlier age of onset tends to be
The Sinuses
patency. Low indoor humidity and
dust regularly provoke the hyper
reactive airway of the allergic
individual as will smoke, fumes and
irritant smells.
Allergic reactions in the nose will
not increase the frequency of viral
infection such as common cold and
influenza as is often thought, but
marked nasal obstruction will alter
the course of the infection and lead
to a sustained purulentThinosinusitis.
Psychological factors have been
thought to play a part in allergic
subjects and may act as predispos
ing factors or exciting factors, or
may be brought on by the long and
incapacitating nature of the condi
tion.
Seasonal allergic rhinitis:
Allergy to pollens of grasses,
flowers, trees and shrubs: It affects
the nasal mucous membrane and
also the pharyngeal, conjuctival and
bronchial mucous membranes.
It usually commences during the
first half of life. About 10°/o of the
population suffer from hay fever.
□cular and nasal symptoms are
closely related and after a few years
the picture is further complicated by
HEALTH ACTION AUGUST 1989 • S3
has taken up the cause of the Child.
We have launched an Unique, Massive 'Rights of the Child Campaign’ (RCC)
™
★ to create an awareness among the people that children have certain rights and that we have the responsibility to
ensure that children are given those rights:
★ to move the nation to eleminate child labour in our country and in cases where this is impossible, to protect their
rights to a fair wage, proper working hours, better working conditions and a minimum education;
* to prevail upon our Governments to recognise the plight of today's children and have political will to change their
tears into smiles.
★ Children are the flowers of our future.
★ They are the best investment the nation can make.
★ They are the citizens of tomorrow, dreamers, planners, decision-makers and achievers.
★ Children cannot be healthy unle'ss they are given all their rights.
* Their rights will ensure that they grow into totally healthy individuals — physically, mentally, socially and spiritually.
★ Give them a gift today — help to create a better world for the children.
The draft convention of the Rights of the Child says:
“All Children, without any exception whatsoever shall be entitled to these Rights, without distinction or )i
discrimination....
— Every child has the Right from birth to a name and nationality..
— That he may have a happy childhood..
— The Right to adequate pre-natal and post-natal care..
— The Right to adequate nutrition..
— The Right to parental affection, love and understanding..
— The Right to an education..
— The Right to adequate medical care..
— The Right to special care for the child who is handicapped..
— The Right to learn to be a useful member of society..
— The Right to be among the first to receive relief in times of disaster..
— The Right to develop abilities..
— The Right to enjoy full opportunity for play and recreation.
The Campaign has four phases:
1
A signature campaign — children will seek from the Government the implementation of their Rights. Signatures
from all school and college going children will be put together and presented to the President and the Prime
Minister of India for their perusal and necessary action.
What you can do:
a sponsor the paper required for the signature and the printing costs.
b organise schools and colleges to participate in the signature campaign
c Mobilise political will to work for the rights of the child.
2
Essay writing, painting, elocution and photography contests on the subject of the plight of the child will be
conducted for school and college students both at the State and National levels.
What you can do:
co
a Sponsor prizes for the various contests
w
b finance the administrative expenditure of this massive project
c organise these contests at the various states levels.
3
A Health Action Run for the Rights of the Child will be conducted in the Twin Cities of Hyderabad and
Secunderabad to mark the adoption of the Charter of the Rights of the Child, the Birth Centenary of Chacha
Nehru and to awaken and motivate the haves to work for the children who have-not.
What you can do:
a Give us your suggestions and active involvement
b finance and/or generate advertisements for the run
4
A special issue on Child Health will be brought out for the Health Action in November highlighting various aspects
of child health in India today. The print order for this issue is one lakh copies.
What you can do:
a Help get as many advertisements for the special issue — the tariff is Rs. 1 □,□□□/- for a full color page.
Join us m this our campaign. Your contributions will be of immense help to us — we need your time, your ideas, your
■■ j involvement and your active support and finance — each idea, each action, each rupee counts I Come work with us to
ensure a better tomorrow for our children, the hope of the Nation.
For details contact:
i
I
The National Co-ordinators
Health Action's Rights of the Child Campaign
157/6 Staff Road Gun Rock Enclave (PB No 2153) Secunderabad 500 003 AP
Phone: 848457 848293 841610
All contributions may be sent by Cheque/DD/MO favouring “HEALTH ACTION'S RCC" to the address above.
COVER STORY
ALLERGIES
the development of bronchial
symptoms (pollen asthma). For this
population of allergic individuals the
risk of developing asthma is
increased two to three fold. When
the allergic subject is exposed to the
appropriate pollen the symptoms of
nasal irritation and itching, recurrent
attacks of paroxysmal sneezing,
nasal obstruction and copious
rhinorrhoea occur. There is also
intense conjuctival irritation and a
sensation of itching in the palate and
pharynx. The eyes may become red
and swollen. The nasal mucous
membrane is congested and varies in
colour from exceeding pallor to dull
red.
Perennial allergic rhinitis:
The causes of allergy are house
dust, mite sheddings and moulds.
Food allergens which are often not
discovered are important. The
common ones are cow's milk,
protein, eggs, fermented drinks, and
citrus fruits. The diagnosis of
perennial allergic rhinitis is made by
inference when it is found in an atopic
individual.
Management:
In all cases of allergic rhinitis a
careful history must be taken which
should include an enquiry about diet,
pets, fumes and dust at home and at
work, cosmetics and soap powders,
seasonal influence or association of
specific locality, family history of
rhinitis, hay fever, asthma or eczema.
The assessment of the severity of
26 • HEALTH ACTION AUGUST 1989
symptoms is crucial to the
management. When examining the
nose, the colour of the mucosa,
presence or absence of ethmoidal
polypi, antro-choanal polypi, septal
deviations, pus or hypertrophic
mucous membrane should be noted.
Tests — Radiological examination
of the sinuses will reveal any
thickening of mucosa or the
presence of polypi. Marked sinus
opacity or fluid levels signify infection
and call for antral puncture.
the soluble allergen extracts in
varying concentrations so that
immunity is stimulated. These
courses are prolonged but have given
good results when known allergens
are used.
Drugs:
Antihistamines block the cellular
histamine receptors and act as
pharmacological histamine antago
nists. They are very useful in
controlling sneezing and rhinorrhoea.
But they usually cause drowsiness in
doses which are required to control
Specific tests for allergy:
Nasal secretion — there may be severe allergy.
8O-9O°/o eosinophils in the secre
Antihistamines are often used in
tions of allergic individuals.
association with oral decongestants
such are ephidrine, pseudoephidrin.,)
Blood tests:
If the nose is the only organ and phenyl propanolamine. The
affected by allergy, the peripheral combination is justified as synerblood eosinophil count will be normal. gisms has been demonstrated
Serum IgE concentrations can be between antihistamine (pharma
measured. High levels are associa cological histamine antagonist) and a
ted with multiple positive skin tests, sympathomimetic compound (physiolo
but again individual cases of allergic gical histamine antagonist). Also
rhinitis may have levels within normal sympathomimetic compounds counter
act the drowsiness produced by
limits.
antihistamines.
Skin tests:
Sodium cromoglycate stabilizes
The skin is raised with a sharp
sterile needle dipped in solutions of mast cells and blocks degranulation
the allergen. The skin shall not be after antigen-antibody union. It can
prepared with spirit beforehand. control both seasonal and perennial
Common allergens used are house allergic rhinitis? It is-commonly used
dust, mite dander, Aspergillus as a nasal spray or as drops or as a
fumigatus, etc. The reaction of the powder for insufflation. Topical and
individual is measured by the systemic steroids are useful in
severe nasal allergy. Often a topical
immediate positive wheal and flare.
Nasal, provocation tests — The steroid is used eg. betamethasone
nasal mucosa is exposed to the dipropionate. But when the symp
allergen and the reaction of the toms are distressing in certain
mucous membrane is assessed as instances for example a student
regards to its appearance, dischar appearing for examinations, syste
mic steroids are justifiable. The drug
ge, sneezing and obstruction.
is administered by a standard
The radioallergosorbent test —
metered aerosol which delivers
This is a sensitive in vitro method for
50 mg of beclomethasone per puff.
estimating IgE antibodies to parti
Many years experience of beclo
cular allergens.
methasone has shown it to be free of
Treatment:
side effects both clinically or on nasal
Allergic Rhinitis may be managed biopsy with the exception of
by (a) avoidance (b) hyposensitization occasional mild nasal bleeding. At
and (c) drugs.
least two-thirds of patients with
Avoidance means avoiding a known perennial allergic rhinitis will benefit
allergen eg feather, dust, detergents, from treatment. Beclomethasone
etc.
dipropionate does not act imme
diately and must be used regularly
Hyposensitization:
It helps people with seasonal throughout the day to achieve 24,
allergy. They are given injections of hours relief of symptoms.E
COVER STORY
From page 11
the child is harbouring any parasites
and to treat it accordingly.
Antihistamines are usually the most
useful therapeutic agents (agents to
reduce the itching in urticarial
disorders). These can be given in the
form of tablets or syrups. A little
extra sedation is one worrying
From page 15
Continue treatment until healing is
complete. Warn the patient about
extreme vulnerability of skin for few
^veeks.
After discontinuation of treat
ment, keep the patient under
supervision until physical and
emotional rehabilitation is complete.
ALLERGIES
problem parents face on giving
antihistamines. If allergic reaction is
so severe Adrenaline injection is very
effective and often life saving.
Corticosteroids are sometimes
used in the more chronic form, but
are prescribed for more refractory
cases. Cortcosteroids if used
without controlling the primary
cause such as bacterial infection of
the skin or tooth, will only prolong the
itching. Very often parents insist on
some topical applications, but they
are not very effective except for a
soothing effect eg: Calamine lotion.
The first episode of urticaria can
be very upsetting and frightening for
both the child as well as the parent
and a basic knowledge about them is
essential to face this problem more
composedly.
■
Chronic Eczema:
Exclude
underlying,
systemic
disease.
Intralesional injections of steroids
are not required, due to availability of
potent steroids &. efficacy of
occlusive dressing. Skillful psycho
logical handling of the patient is of
vital importance. To prevent recur
rence, prophylactic use of emollients
& psychotherapy are important.
Secondary factors are of greater
importance.
— Effects of rubbing;
— Secondary infection;
— Sensitization to applied medica
tion may dominate clinical picture;
— Persistent eczema may lead to
loss of employment & severe
anxiety.
Unique Opportunity for Christian Service
in a Rural Eye Hospital
Applications are invited for the post of Medical Superintendent of Bamdah Christian Hospital,
Bihar (25 miles from Baidyanath, Deoghar).
The Hospital is primarily an Eye Hospital to which 3,000 to 4,000 patients come every winter for
surgical and medical treatment of eye conditions, the most common being cataract. In the summer
months, off season, the hospital provides, within limits, general medical services to the surrounding
rural population.
A qualification and /or good practical experience in Ophthalmology is essential. A post could
also be available for a suitably qualified wife, medical, nursing, or paramedical. Starting salary for a
doctor with not less than Rs. 2,500/- per month plus an administrative responsibility allowance of
Rs. 300/- per month. There would also be generous education allowances for up to three children of
school age. Annual leave would be two months, with further periods for study leave from time to time
in the off season. This could be used to gain further experience in other hospitals.
Funds are available for the development of the hospital, purchase of new instruments and
equipment, and for Community Health projects.
Attractive living quarters are provided.
The Hospital has provided an ophthalmic service to a wide area of Central Bihar for over ninety
years, and now looks for the doctor with initiative and enterprise who will take up the challenge of
ensuring its future. Suitably qualified and interested candidates should not be deterred from
applying, if they are not immediately free. The date of joining duty is negotiable in 1989/1990.
Please write, including biodata, to:-
Dr Bryan E L Thompson
St. Luke's Hospital
P.O. HIRANPUR 816 104
Dist. Sahebganj, Bihar
HEALTH ACTION AUGUST 19B9 • 27
‘The primary role of the medical profession
in 'Health for all by 2000 AD’ is gradually
becoming more and more significant.ln order to
be effective, a synthesis of traditional medical
knowledge and application of modern methods
of medical management is essential.
JAMA India has been making significant contri
butions in this direction.
It is expected that the professional contents
of JAMA ■ India alongwith the Indian perspectives,
will make significant advances towards taskoriented training and continuing education of the
members of the medical professionals in India’.’
Dr. Indra Bhargava
M.S..D Sc . M.SC..FAM.S.. F IAP
Deputy Director General of Health Services,
Government of India. Hew Delhi.
JAMA
The Journal of the American Medical Association : India
Delhi Office:
JAMA-India
Bombay Office
JAMA-India
Jain Medical centre,
Jaslok Hospital and Research Centre,
A-39, N.D.S.E.-II, New Delhi-110 049 (5th Floor),
Tel. No. : 6440726, 6440928,
15, Peddar Road, Bombay 400 026.
6448878
Tel.. No. : 4937079
Telex
: 31-71315 JAIN IN
Telex
: 011-75743 J ASH IN
Hyderabad Office
JAMA-India
5-9-8/2A, Nowbat Pahad,
Opp. Reserve Bank,
Saifabad, Hyderabad 500 004
Tel. No. : 240165
Telex
: 0425-6444
Madras Office
JAMA-India
Apollo Hospitals, 7, Bishop Gardens,
R.A Puram, Madras 600 028
Tel. No.
Telex
: 838359, 837358
; 041-21059 FOEP IN
HEALTH NEWS
The white spot prejudice
IDr CH Rajasekhar
Features:
"It has been stated that the biggest
problems in the world are very tiny —
tthe atom, ovum and the touch of
pigment".
Sitting in the clinic I come across a
omber of curious questions:
loctor,
• I am having a white spot for the
last 6 months, gradually increas
ing in size, I feel I am not perceiving
normal sensation over it. Could it
be leprosy?
• My boy is having many white spots
over back and chest, are they
dangerous?
® My father is suffering from
leprosy, will I get the disease?
To answer all these questions, we
must have an understanding of the
normal physiology of pigmentation
and the diseases which affect
pigmentation.
S
LWhat is the normal skin color due to?
It is due to the amount of pigment
called 'melanin' present in the skin,
the pigment being produced by cells
called melanocytes. The number of
melanocytes is the same in all races.
TThe difference in the colour of the
skin is due to variations in the
amount and distribution of pigment in
the skin.
IWhat produces white spots?
White spots are due to a decrease
or absence of the pigment forming
cells or an abnormality in the
synthesis and dispersal of the
pigment in the skin.
Conditions producing white spots:
II At birth: Albinism, phenylketonuria,
naevi;
2 Childhood: Pityriasisalba;
3
• The infective types account for
only 20°/o of the cases and are
seen in persons of lowered
immunity. The non-infective form
constituting 8O°/o of Leprosy
patients is seen in persons with
fairly good immunity.
early leprosy;
Adults: Leprosy;
versicolor;
vitiligo;
vitiligo;
Tinea
Why should we know about them?
• Patients presenting with white
spots is relatively a common
problem encouraged
in
the
society.
• Their early detection helps to
prevent grave complications. For
instance, the gross deformities
seen in leprosy can be completely
averted if diagnosed early.
o An infectious type if treated early
can prevent its spread in the
society.
o It becomes the duty of a doctor to
alleviate/remove the misconcep
tions & prejudice against white
spots.
The cardinal features are:
• White spots with partial or
complete loss of sensation, the
earliest being loss of thermal
sensation.
• Thickened nerves, usually at the
elbow, knee or behind ear.
o Sometimes there is loss of hair in
the white spot.
Non-infective
The number of spots is few
ranging from 1-10.
2 Thickening of nerves is early.
3 Deformities are frequently seen.
1
Infective
1
★ What is Leprosy?
It is a chronic disease caused by a
bacterium called Mycobacterium
leprae.
Magnitude of the problem:
— About one-third of the world
cases of leprosy are found in India
numbering about 4 million. About
half of these cases are concentra
ted in the two southern states of
Tamilnadu and Andhra Pradesh.
— Another perview of it being
considered a major problem is the
social stigma attached to it.
Transmission:
Leprosy is probably transmitted
from its only source, man by
dispersal of the bacteria from the
nose or mouth of an infectious case
or by prolonged skin to skin contact.
Heredity:
The misconception that leprosy
runs in families, from parents to
children is totally baseless. Parents
suffering with leprosy beget normal
healthy children.
Types:
• Infective and non-infective.
Spots are numerous. Nodules
are frequently seen.
2 Thickening of face, earlobes and
loss of eye brows may be seen.
3 Loss of sensation over hands and
feet may be present bilaterally.
Does Leprosy lead to complications?
YES
o Leprosy may produce a number of
deformities if not diagnosed early
& treated. They may be due to
nerve damage — clawhand, wrist
drop; Foot drop lagophthalmos.
or
loss of sensation — ulcers on
hands £. feet leading to repeated
loss of fingers and toes trauma.
o Infective form of leprosy in some
cases may produce damage to
nerves, eye, bones, testes &
kidney.
How to diagnose leprosy?
Leprosy can be easily diagnosed.
1
By clinical examination:
— by studying the morphology of
lesions
— by testing for loss of pain
sensation with a prick of a
HEALTH ACTION AUGUST 1989 • 29
HEALTH NEVUS
The white spot prejudice
Dr CH Rajasekhar
• The infective types account for
only 20% of the cases and are
seen in persons of lowered
immunity. The non-infective form
constituting SO°/o of Leprosy
patients is seen in persons with
fairly good immunity.
Features:
"It has been stated that the biggest
problems in the world are very tiny —
the atom, ovum and the touch of
pigment".
Sitting in the clinic I come across a
^umber of curious questions:
^Doctor,
• I am having a white spot for the
last 6 months, gradually increas
ing in size, I feel I am not perceiving
normal sensation over it. Could it
be leprosy?
• My boy is having many white spots
over back and chest, are they
dangerous?
• My father is suffering from
leprosy, will I get the disease?
To answer all these questions, we
must have an understanding of the
normal physiology of pigmentation
and the diseases which affect
pigmentation.
What is the normal skin color due to?
It is due to the amount of pigment
called 'melanin' present in the skin,
the pigment being produced by cells
called melanocytes. The number of
melanocytes is the same in all races.
The difference in the colour of the
skin is due to variations in the
amount and distribution of pigment in
the skin.
What produces white spots?
White spots are due to a decrease
or absence of the pigment forming
cells or an abnormality in the
synthesis and dispersal of the
pigment in the skin.
Conditions producing white spots:
1 At birth: Albinism, phenylketonuria,
naevi;
2 Childhood: Pityriasisalba;
early leprosy;
Leprosy;
versicolor;
3 Adults:
vitiligo;
vitiligo;
Tinea
Why should we know about them?
• Patients presenting with white
spots is relatively a common
problem encouraged in the
society.
• Their early detection helps to
prevent grave complications. For
instance, the gross deformities
seen in leprosy can be completely
averted if diagnosed early.
• An infectious type if treated early
can prevent its spread in the
society.
• It becomes the duty of a doctor to
alleviate/remove the misconcep
tions & prejudice against white
spots.
★ What is Leprosy?
It is a chronic disease caused by a
bacterium called Mycobacterium
leprae.
Magnitude of the problem:
— About one-third of the world
cases of leprosy are found in India
numbering about 4 million. About
half of these cases are concentra
ted in the two southern states of
Tamilnadu and Andhra Pradesh.
— Another perview of it being
considered a major problem is the
social stigma attached to it.
Transmission:
Leprosy is probably transmitted
from its only source, man by
dispersal of the bacteria from the
nose or mouth of an infectious case
or by prolonged skin to skin contact.
Heredity:
The misconception that leprosy
runs in families, from parents to
children is totally baseless. Parents
suffering with leprosy beget normal
healthy children.
Types:
• Infective and non-infective.
The cardinal features are:
• White spots with partial or
complete loss of sensation, the
earliest being loss of thermal
sensation.
• Thickened nerves, usually at the
elbow, knee or behind ear.
• Sometimes there is loss of hair in
the white spot.
Non-infective
1 The number of spots is few
ranging from 1-10.
2 Thickening of nerves is early.
3 Deformities are frequently seen.
Infective
1 Spots are numerous. Nodules
are frequently seen.
2 Thickening of face, earlobes and
loss of eye brows may be seen.
3 Loss of sensation over hands and
feet may be present bilaterally.
Does Leprosy lead to complications?
YES
® Leprosy may produce a number of
deformities if not diagnosed early
& treated. They may be due to
nerve damage — clawhand, wrist
drop; Foot drop lagophthalmos.
or
loss of sensation — ulcers on
hands S. feet leading to repeated
loss of fingers and toes trauma.
• Infective form of leprosy in some
cases may produce damage to
nerves, eye, bones, testes 8.
kidney.
How to diagnose leprosy?
Leprosy can be easily diagnosed.
1
By clinical examination:
— by studying the morphology of
lesions
— by testing for loss of pain
sensation with a prick of a
HEALTH ACTION AUGUST 1989 • 39
I HEALTH NEWS
needle, that of temperature by
hot 8. cold water & that of
touch by a wisp of cotton.
— by looking for thickened nerves.
Is Vitiligo curable?
2
By Skin smear examination
■k Other conditions producing White
3
By Lepromin test
spots:
Confirmation of the diagnosis is by
skin biopsy.
Yes. Vitiligo is curable and
effective drugs extracted from plants
called psoralem are available.
Pityriasis alba:
Very common in children, it is often
confused with early leprosy or Vitiligo
Leprosy is 1OO°/o curable. Today causing parental anxiety. White
highly effective and less expensive spots are usually found on the face.
drugs are available to achieve a They are harmless and gradually
complete cure. An infectious patient disappear with age.
is made non-infectious within a Tinea Versicolor:
It is an infection caused by a
period of few weeks by applying the
multidrug regimen. The drugs fungus called Pityrosporum orbicuprimarily used are Dapsone, Rifampi lare. The white spots are typically
cin, and Clofazamine. These drugs found on upper back and chest. It is
need to be taken for a period of 6 completely curable by drugs like
months to 1 year for the noninfective type &. for 2 years in the
infective type of leprosy.
Treatment:
sulfur, selenium sulfide, salicylic acid
and other drugs.
Conclusion:
A white spot found on your body
should not be a matter of mental
agony but a condition for prompt
action.
Consult your doctor as and when
you notice
• a white spot with alteration of
sensation or without;
• loss of eye brows or eye lashes;
• lossof sensation of hands and feet
with or without swelling;
• Any deformities of hands and feet
appearing suddenly;
Let us commit ourselves to control tfy
eradicate leprosy from our country. ■
* Vitiligo:
Another most common cause of
white spots is vitiligo. The problem
lies in
1 it being confused with leprosy (in
some areas it is known as "white
leprosy’’);
2 the popular belief that the disease
in incurable, which is baseless;
3 its cosmetically disfiguring nature;
What is Vitiligo?
It is a hereditary, acquired disease
due to localised loss of pigment cells,
they being destroyed by an unknown
mechanism. It is a benign condition
with no serious underlying disorder.
The problem:
It is seen in 1°/o of the population
and affects all races.
Heredity:
Vitiligo is a familial condition; about
3O°/o of the patients give a history of
another member in the family
suffering from it.
Features:
Vitiligo is characterised by chalky
white spots which may be seen
anywhere on the body. There is no
alteration of sensation. Whitening of
the hair in the lesion may be seen.
The number of spots vary from few
to many.
Rarely it may be associated with
diabetes or thyroid disorders.
30 • HEALTH ACTION AUGUST 198S
CHOPAM - III
CHAI announces the third Community Health
Organization, Planning & Management Course
to be held from October 10 - 25th, 1989
Those eligible
Middle level workers with decision making powers as:
Programme Planners, Supervisors, Trainers
Aims & Objectives
To equip personnel with concepts and skills for innovative
community health and development programme.
To develop skills for scientific management of community
health and development programmes.
To promote effective training skills for
training grass root level leaders.
Language
English
Venue
Aquinas College
(Vincentian Philosophate)
Gopalpur-on-Sea
Ganjam Dt. ORISSA 761 002
For details, prospectus and application forms please contact:
Programme Director
Community Health Department
Catholic Hospital Association of India
PB 2126, Secunderabad-500 003. A.P.
PRIORITY PROBLEM
• The resistance developed by the
No I killer malaria parasite —
Plasmodium falciparum — to
antimalana drugs, and especially to
chloroquine which is widely used
around the world. Resistance is the
response of malaria parasites to the
growing use of anti-malaria drugs in
doses insufficient to eliminate them.
Resistance to chloroquine was first
recorded in 1957, and it has now
been detected in some malana areas
in more than 50 countries.
• The implementation of large
development projects in agriculture,
^Global eradication: the unrealistic goal
industry and mining, along with the
In November 1987, the people of passing on of malaria by attacking building of the associated infrastruc
the IndianOcean island of Madagas
car were expecting the rams that
mark the beginning of the wet
season. But they were not prepared
for what came with the rains: a
malaria epidemic that, by the end of
the season in April 1988, claimed
1 □□,□□□ lives.
After almost 20 years of absence
— due to the eradication campaign
by the then French colonial
administration between 1950 and
1970 — malaria mosquitoes
returned to breed in the irrigation
channels of the paddy fields in the
highlands of Madagascar. Then the
insects bit people who had lost
tolerance to a disease that had not
affected them for a generation.
Although the extent of the killer
epidemic in Madagascar appears to
have been exceptional, many areas of
Africa, Asia and Latin America have
been facing the resurgence of
previously controlled diseases like
malaria.
Significant progress was achieved
in several malaria areas of the
developing world — especially in Latin
America and some parts of Asia —
during the 1950s and 1960s. It was
thought malaria could be eradicated.
At that time, the strategy of the
World Health Organization (WHO)
was -two-pronged: first, halt the
infected mosquitoes with residual ture like hydroelectric dams. These
insecticides: and second, destroy projects have created enormous
malaria parasites in human blood ecological changes that promote the
streams through treatment with growth of germ-carrying mosquitoes
through increasing their contact
anti-malaria drugs.
Financial, technical and logistical with people.
Areas which were malaria-free are
resources provided by the multi
lateral and bilateral agencies helped now threatened with re-infestation
to set up the needed infrastructure. due to the rapid movement of both
As a result in most nations of Latin carrier insects and infected people
America, for example, deaths from from endemic to non-mfected areas.
malaria practically disappeared by • Massive migrations of people in
1970.
search of land and work, which is
But the achievements did not last related to the above. In Brazil, for
long. The goal of eradication proved example, along the Trans-Amazon
to be unrealistic. There have been highway — an agricultural colonisa
tion project aimed at resettling some
several reasons for this:
• Once the bilateral and/or multi 1 million families — as many as a
lateral organisations helping with quarter of the settlers have been
malaria eradication withdrew from incapacitated by malaria year after
the scene, local governments either year.
Similarly, migration of rural people
could not afford the follow-up needed
to consolidate the results already to cities has led to the random
attained, or they had different settlement of marginal groups in
precarious housing in areas without
priorities.
• The wide and indiscriminate use of paved roads, sewage or garbage
chemical pesticides in agriculture * collection. Poor sanitation contri
which has led to carriers of malaria butes to the increase in mosquitoes
becoming genetically resistant to in suburban areas.
insecticides. Currently, many species • The lack of financial resources to
that carry malaria parasites are invest in health, sanitation and
resistant to more than one education, all of which are vital to
insecticide, including chlorinates, keeping malaria under control.
organophosphates and some carba
This situation has been worsened
mates.
by the financial constraints imposed
HEALTH ACTION AUGUST 1989 • 31
PRIORITY PROBLEM
by the external debt crisis in all
developing countries. Programmes
of structural adjustment usually
demand heavy cuts in social
expenditure — which means the sort
of service described above.
The combination of these econo
mic, environmental, socio-cultural
and technical factors proved that it
was unrealistic to believe that
malaria was being eradicated.
Instead, malaria is on the increase
again — and it is being found not only
in known areas but also in zones that
were previously disease-free.
According to WHO’s latest
estimates, there are 100 million
clinical cases of malaria in the world
each year, 80 million of which occur
in Africa (World Health Statistics
Quarterly, 40, 1987). At the turn of
this century, the number of cases
was 250 million throughout the
world.
But statistical analysis by Swiss
scientist O.Sturchler suggests that
a realistic estimate for 1986 is 489
million clinical cases — including 234
million due to Plasmodium falciparum,
of whom at least 2.3 million would
have died (Parasitology Today, Vol 5.
No 2,1989).
Despite the differences, by
WHO's own account, “malaria
remains a major public health
problem and continues to be an
obstacle to development.”
from Panoscope
Health for All
Health is the most precious birth-right,
Owned by every living person on this earth,
This adage health for all, and all for health,
From and for everyone it must be felt.
Expectant parents, Ante-natal visits you must make,
Be ready for health and other responsibilities to take,
Ante-natal mothers you care for the health of two,
Balance diet and nourishment for the foetus and you,
Mothers, you have already began your task,
Breast-feeding, immunization, health education you ask,
Infants, todlers, school children growing day by day
Child welfare clinics lead children in a healthy way.
Teenagers, Youth, adults, are in the prime of life,
Care for yourselves in minor ailments and strife,
32 • HEALTH ACTION AUGUST 1989
Prevention of occupational hazards in your role,
Promotion of health in work places is your goal.
Geriatric people good health is your very own,
You are weak, weary, lonely unsteady and worn,
You must eat good food, and must take good rest,
Visits to primary health clinics will be the best.
Politicians, a very important role you play,
Provision of basic needs and health facilities need today.
You may be young or you may be old,
For health cannot be bought or sold,
So it is up to us to work heart and soul,
And by 2000 A.D. we must reach our goal.
by Mary Rozario RN RM
Madras
ALTERNATIVE MEDICINE
Most people think that Medita
tion is sort of a religious activity,
involving some attempt to control
the mind and it is intended only for
religious or mystic people. But now it
is being increasingly recognised by
modern physiologists, psychologists
and sociologists that meditation
should become a part of our daily life
to protect us from the stress. The
intense, active mode of life that we
lead puts a lot of pressure on us.
Stress has become a major
inescapable problem in the present
society since it is a part of our daily
life. Today man is being subjected to a
far greater mental stress and strain
than anytime before in history. Our
technical and economic progress
has created a life-style with which
the individual finds it difficult to keep
pace. Stress and strain is the penalty
which he pays for being civilised.
Stress acts like a slow poison and
when prolonged, can cause serious
physiological and psychological dis
orders, the so called Psychosomatic
diseases. These psychosomatic dis
orders are increasing in the present
society.
Before knowing how meditation
protects from the stress, let us try
to understand what stress is:
Stress can be physical, emotional or
mental. Stress is a demanding situation
on the human physiology.
catecholamine (any of various
substances that function as harmoStress are of two types—One is
nes or neurotransmitters or both)
physical stress like accidents, burns,
secretions
of the adrenal medula i.e.
major surgeries etc. which make
more demands on the entire Adrenaline and Noradrenaline prepa
physiology. The other is psychological res the organism for fight or flight.
stress which is on the rise in the The strength, regularity and the rate
present society, like fear, anxiety, of the heart beat speeds up, spleen
tension, worry, jealousy, anger, contracts, liver releases glucose,
hatred, emotional upsets, over blood supply is directed from skin and
viscera to the brain and muscles,
excitement.
pupils dilate, bronchi dilate, digestion
There are many causes of stress.
stops, the arteries constrict and
Failure to adapt, failures in daily.life,
cause an increase in blood pressure.
changes in the life pattern, death of a
Thus the whole body is prepared
dearest one or changes in work or
against stress. The body exhausts if
residence, noisy environment, disrup
remains for long in the above
tion in the circadian rhythm (internal
situation. After release from stress
rhythm of biological process which
ful
condition,
para-sympathetic
follows a cycle of 24 hours) are some
nervous system in combination with
of the important causes. In the
the harmones of the adrenal cortex
modern society with a fast life-style
restores the normal balance of the
there are hundreds of situations
body by lowering the blood pressure,
which produce stress. Some indivi
heart rate and directing the blood to
duals are easily susceptible to stress
skin etc. If stressful situations are
than others. These people show a
severe and prolonged and if they
high pulse rate, high respiratory rate,
become a continuous feature, the
increased systolic blood pressure,
body's adaptation mechanism fails,
increased metabolic rate etc.
the body is exhausted. The effects of
A certain degree of stress is a part stress depends upon the intensity of
of our daily living and our body adopts the demand made upon adaptive
well to the situation of stress. When capacity of the body. The changes
exposed to a stressful situation, the brought by the body mechanism
body tries to minimise it or eliminate cope with stress such as increase in
it completely by means of a number heart beat, blood pressure etc. and
of systematic physiological or cause disruption of normal working
psychological responses. In times of of the body which may cause
stress, the sympathetic nervous diseases.
HEALTH ACTION AUGUST 1989 • 33
ALTERNATIVE MEDICINE
The resulting physical diseases
are essential hypertension, coronary
heart disease, diabetes mellitus,
bronchial asthma, migraine head
ache, peptic ulcer, insomnia, back
ache, skin diseases like psoriases
(chronic skin disease chracterised by
circumscribed red patches covered
with white scalds) and even
malignancy. Mental illnesses such as
anxiety neurosis, hysterical neurosis,
phobias, depression, psychoses,
schizophrenia, inability to concen
trate and make oecision etc. can
occur. At the social level, the
pathology resulting from stress is
alcoholism, smoking, addiction to
drugs which are psychomimetic and
hallucinogenic such as mescaline,
opium, lysergic acid diethlamids
(LSD) etc. maladaptive delinquency,
white-collar crime, mental illness and
lastly suicides.
There are many coping methods
which people employ to reduce
stress. The Chinese were famous for
smoking opium: Siberians used to
chew the Sacred mushrooms; Arabs
used to inhale hashish. Now-a-days
tranquilizers such as valium, librium,
anti-depressants, drugs like mari
juana, opiates etc.alcohol and
smoking are employed to cope with
stress. These coping techniques are
inadequate and bring only temporary
relief and the negative aspect is
people become addicted and depen
dent on them. The side-effects of
these techniques are well known to
everyone.
The more positive and ameliorative
techniques to cope with stress are
relaxation, bio feed back, meditation
and behaviour therapy. The best
method as proved- by scientific
investigations is meditation. It
provides relaxation of mind and body.
The method of relaxation is based on
the premise that there is a
correlation between muscle tension
and emotional stress, and from this
premise arose the supposition that if
muscle tension could be relieved,
mental relaxation could be attained.
So the person is advised to relax
various muscle groups in the head,
neck, knees, legs, chest, arms, and so
on throughout the body. This type of
34 • HEALTH ACTION AUGUST 1989
release of tension, if properly
practised has a beneficial effect.
However, by meditation we can learn
to control our entire personality by
which a more effective and lasting
means of removing tension can be
obtained.
Biofeed back is the recent
approach to the control of stress
related conditions. This method
needs many sophisticated instru
ments which are not within the reach
of every one at present. But the
instruments don’t change the
subject, they provide information
about his body functions allowing him
to exercise voluntary control of
functions. By meditation the whole
personality changes. The change
comes from within the subject
himself. But even behaviour therapy
is not within the reach of every one at
present.
Meditation is a process of growth,
a growth of our total living out of our
total living. It is a total flowering of
our personality. Spiritually medita
tion has a higher place. Buddhism,
Zorastnanism, Sufism, Islamic mys
tics, Christian monks, Yogs, all give
importance to meditation. According
to Swami Vivekananda, "Meditation
is the HIGHEST STATE. IT is a
spiritual unfoldment leading to self
knowledge."
Meditation can be defined as a
practice or method by which the
activity of conscious mind ceases
and the mind enters into pure
consciousness. It is a technique by
which the wayward destructive mind
can be diverted into planned,
constructive channels. When the
mind has been trained to remain fixed
on a certain internal or external
location, then it aquires the power of
flowering in an unbroken current
towards that point. This state is
called Meditation. Meditation relie
ves ail types of physical, physiological
and psychological stress and gives a
deep relaxation which can be
experience within a few days or
after weeks of practice. Meditation
has been proved to cure psychoso
matic disorders which are on the rise
in the world.
Many scientists have investigated
meditation in various aspects of
today’s life. Around a thousand
researches have been conducted in
this field.
Dr Kasamatsu, a
neurophysiologist of Japan in 1957
and Dr. Sugi and Akutsu, Japanese
physiologists in 1968, carried out
research on Zen Meditation. Dr S
Anand, Chhiva, Baldev Singh from All
India Institute of Medical Sciences of
New Delhi in 1961 did research on
Yogic Meditation. Dr Robert Keith
Wallace, at University of California,
Dr Herbert Benson at Harward
Medical School in 1970, Dr JeanPaul Banquiet a Neuro Physiologist
from U.S.A, in 1972 are some of the
Scientists who have done valuable,, >,
research on Transcendental medi- '
tation.
Now let us see the physiological
changes produced by meditation
which provide a deep relaxation.
When we are in a state of
wakefulness, the oxygen consump
tion, metabolic rate, cardiac output,
etc. are within a range according to
the activity. Electroencephalogram
(EEG) shows a low voltage mixed
frequency and/or alpha activity, and
a moment of tension or an attempt
to solve a mental problem may
disrupt it.
When we are sleeping, metabolic
rate decreases, oxygen consumption
decreases by about 1O-15°/o,
cardiac output decreases by about
2O°/o. During deep sleep the heart
rate, respiratory rate and blood
pressure falls to the lowest level of
the circadian rhythm.
During
Meditation significant
changes occur in the above
mentioned things which indicate a
deep level of relaxation of mind and
body. During meditation, the oxygen
consumption decreases by 2O°/o
within a few minutes after the onset
of meditation, thereby resulting in a
decrease in metabolic rate. Cardiac
output decreases significantly with a
mean decrease of about 25°/o. The
heart rate shows a mean decrease
of about 5 beats per minute. The
respiratory rate decreases with a
mean decrease of 3 breaths per
minute. Respiration becomes slow
and shallow. The blood pressure
ALTERNATIVE MEDICINE
tends to decrease with intermediate
fluctuations. Electromyogram (EMG)
indicates a deep relaxation of
muscles. The sympathetic nervous
system is relaxed, with lower levels
of the stress hormones adrenaline
and noradrenaline. Electroence
phalogram (EEG) shows an increase
in alpha wave activity (usually 8-9
cycles per second) that occurs in the
central and frontal regions. Some
times rhythmical Theta-wave activity
(5-7 cps) that occurs in the central
and frontal regions. Sometimes
rhythmical Theta-wave activity (5-7 cases of anxiety, wherein sweating
cps) appears in the frontal regions. occurs. Because of moisture, the
Neurologist Dr Jean Paul Banquiet resistance decreases, and the
jjpund that the brain wave patterns current passes more easily. A high
tend to synchronize during deep level of GSR increases by about
transcendental meditation. He obser 5O°/o. In meditation it has been found
ved synchronuous Beta waves of an out that there is an increase of
almost constant frequency and 500°/o in GSR after only 10 minutes.
amplitude from all points on the
All these findings suggest that
scalp. According to him, the Meditation produces a wakeful
frequency of this highly ordered hypometabolic, physiologic state of
pattern indicates inner wakefulness deep relaxation. Dr. Robert Keith
and may represent the underlying wallace, President, Maharishi Inter
physiology of the reported experi national University, proposes this
ence of profound wakefulness or state as a fourth major state of
pure consciouness.
consciousness.
An important finding is blood
Investigations
conducted
on
lactate concentration. Lactate is patients practising meditation show
produced by anaerobic metabolism in improvement in a wide variety of
muscle tissue and the level of blood physical and mental disorders. They
lactate is a biochemical index of include Hypertension, Angina Pecto
stress. A high level of blood lactate ris, Bronchial Asthma, Chronic
during stress is seen, in anxiety Bronchitis, Diabetes Mellitus, Menor
1 neurosis. The levels decrease when a rhagia, (abnormally profuse mens
person is at rest or asleep. In trual flow) Allergies, dyspepsia,
meditation the blood lactate concen (indigestion) Insomnia, Depression,
tration was found to decrease at an Epilepsy, Anxiety neurosis, Obsessive
average of 33°/o and the rate of compulsive neurosis, Chronic head
decline was more than three times aches etc. Studies continue to show
faster than the normal rest. A that regular practice of meditation
decrease in Glucose metabolism in reduces or completely eliminates the
Red Blood corpuscles (R.B.C's) is use of both prescription drugs such
found.
as amphtamines, barbiturates, tran
The State of relaxation is quilizers, anti-anginal and anti
measured by the Galvanic skin hypertensives and non prescription
resistance test (GSR). GSR is mainly drugs such as marijuana, opiates,
used in lie-detector test. GSR is a hallucinogens etc. and also alcohol
measure of the resistance of the skin and cigarettes. Studies conducted
to a mild electrical current flowing on pregnant woman practising
between two electrodes usually on meditation show fewer medical
the palm of the hand. When the complaints during pregnancy, less
person is relaxed the skin is dry and pain and anxiety during pregnancy
the current passes relatively slowly and child birth, shorter duration of
as the resistance to its flow is high. labour, lower frequency of instru
mental intervention during labour,
greater frequency and longer
duration Of breast feeding.
Psychologically, practising medita
tion shows an increase in mental and
emotional balance, decreased anxi
ety, reduced depression and neuroti
cism, increased self confidence,
increased learning ability, speed in
solving problems accurately, orderli
ness in thinking and integration of
personality.
To learn meditation, there are
various schools of meditation like
Zen Meditation
of Buddhism,
Patanjali’s Yogic Meditation, Maha
rishi Mahesh Yogi’s Transcendental
Meditation, Vipasyana meditation
etc. which teach Meditation. These
various schools of meditation differ
mainly on one or two technical
aspects of Meditation, but all give
importance to spiritual side of
meditation, that is self realisation or
Nirvana.
Therapeutically speaking, one can
learn any type of Meditation, but
after consulting his doctor and only
under an expert's supervision.
REFERENCES:
1
Mental tension and its cure — Dr OP Jaggi
2
Neurophysiology of Enlightenment —
presented by Dr Robert Keith Wallace at
26th INTERNATIONAL CONGRESS OF
PHYSIOLOGICAL SCIENCES NEW DELHI.
OCTOBER 22nd. 1974.
3
Scientific Research on Transcedental
Meditation collected papers, Vol 1 eds
David W Orme Johnson, Lawrence H.
Domash and John T Farrow (Los Angles,
USA. MIU Press)
4
Paths of Meditation (Ramakrishna Math
Publication)
5
The complete works of Swami Vivekananda (Ramakrishna Math Publication).
6
Concentration and Meditation — Swami
Sivananda.
Wanted
R male doctor in General Medicine,
MI3BS interested to serve in a rural
General Hospital uuith 40 beds.
For further details contact:
The Administrator
St. Joseph's Hospital
Palakurichy, Trichy Dt.
Tamil Nadu 621 308
HEALTH ACTION AUGUST 1989 • 35
IWW
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racks, storage cabinets and seve{al_types*6f trolleys.
^ABHAZj Conveyor, ratchet and timed model dishwashers, cooking
ranges, ovens, tilting frying pans, deep fat fryers, jacketep^essels fpr steam
tgs puffers.
cooking, service counters, hot cases, bain maries. chOpnr'rH''' A’®*
salamanders.-various refrigeration equipmenTthcli^Itlg
oilers-god
different types of trolleys.
f
II
We offer layout design for some ofithack
hospitals such as CSSD, TSSU, Operation Theatres. (aund
Our after-sales service is prompt arid effi<
Nat Steel Equipment Pvt. Ltd.
(incorporating: National Steel Equipment Co.)
G D. Ambekar Marg. Dadar. BOMBAY-400014
Branches
’ Bombay ' Calcutta ’ Madras ’ New Delhi
’ Bangalore ‘ Secunderabad ’ Trivandrum
HEALTH NEWS
A sip that saves live...! A Report
“She is weak, tired and wants to sleep.
Her eyes look sunken and dry.
She has no tears.
Her tongue is dry. She feels thirsty.
The soft spot on a baby’s head gets
sunken.
Her skin loses its firmness and looks
wrinkled.
If her skin is pinched, it stays folded for
a few seconds.
’
starts panting or breathing fast.
|‘-«he faints or gets convulsions.
She passes little or no urine.
Her stomach gets distended, especially
in a malnourished child —
because there isn't enough water in
ter body. It is diarrhoea which expels
precious water from the body, the
result is — DEHYDRATION! Every
20 seconds, while we are either
working, eating, sleeping or relaxing,
a child dies somewhere in the
country because there is not enough
water in the body.
Why do so many children
die of
approximately 1.5
million every year in India alone I
dehydration? —
Is the cure very expensive and out of the
reach of the poor?
No! The cure is simple, cheap and
fican be made available anywhere,
what we need is the 'will' to let people
know what it is.
UNICEF, Health Action under
Catholic Hospital Association of
India and the Government of AP
decided to take on the overwhelming
responsibility of spreading the
message, the message of Oral
Rehydration Therapy. It was an unique
project indeed, a pioneer effort
launched in the Twin cities of
Hyderabad and Secunderabad on an
experimental basis. The project
spanned a period of about two
months starting from 1 Sth of May
1989 to Sth of July 1989. College
. girls who were having holidays came
forward to set up ORT Corners in the
Twin cities. These girls were given an
intense Two-day Orientation Course
The girls being indoctrinated by Dr PS Murthy, Superintendent, Niloufer Hospital, Hyderabad
during the Orientation Course.
on the causes, symptoms, treatment
and prevention of diarrhoea.
Dr PS Murthy, Superintendent,
Niloufer Hospital, Hyderabad, Dr
Shivalingam, in-charge ORT Corner
at the same hospital and Dr GK
Gupta of St. Theresa's Hospital,
Sanatnagar, took time off their very
busy schedule and imparted basic
knowledge of diarrhoea treatment to
the girls.
About 1 ORT Corners were put
up in Hyderabad and Secunderabad
at vantage points to take the
ORT Corner at Nampally Railway Station, Hyderabad
HEALTH ACTION AUGUST 1S89 • 37
HEALTH NEWS
HEALTH ACTION,
July 1989 Issue —
Community Health
some errors
Guest Editorial Para 5:
'Activities and researches' should read as
'activists and Researchers'
Page 5:
Note on CHC team. Bangalore
'promoted' should read as promotes
ORT Corners at the City Bus-depot. Atzalgum
message to the people. The areas
covered were the Railway stations,
General Post-offices, the two Bus
depots, Airport, Health Museum,
etc. The ORT Corners were made
attractive with the girls spreading
the ORT message, dressed in smart
aprons bearing the ORT ‘Water-islife' symbol. They were also provided
with a can, glasses, oral rehydration
solution packets and pamphlets
These ORT Corners were found to
be very effective. The personal touch
provided by the team helped
immensely in conveying the message
meaningfully. Almost a lakh of people
were enlightened on the frightening
casualities resulting from dehydra
tion and the easy method of tackling
it. We hope these, in turn, will pass on
the message of ORT to as many
others around them.
Page 5:
Box No. 1 neither numbered nor indicated in
the text.
Page 6.
Box No. 3 not indicated in the text.
Page 1O:
Last 2 paras of Box No. 4 not shown in bp<
fashion.
)//
BOLD letters should have been used to start
Alternative Health Project...
Page 11:
Last column, para 1: 'leaving' to 'learning'
Page 13
Box No. 7 'alloted' to 'slotted'
Page 13:
Search and Experimentation.... sub-title not
numbered 'c'
Page 14
Recognition..
numbered ‘d’
resources...
sub-title
not
Box No. 8 should have appeared on page 14.
Box No. 8 para 2: meaning of the starting
sentence changes because of a semi colon
after government. It is 'Government ANM' and
not 'Government; ANM’
Page 15:
'IT last para should have ended with 'and so on'
There is no mention of Box 9 in the text.
Box No. 9 ‘The Mandwa Experience', para 1:
□ne line has been left out 'if they were
contacts of the sputum....' should read as 'if
they were contacts of known cases If
diagnosis ... of the sputum'.
Page 20:
Para 5. 'all these who' to 'all those who'
Page 22:
Negative trends should have haij a bold
heading (central column)
giving in brief all the necessary
information in English, Telugu and
Urdu. These Corners were open
from 1 am to 5 pm and a team of
two girls each demonstrated
preparation of the solution, talked to
people about how to feed diarrhoea
victims, how to monitor the
symptoms, the kind of food that
should be given etc.
38 • HEALTH ACTION AUGUST 1989
We dream and plan for projects in
other areas, aim to cover the entire
population of India, thus eliminate
'Diarrhoea Deaths' from our country
in the very near future. We hope that
no more buds are nipped before they
flower — to give their fragrance and
beauty and serve the humanity.
Yes, we have a dream!
You can help it come true I
Page 24:
Para 1: 'circulation' courses should read as
orientation’ courses
Page 29:
Exploring Jargaon' is CHC’s contribution while
ALMA ATA — Ten Years After' is a separate
HEALTH NEVUS
amounts of the drug can enter the
From our files....
body through milk (eg: if the cow is
given antibiotics or other drugs).
Pill users run risk of
□nee a person develops allergy it is
usually permanent and will develop breast cancer
allergy every time the person is
Young women who take birth
exposed to it or to similar drugs. So it control pills for more than four years
is very important to make a list of run a significantly increased risk of
drugs one is allergic to and show it breast cancer, according to a major
EVERYTIME he consults a doctor.
British study published, Reports AP.
Combination drugs are very
That any drug can produce drug
popular among doctors. But when a
The researchers said that among
allergy?
patient develops a drug allergy it will women younger than 36 they found a
Allergic reactions to drugs be difficult to know which drug has 43°/o increase in the risk of breast
(medicines) are very common these produced the allergy. For eg: a single cancer after four years of pill use and
days due to the increased use of capsule of Spasmo Proxyvon con a 74% increase after eight years.
drugs. In addition self medication is tains the following 4 drugs:
They called on doctors to tell
J^ll rampant.
1 Dicyclomine Hydrochloride
women about the possible risks of
There are various types of drug 2 Dextro Propoxyphene
breast cancer before they prescribe
allergies. Some are harmless and self
Hydrochloride
contraceptive pills, but they did not
limiting. But some are severe enough 3 Acetaminophen
advocate avoiding oral contra
to be fatal inspite of prompt 4 Chlordiazepoxide
ceptives.
treatment..
□nee a drug allergy is diagnosed
The study published in the
Some doctors firmly believe that the suspected drug must be prestigious medical weekly The
certain drugs do not produce allergy stopped. If it is difficult to be certain Lancet, is the most comprehensive
since they have not come across which drug has produced the allergy look at the pill and breast cancer ever
such cases. Though certain drugs and if the patient has taken multiple undertaken in Britain and one of the
produce allergy more often than drugs, all drugs must be stopped.
largest in the world.
others, practically no drug is free
For some drugs,test dose helps to
Ms Clair Chilvers of the Institute
from allergy. Often when a patient know about the possibility of allergy.
of Cancer Research in London, one of
develops an allergic reaction he does But sometimes test dose itself can
the authors of the study advised
not go back to the treating doctor. produce a fatal allergic reaction.
women to use only the lowest dose
Moreover, sometimes the doctor
□nee the drug eruption has pill and that too for the shortest
fails to recognise the drug allergy and completely subsided it may be
possible time.
assumes some other cause for the justified to do a challenge test with a
Earliest studies on the relationship
patient's new complaints. The suspected drug if the type of allergic
r patients should also keep in mind reaction is mild (eg: fixed drug between the pill and breast cancer
that drug allergy is not the doctor’s eruption) and if the suspected drug is have reached conflicting results. In
January, a US Food and Drug
fault unless the doctor administers a likely to be used in future.
Administration committee of ex
drug inspite of the patient informing
Mild drug allergies are treated as perts declared that recent research
about the past allergy.
outpatient. Severe reactions will on possible links between the pill and
It is not always possible to predict need admission to a hospital and
breast cancer was inconclusive.
drug allergy unless the person has powerful medications to suppress
- The Statesman
developed allergic reaction to a the allergy.
certain drug in the past.
Occasionally successful desensi
It is uncommon to develop an tisation can be done and the allergy
allergic reaction to a particular drug can be overcome. This is usually a
when a person is exposed to it for the difficult procedure and is attempted Rheumatology unit of the Nizam’s
Institute of Medical Sciences,
first time. It takes time for the only for special situations.
Hyderabad is conducting a continu
person to develop allergy which can
A person who is allergic to a ous Medical Education Programme
vary from days to many years. In
particular drug can also develop ‘Rheumatology Update’ on 12thinstances of allergy at the first
allergy to yet another drug.
13th of August 1989.
exposure, often the person is
exposed to related chemicals and
For more details contact:
drugs and gets sensitised and By Dr Paul Neelamkavil
Skin
Specialist
develops allergy when exposed to
Dr URK Rao
drugs which have similar chemical Amla Hospital
Organising Secretary
composition. Sometimes minute Trichur-680 553
I
HEALTH ACTION AUGUST 1989 • 39
REFERENCE POINT
Various journals are scanned regularly at
CHAI (Catholic Hospital Association of India)
and articles that are of interest are identified
and documented for the use of all health
conscious people Should you require any of
the articles listed below, please write to:
Documentation Department
CHAI, PB No 2153, Secunderabad.
A nominal charge of 60 ps. per page plus
Postage will be payable.
I
Health Care and Medical Issues
1
AIDS — Whose Priority?
by D Bannerji
Health far the Millions
April 1989 P 9
Should we be tracking AIDS virus
transmission in India
by Jacob John
Health for the Millions
April 1989 P 5-8
Aids and discrimination
by Jonathan M Mann
World Health
April 1989 P 14-15
2
3
4
5
6
7
8
9
10
11
12
Aids — Transmission and Prevention
Health for the Millions
April 1989 P 2-4
Guidelines for Nursing Management of
People Infected with HIV virus
Nursing Journal of India
June 1989 P 151-153
The Limited Reliability of Physical Signs
for Estimating Hemodynamics in chronic
Heart Failure
by L W Stevenson
JAMA — INDIA
May 1989 P 143-147
Journal Scan — August 1989
13
14
Autonomic Dysreflexia, a life threatening
Emergency
by Mary Verghese
Nursing Journal of India
May 1989 P 134-135
The Indo-US Vaccine Action Programme:
a recipe for disaster
by Praful Bidwai
Medico Friend Circle Bulletin
No 148 P 1-5
26
Tribal land rights in danger
The Lawyers
April-May 1989 P 27
27
Occupational health hazards of Bombay's
sewerage workers
The Otherside
March 1989 P 46-53
28
The Policing of India
by K Balagopal
The Lawyers
April-May 1989 P 5-10
15
Therapeutic Environment: An inseparable
Part of Good Bedside Care
by Chellamma Jacob
Nursing Journal of India
Jun 1989 P 157-158
IV
Womens Issues
16
Relationship between the work values
and job satisfaction in Nursing profession
by Dr B Nagarathnamma
Nursing Journal of India
May 1989 P 125-126
29
Women and the Mass Media : The Neec
for Positive Projection
NIPCCD Newsletter
Jan — February 1989 P 8-9
30
17
Breastfeeding as a Family Planning
Method
Mothers & Children, Supplement
Vol 8 No 1 1989
Working with Mothers for change
by Ranjana Mehra and Angela Reidy
Community Eye Health
No 1 1988 P 10-11
31
II
Nutrition
18
Integrating Child Development with
Health and Nutrition
Mothers <S Children
Vol 8 No 1 P 1-2
Changes in Women's Employment in
Rural Areas, 1961-83
by Jeemol Unni
Economic & Political Weekly
April 29,1989 P WS 23 — WS 31
32
19
Average daily blood pressure, not office
blood pressure, determines cardiac
function m patients with hypertension
by W B White et al
JAMA —INDIA
May 1989 P 157-161
The Nutrition Magician Integrating
Nutrition into Basic Education
Mothers and Children
Vol 8 No 1 P 6-7
Taking Dung — work seriously: women’s
work and Rural Development in North
India
by Roger Jeffery and others
Economic & Political Weekly
April 29 1989 WS 32 - WS 37
20
The Papanicolaou Test for Cervical
Cancer detection — a triumph and a
tragedy
by Leopold G Koss
JAMA — INDIA
May 1989 P 165-171
Child Nutrition' a Primary Health Care 33
Approach Towards Health for All by
2000 AD
by Usha David
Nursing Journal of India
May 1989 P 117-119
Women's work is never done : Dairy
'Development' and health in the lives of
Rural women in Rajasthan
by Miriam Sharma
,
Economic & Political Weekly
(
April 29 1989 P WS 38 — WS 44
21
Vitamin A Deficiency and the Eye
Community Eye Health
No 1 1989 P 4-5
34
Changing patterns of Juvenile Sex Ratios
in Rural India, 1961 to 1971
by Barbara Diane Miller
Economic & Political Weekly
June 3, 1989 P 1229-1236
Brain Tumours
by Atul Goel
2001
June 1989 P 58-59.61
Burns
by Shailesh Vadodana
2001
June 1989 P 56-57 and 66
Endoscopic Sclerotherapy
by Mrs Sreekumary D
Nursing Journal of Inidia
June 1989 P 147-148
Highlights of ICMR Research on
Communicable Diseases (1987-88)
Part I and Part II
ICMR Bulletin
March 1989 P 21-27 and April 1989
P 37-44
4D • HEALTH ACTION AUGUST 1SB9
III
Social-Economic-Political Issues
22
Slum Improvement: Who benefits
by Meera Bapat
IDRC Reports
January 1989 P 24-28
35
Reaffirming the Anti-Dowry struggle
by Rajmi Paltriwala
Economic & Political Weekly
April 29.1989 P 942-944
23
National Housing Policy: The Implications
by Arun Kumar
Economic & Political Weekly
June 10,1989 P 1285-1294
36
Women's Right to Matrimonial Home
by Freddy Farm
The Lawyers
April-May 1989 P 24-26
24
Article 21 — "Life" includes Livelihood
by M J Miranda
The Lawyers
April-May 1989 P 22-23
37
Reservations for women in Panchayats
by DN
Economic & Political Weekly
June 10,1989 P 1269-1270
25
Traffic in Children and teenagers
by Bharat Dogra
The Otherside
March 1989 P 16-22
See page 40
COMMUNITY HEALTH
(This article highlights some of the
attempts made in St. John's Medical
College, Bangalore, to orient Health
Workers, including medical students,
towards Community Health Care.
The attempts have provided invalu
able insights into this important goal.
Being a Medical College, St. John’s
aims at providing the training
component in the formation ofhealth
teams]
The Salient feature of our present
programmes are:
1. Health Team Training
St. John's Medical College is in a
unique situation to train various
^embers of the health team under
one roof. We are able to create a
better understanding among the
members of the team of each other’s
role. Medical students, Nursing
students, Community Health Wor
kers, Deacons, School teachers,
Village mothers etc. are the various
health team members who get their
training at the college.
While the ideal objective is health
and development, by virtue of the
training and competence of the
faculty, the emphasis has been on
training in health. It is complemented
by training in development by.other
organisations.
Community Participation
Training for Community
Health Care: a medical
college experience
Dara S Amar
The following three articles are a spillover
from our
‘Community Health’ issue of July '1989.
Coordination with other agencies
We work in coordination with
governmental and non-governmental
health institutions. Programmes
such as the Rural Mobile Clinics,
Universal Immunization Pro
grammes, integrated Child Develop
ment Scheme, National Social
Service and Rural Internship Training
are examples of such coordinated
efforts. Our teaching faculty also act
as guest faculty for various sister
institutions and organisations invol
ved in health and development.
One of the main objectives of the
. community health programme of the
’ college is the development of a
participatory process wherein the Integrated Health Care
Villagers in India often resort to
villagers themselves are responsible
for the financing of health care, indigenous systems of medicine. The
supply of materials and manpower. training at the college of the health
This is particularly exemplified by the workers including our medical
Mallur Health Co-operative Centre, students, includes training in Herbal
a project initiated jointly by the medicine, Herbo Mineral Medicine,
college and the Mallur Milk Acupressure, Homoeopathy and Yoga.
Cooperative in 1973. Village Health Many of our graduate doctors
Committees have been formed at working in remote rural areas, have
each of the rural health centres and substantiated the fact that there is
decisions are participatory in nature. need for integration with other
A large part of the organisation of systems of medicine as is being
speciality rural camps are also done attempted at the college.
by the villagers. This is through their Health Education — A Priority
After years of experience in
village youth groups and Mahila
Mandals. Even in the training of the training health team members for
health workers including medical the villagers, we feel there is a
students, the village leaders are greater need to pay attention to
training in health education. In the
drawn in as resource persons.
long run, it is the health education
programmes that have paid off the
maximum dividends. With this in
view, health education receives a top
priority in the training programmes
conducted at the college. Innovative
methodologies such as Child to child
health education, rural mothers
motivation programmes and rural
school teachers health education
training programmes are some of
the important programmes organi
sed by the college. The health
Announcement
VHAI is organising a five day training
programme along with State Forest
Research Institute, Jabbalpur on
procurement of seeds of medicinal
plants, ethno-botanical aspects, culti
vation techniques and processing.
There will also be a visit to natural
forests where medicinal plants a^e
used as spices, food and medicines by
local inhabitants in the last week of
September, 1989.
For further details contact:
Programme Officer, TSM
VHAI 40, Institutional Area
South of 1IT, New Delhi 110 016
HEALTH ACTION AUGUST 1989 • 41
COMMUNITY HEALTH
education methodologies include the operative care through the use of
development of local audio-visual trained school teachers, youth
aids in the form of simplified volunteers and traditional healers.
demonstration models using locally Specialist care is thus made available
available materials rather than at the village itself. In the bargain, the
sophisticated charts, photos, films faculty have gained confidence that it
etc. The materials for most health is possible to reach out with even
education sessions are prepared by advanced health care to the villages.
the village school children and village These exercises have also proved to
school teachers. Nutrition education be an important force of cohesion
involves teaching the village mothers among the various hospital depart
to use their own traditional recipes in ments and Community Medicine
a nutritionally correct manner. The Department. The rural mobile clinics
aim here is to strengthen the further carry the health care
existing traditional diets which are facilities to over 12 health centres,
often nutritionally far superior to the spread through three Community
imported diet from the urban areas, Development Blocks covering over
greater stress is laid on the use of 300 villages. In this process of
local cereals, pulses etc., along with rendering services to the unreached,
promotion of breast feeding as well our trainees (through the partici
as local weaning diets for the pation in such programmes) gain
invaluable experience.
children.
Sensitisation to the rural milieu
In order that all the trainees at St.
John’s, including medical students
and nursing students, must under
stand the dynamics of rural life,
special training programmes are
organised on a residential basis at
our rural health centres. These rural
residential training programmes
stress on understanding the various
factors which govern rural life and in
turn the health of the people. Areas
such as agriculture, animal husban
dry, small scale industry, customs
and traditions, housing and environ
ment, role of women in society, food
practices etc., are all studied
through field projects by the various
groups of trainees. The training
programmes are thus oriented to
sensitize the health worker to the
various aspects of rural life and how
each of these aspects is related to
the total health of the villagers.
Reaching out
Considering the resources and
facilities available for health care at
St. John's it is quite natural to try and
reach out to the underserved areas
using the available resources for
health care. Rural camps in the field
of eye, ear, nose and throat, skin,
teeth, child health and General
Surgery are conducted in the
villages. Methodologies have been
evolved at the village level to ensure
asepsis and follow-up for post
42 • HEALTH ACTION AUGUST 1989
Understanding
holistically
health
and
disease
In order that our health team
trainees do not dichotomise health
care into various compartments, the
training programmes focus on
families rather than individuals.
Through programmes such as the
Clinico-social case study and field
family health care projects, the
trainees are made to understand the
cause and consequence of disease in
terms of multiple factors rather than
only the clinical signs and symptoms
of the disease affected person.
Emphasis is laid on the planning and
management of health care at
minimal cost. Our graduates would
also be cost conscious and make
their programmes financially self
perpetuating in the village communi
ties rather than make the people
dependent on charities.
Serving the urban under-privileged
Urban slums in and around
Bangalore, are also served by the
Medical College. Health programmes
such as immunization coverage
against the major killer diseases for
children, maternal and child health
clinics for expectant mothers and
school health programmes, are
some of the urban based health
activities. In addition, the MedicoSocial Unit also aids in counselling for
alcoholism, drug addiction, juvenile
delinquency etc.
Continuing education
Although basic training in health
care is imparted to various
categories of health workers, it is
important a follow-up is done on the
utilisation of the knowledge gained at
St. John's. For this purpose, several
methods are followed. At the
professional level, doctors can seek
elective posting in selected speciali
ties for further skill enhancement.
Regional colloquia are organised for
sharing professional experience
among Community Health Workers
and Rural doctors. This provides an
opportunity for learning from each
other. Continuing education is also
provided by St. John's for health
agencies from afar. The UnitedPlanters Association of Southern
India (UPASI) works in collaboration
with the Department faculty to train
their Medical Officers, Nurses,
Compounders and even their Estate
Managers in the field of health care
and health management. Periodical
newsletters also act as a means of
networking for graduates and
community Health Workers working
in various parts of the country.
Development as part of health
Extension training in agriculture,
water resources and veterinary care
for village youth, are part of field
training programmes given in rural
health centres. The stress is on
youth motivation and training in
these areas, especially among the Au
rural unemployed youth. Functional
literacy programmes and vocational
guidance are some of the other
services rendered in the villages. Our
health trainees, including our medical
students participate in these
developmental programmes under
their National Social Service activi
ties, which is coordinated by the
department faculty.
Conclusion
All the programmes are updated
constantly, depending on the feed
back received of their effectiveness
and efficiency. The emphasis is on
training and health education rather
than mere provision of multiple
services. This ensures that whatever
have been the programme inputs,
the results will be long-lasting, self
perpetuating and effective.
®
COMMUNITY HEALTH
A REPORT FROM KERALA
Basic Health Communities
Fr Edwin MJ
O
LS»uilding communities is yet to
become an integral part of the
mental concept of a good many of our
community health workers.
What is a community? Or: what
,4ire the characteristics that make a
Vnass of people into a community?
We need to have consensus of what
we mean by community when we
speak of community health. Some of
the guiding principles of a community
are:
1 A community is not a crowd. It is
not a transient aggregation of
passers-by. Community has
certain amount of permanency.
2 A
community
presupposes
commitment to one another.
And this commitment is actually
the most identifying factor.
3 A community has a shared
vision. Consensus on objectives
holds the community together.
In this sense a community works
together.
4 A community means its mem
bers feel with one another. A
community, devoid of feelings, is
not yet a community. It may be
just a task force.
5 A community celebrates toge
ther. It brings imagination,
feelings and art to play in the
collective affirmation of persons
and events and mysteries of life.
6 A healthy community heals not
only by the explicitly therapeutic
programmes but also by its
process of affirmation and the
strength of the relationships.
Community is an antidote
against alienation, loneliness,
insecurities and the resultant
psychosomatic problems.
7 A liberating community, con
sequently a healing community is
v
Do we have such communities?
Such structures or infrastructures
that would make community health
action more sustained and more
participatory at grass-roots?
Until we have such communities
whatever we call community health
programme may at the most be a
rural extension programme and not
real community health action.
Community health is not just a
programme for the people; it is also
something of the people and by the
people.
They say examples speak louder. Let
me share with you an attempt where
we try to integrate the community
structure aspect or the infrastruc
ture aspect, into community health
action.
We call this project Basic Holistic
Health Communities.
a participating community. Parti
cipation in decision making is
what makes a mass into a
people. When people decide
together they become conscious
of their dignity as partners in
progress, as subjects and equals
and not just objects and the
ruled.
8 A community that is empower
ing, hence liberating and healing,
makes its members not only to
decide on the choice of various
solutions proposed but also to
see the problems together. BASIC HOLISTIC HEALTH
Knowledge is power. A commu COMMUNITIES
nity that has been enabled to
□ur first step here is to start
identify the problems and organising basic communities of
constantly to evaluate them is thirty houses each. We have
an empowered community. Few altogether 170 such basic communi
will dare to exploit that ties now.
community.
These communities are geogra
9 A community that is effective is phical, ensuring that nobody is left
necessarily .small. This follows out. This geographical aspect
from our earlier principles. A big ensures also a permanent identity
community can neither offer for the communities. As long as the
powerful relationships nor scope houses are in a given geographical
for participation. Only a fellow area the communities are also there.
with a big voice can make himself Even if for some reason or other
heard in a big village. Small men some communities or all the
feel too small to speak up in communities in a village remain
bigger structures.
dormant for sometime the day
10 A community that intends to somebody wakes them up they come
have wider macro level im-pact alive, ready to jump into action.
ensures linkage with other
These communities meet once a
similar communities through week or twice a week or even oftener
representative structures at as the case may be. These meetings
various levels. This ensures both are either for prayer, or for
the smallness of the community celebration, or for nonformal educa
and the wider level effective tion or for discussions on problems
action with effective grass-root affecting them and so on.
participation.
Five representatives from each
11 A healing community takes a community make the representative
holistic view of health that general body of the village. One
includes the various social, representative from each commu
economic, environmental and nity makes the executive body of the
village.
other factors affecting health.
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COMMUNITY HEALTH
Representatives from the villages
make the zonal representative
bodies, the general body having a
representative each from the
communities and executive commit
tee having village representatives at
the ratio of one representative for
five communities. What is discussed
below that is at grass root
communities, reach up to the top
through their representatives at
various levels and what is discussed
at the top is reported back to the
basic communities.
□ur system of handling finance in
one of these villages called
Kodimunai, will make this accountabi
lity to the grass roots clearer. Here
the Treasurer is free to spend at his
own discretion upto Rs. 5C.00 for
emergency expenses. When the
President and the Treasurer decide
together they can spend upto
Rs. 10O.OO. The Executive Commit
tee of the village can spend upto
Rs. 500.00. The representative
general body of the village having five
representatives each from the
communities can spend upto
Rs. 1000.00. If it is more than
Rs. 1000.00 the representative
general body of the village makes the
decision and sends it for referendum
among the basic communities. The
decision is not carried if more than
half the number of the communities
fail to support the decision.
'
This type of two way communica
tion helps for sustained action. It is
enough for anybody in any of these
170 communities to remember the
problem and the issue will come alive
again.
Once we build these basic
communities we use these communi
ties for nonformal education on
health concerns. They become grass
root forums for health motivation,
participation through decision
making evaluation and follow up.
Here the care is taken not just to
propose solutions but more espe
cially to make them see the problems
themselves so that through the
process of ongoing situational
evaluation they are enabled to
remain empowered.
This we do through various
processes. One such programme is
our holistic health orientation camps
in basic communities. This will be a
week long programme where trained
volunteers help conduct health
discussion sessions in the basic
communities with the help of a few
structured community-discussion
exercises. Each community will be
encouraged to do also creative
assimilation programmes: whatever
they learn in the discussions in an
evening is translated by the
community into cultural program
mes to be staged in the community
next evening. The village level
celebration that will take place the
last day will bring to a wider audience
the best of the cultural programmes
produced by these communities.
This health camp normally will include
an exhibition and also half a day or
one day seminars to various
categories of people with or without
audio visual programmes. Wherever
possible we would also include house
visiting programmes and a health
survey of the village.
In addition we prepare discussion
themes and circulate them among
the basic ■ communities. These
discussion themes are structured in
such a way that they elicit
participation of the community. Each
theme contains an initial activity
related to the theme, questions to
elicit participation, a deepening
process through the points given,
questions leading to community
decision, and a concluding activity by
way of a song or so.
□ur next process will be to make
these communities accept responsi
bility for their own health care. This
we intent to do by way of promoting a
holistic health insurance scheme run
by the people themselves.
□ur health insurance programme
is expected to consist of the
following components: non formal
education through basic communi
ties, collection of funds through basic
communities, primary health care
through village level representative
body and its appointees, secondary
and other levels of health care
through zonal bodies and the referral
centres chosen by them.
Unfortunately, even the example
given is not "yet a realised dream.
Well, this is the vision. We are not
yet sure how far we will reach. May
be in spite of our optimism we may
reach only half way. But we feel even
that would be worth the efforts, as it
would be a step in the right direction.
Health of people is wealth of
Nation
Dr. Jacob Cherian
Director & Chief Surgeon
Christian Fellowship Community Health
Centre
AMBILIKKAI, Tamil Nadu
The present National scheme of
Primary Health Centre is not so
much a success as it was expected
to be (World Health Organisation
Report). Still thousands of people in
our country die of infectious
conditions, poor nutrition and bad
sanitation. Alternative and appro-
priate systems of delivery of Primary
Health Care have been explored,
tried and met with success at many
many places.
Christian Fellowship Community
Health Centre at Ambilikkai trained
Multipurpose Community Health
Workers for the first time in our
HEALTH ACTION AUGUST 1989 • 45
COMMUNITY HEALTH
country as early as on 1958. The areas. Once detected and diagnosed,
training was reorganised into a cases are held (followed up) by Multi
regular course in 1972 with Purpose Health Workers (C.H
Government recognition. In those Guides). Soon we are hoping the
days we used to call them National' Leprosy Eradication Pro
Community Health Guides. The gram will be integrated with
training was much appreciated and it Community health net-work, which
is
was crowned with success. The the Government of India
Government of India accepted it as contemplating to do in 1992. Since
Multi Purpose Health Workers our Community Health Guides are
scheme later on. Community Health well experienced and quick in the
Guides (M.P.H.W) working in the field delivery of Health Services and also
of Health and Medical officers, are many of the targets to be achieved
doing a wonderful job. In our area 48 by the turn of the century (2000 A.D)
community Health Guides, covering alloted to them in the limited
1.5 lakhs of rural population, are population (2500 population for each
doing dedicated work. They have Health Guides) are already achieved,
achieved remarkable results during they are turning their attention
the last 25 years, e.g, Infant towards socio-economic develop
mortality rate was brought down ment, as health is very much
from 130 per 1 □□□ to 69 per 1 □□□, dependent upon socio-economic
birth rate from 31 per 10DD to 19.5 development.
per 1000 and general death rate
Limitation of funds is the greatest
from 18 per 1000 to 9 per 1000. handicap of any Voluntary Organi
Almost all infective conditions are sation. If dedicated service of
wiped out from the area. We work Voluntary Organisation could be
through a network of mini Health coupled with adequate and timely
centres. Two Multi purpose health supply of material and monetory
workers and three village health resources, great things could be
workers work in each mini health achieved in any field, especially in the
centre covering 5000 population.
important fields of Health and
Similarly in Voluntary sector, other Development.
institutions like the one in Jamkhed
In the usual development process
are training and placing simple in any country, one could see that
illiterate village women as Voluntary Voluntary pilot modules or models,
Health Workers in their project. research and experiments, lead the
They too have achieved very good nation on the right track. A good
results. This was also recognised by community Health system based on
World Health Organisation. Training mother and child care, sanitation,
and organisation of Mathersangams immunization, nutrition, control of
and Balwadies are other examples of population growth and proper care of
success-ventures and alternative minor ailments, should be further
system piloted by voluntary sector boosted by Health Education and
though it may not give the full adult Education, and economic
coverage. Delivery of Health through development. Early five-year plans in
Health insurance by Voluntary our country were concentrating on
Health Service, Madras is yet building up big hospitals, Medical
another example of success story in colleges and post-graduate teaching
the field of health-delivery by institutes and, also much thrust was
adopting a different system using given on green revolution. This was a
lay-first-aiders.
good move in the right direction but
In our Community Health Field, side by side industrial revolution
even leprosy program is integrated should have been given its due
with Multi Purpose Health Worker's importance. Thank God the trend of
service. The leprosy/paramedical general policy of our Government in
workers are expected to detect the the latter periods of five-year-plans
new cases which have become is set in the right direction, towards
comparatively much less in our Balance
economy,
Community
Health and Control of population.
Adult education, Industrial revolution
(both small and big) and Green
revolution are pushed to the fore
front. Soon it is hoped that craziness
for sick palaces (Big Hospitals) and
urban Medical Colleges on the part of ■
the government will be replaced by
Community Health Projects, Adult
education and family welfare pro
grammes and socio-economic and
agriculture-promotion activities.
It is a pity that still our country is
not able to prevent its citizens
becoming victims of drought and
flood by developing ecology (Social
forestry) and preservation of rain
water and connecting all rivers wifjfc
canals after building sufficient dams
and also building bunds on all the
banks of rivers. Vast population
already existing is an asset to work
up such herculean tasks. Why do we
think here of those areas of
economic development? Because
unless socio-economic condition is
improved, health of the people
cannot be promoted beyond a
certain limit or level. Unbalanced
race for scientific achievements and
material targets are also equally
dangerous unless it is balanced with
selfless service, deep spiritual
mottos and motives and also our
hunger and thirst after high moral
values.
4
Reminder
Human vanity can best be
served by a reminder that,
whatever his
accomplishments, his
sophistication, his artistic
pretension, man owes his very
existence to a six-inch layer of
topsoil — and the fact that it
rains.
COMMUNITY HEALTH
'microscopic research' are such
'baloonist researchers’ available for
the task?
FROM INTRACELLULAR TO
SOCIETAL RESEARCH
—i
—
The Research and Research Centres given below is a sub-section
of the July 1989’s Cover Story “Community Health Scene in India
NGO Research Centres in Community
Health: Some Profiles
* Foundation For Research in Commu
nity Health, Bombay, (Maharashtra),
Estb:1975
The new approaches to Commu
The development of NGO health
Non-government research centre
nity Health evolving in the country research units keeping in tune with
which undertakes conceptual as well
have shown that a very important and exploring in depth issues arising
as field level research to study,
but neglected area is research into out of the emerging Community
analyse and wherever possible
socio-economic-political-cultural fac Health movement are few but these
influence the cultural, economic and
tors that affect health and disease are atleast positive signs.
political factors that affect the
and determine the nature of health
The Foundation for Research in health of the people.
care development as well as the Community Health (Bombay) the
Initiatives and studies include
response of the people.
Action Research in Community
™ Medical research in India has been Health, Mangnol (Gujarat), Society evolution and study of low cost
community based health systems in
preoccupied as in other parts of the for Education Research and Training
Uran and Mandwa. Socio-economic
world with intracellular or molecular in Health, (SEARCH) Gadchirale
study of rural transformation;
(Maharashtra),
Community
Health
biological roots of disease and much
Women's work fertility and access
of the research efforts sponsored by Cell (Bangalore) are examples.
to health; PHCs in Maharashtra;
ICMR and other national and
A few of the larger NGO Health Health Service projects (NGDs in
regional, government and private Projects like CHOP, Pachod, (Maha
Maharashtra) Health Financing in
research centres has been in this rashtra) SEWA-Rural (Gujarat), CINI
direction. Most of it has been (Calcutta), Jamkhed (Maharashtra) India, Stigma against leprosy,
Alternative school health project,
imitative research, 'we too have done and RUHSA (Tamilnadu) have also
it in India’ sort of focus and there is begun to take up some key research Facilitation of ICMR-ICSSR Joint
study group on Health for All an
the continued myopic view that the issues but this whole interest is still
alternative strategy.
future of health in the country will be in a nascent state.
determined by the discovery of a few
The Social Medicine and Commu * Action Research in Community
more vaccines and maybe the odd nity Health Department at JNLJ is
Health — (ARCH) Mangrol, (Gujarat),
drug or contraceptive. This techno the only other national centre which
Estb:1978
logical focus has blinded us to the is undertaking societal research
A group of individuals of diverse
fact that the world- over health care relevant to Health Care and Health
action initiators are proving again policy issues. The medico friend background got together to establish
and again that the clue to health of circle's efforts in providing counter this centre in the eastern tribal belt
’ the people is in greater societal research expertise in the Bhopal of Gujarat to study the developmen
problems in the wider social reality disaster and its aftermath was also tal process using the health of
children and women of the poorer
and to study them in a socio- a beginning of this new trend.
sections of society as the guiding
epidemiological context to determine
Much needs to be done by both thread.
bottlenecks and to evolve creative
innovations is the need of the hour. governmental and non-governmental
The approach was to get involved
Some ICMR institutions like the groups, if the emerging 'Community in the complex process of develop
National Institute of Nutrition in Health' approach and movement has ment (ACTION) and to study
Hyderabad, National Tuberculosis to be put on a sound researched critically the health of the community
Institute in Bangalore and the social and epidemiological basis. But and the processes which results in ill
Vector Control Research Centre in this needs people who see Research health (RESEARCH).
Pondicherry have treaded the path of as an important need. It also needs
Field based strategies evolved
societal research and made unique innovative 'researchers' who will be were programmes to attack preva
willing
to
learn
existing
health
care
contributions to Primary Health
lent diseases, methods and skills of
Care and Community Health but research methodologies and then community diagnosis and interven
these are the exceptions to the creatively adapt it through interac tion, training of health assistants and
tive, participatory approaches to part time community health workers,
overriding rule.
Have the NGO Health action study the dynamics of Community non-formal school and finally a just
initiators fared better? Is anyone Health care and the evolving and human rehabilitation policy for
interested in health related societal movement.
tribals displaced by an ambitious
With the preoccupation with irrigation project in the area.
research in the country?
HEALTH ACTION AUGUST 1989 • 47
COMMUNITY HEALTH
* Society for Education, Awareness
and Research in Community Health
(SEARCH), Gadchiroli (Maharashtra)
Estd:1984
This Society has adopted Gadchi
roli district, a predominantly tribal
district in Maharashtra, for its
education, awareness building and
research activities. Presently they
have long term projects on the study
of Active Respiratory Illnesses in
children; and a study of women's
health focussing on the community.
The Society also seeks to evolve
methods of intervention which will be
at the level of the multipurpose
workers of the government PHC.
Due to its increasing community
involvement the Society has also
begun to explore the dynamics of
women’s health and other related
issues, the forest issues affecting
tribal and the illicit liquor issue in its
community context. It has also tried
to modify the health care/medical
practices at the District level to
make it more responsive to the
needs of the people's situation.
NGO (Non-Governmental Organiza
tions) Research Centres in Community
Health: Some Profiles
■k Foundation For Research in Commu
nity Health, Bombay (Maharashtra),
Estb:1975
Non-government research centre
which undertakes conceptual as well
as field level research to study,
analyse and wherever possible
influence the cultural, economic and
political factors that affect the
health of the people.
Initiatives and studies include
Evolution and study of low cost
community based health systems in
Uran and Mandwa,
Socio-economic study of rural
transformation.
Women's work fertility and access
to health;
PHCs in Maharastra:
Health service projects (NGOs in
Maharashtra);
Health financing in India;
Stigma against leprosy;
Alternative school health project;
48 • HEALTH ACTION AUGUST 1989
Facilitation of ICMR-ICSSR joint
study group on Health for All an
alternative strategy.
Research in Community
Health — (ARCH) Mangrol, (Gujarat),
Estb:1978
k Action
A group of individuals of diverse
background got together to establish
this centre in the eastern tribal belt
of Gujarat to study the developmen
tal process using the health of
children and women of the poorer
sections of society as the guiding
thread.
The approach was to get involved
in the complex process of develop
ment (ACTION) and to study
critically the health of the community
and the processes which results in ill
health (RESEARCH) Field based
strategies evolved were program
mes to attack prevalent diseases,
methods and skills of community
diagnosis and intervention, training
of health assistants and part time
community health workers, . non
formal school and finally a just and
humane rehabilitation policy for
tribals displaced by an ambitious
irrigation project in the area.
* Society for Education, Awareness
and Research in Community Health
(SEARCH) Gadchiroli (Maharashtra)
Estb:1984
From page 40
V
Medical Ethics G Human Rights
38
Medicine at Risk: Doctor as human
rights abuser and victim
by Amnesty International
Radical journal of Health
September — December 1988 P 35-39
39
They Condone torture
by Cesar A Chelala
World Health
April 1989 P 24-25
40
Health Ethics and the law
by Sasan Scholle Connor and Hernan L
Fuenzalidapuelma
World Health
April 1989 P 10-13
41
Ethics and Health
by Zbigniew Bankauski
World Health
April 1989 P 2-6
•
42
Genetics, Medicine and Ethics
by Zbigniew Bankowski
2001
May 1989 P 43-44 and 83
VI
Environmental Issues
43
Another Morvi in the Making
by Denis Rodrigues
Economic & Political Weekly
April 8,1989 P 714-715
44
Defenders put
Eucalyptus
South
June 1989P79
45
Water-Logging in Koshi river project
areas
by Mukul
The Otherside
March 1989 P 37-39
the
case
for
the
The society has adopted Gadchiroli
district, a predominantly tribal
district in Maharashtra, for its 46 Fuelwood Famine in India
Facts for You
education, awareness building and
May 1989 P 40-44
research activities. Presently they
have long term projects on the study VII Consumer Issues
of Active Respiratory Illnesses in 47 Legal Status of a Telephone owner
children; and a study of women's
by KD Gaur
The Lawyers
health focussing on the community.
April-May 1989 P 13-14
The society also seeks to evolve
methods of intervention which will be
Healing Presence of The Church
at the level of the multipurpose
workers of the government PHC.
by
Due to its increasing community
Thomas Sebastian
involvement the society has also
Panachickavayalil OFM Cap
begun to explore the dynamics of
women's health and other related Published by
issues, the forest issues affecting Good Tidings Publications
tribal and the illicit liquor issue and its 8/4 MT, Main Road, Mathikere
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ISSN 0970 - 4221
ST. JOHN'S MEDICAL COLLEGE
JOURNAL OFMEDICINE
VOL III No 4
December 1990
EDITORIAL
96
DERMATOLOGY SYMPOSIUM - ALLERGY
Foreword
100
Abstracts
101
Food Allergy
105
Practical Skin Test, Procedures in Allergy I - Patch Testing
108
Practical Procedures in Skin Tests for Allergy II - Prick Testing
110
REVIEW
Autologous Blood Transfusion : Its role in Oral and Maxillofacial Surgery
112
INFORMATION FOR CONTRIBUTORS
EDITOR-IN-CHIEF
Ashley. J. D'Cruz
Submitting the Manuscript
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The St. John's Medical College Journal of Medicine accepts scientific contributions from all fields of
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journal is a part of it's commitment to continuing medical education. Articles and all editorial
communications should be addressed to the Editor, Alumni Office, St. John's Medical College.
Bangalore-560 034.
Rajini Macaden
Ravi C. Nayar
Mario Vaz
Original articles, short case reports and review articles are accepted for publication. Review articles
and editorials are usually on invitation by the Editorial Board. Letters to the Editor will be considered
tor publication only if received at least six weeks prior to the next publication.
A.B. Kilpadi
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St. John’s Medical College Journal of Medicine
EDITORIAL
LIVER SURGERY : PRESENT AND FUTURE
INTRODUCTION
Till recently the liver, despite being the largest organ in the body, remained elusive. Its functions were inadequately
understood, surgery was regarded as foolhardy or unnecessary, and the diagnosis, when possible, was an academic and
often fatalistic exercise. While hepatitis was, and remains the commonest affliction, the last two decades have seen significant
advances in the diagnosis and treatment of focal lesions of the liver.
Asian countries have an endemic prevalence of the hepatitis viruses, and a correspondingly high incidence of both hepatic
malignancies and cirrhosis. As populations in these countries are high, primary hepatic cancer is now the malignancy affecting
the maximum number of people in the world. Not surprisingly, a number of the advances in liver surgery have come from
countries of this region.
With the establishment of liver transplantation in the eighties, the future promises to witness increasing attempts to treat
disseminated diseases of the liver like cirrhosis, acute and chronic liver failure, and congenital disorders of metabolism.
While the majority of digestive surgeons seem reluctant to subspecalize, it is time to take stock of liver surgery. Along
with immunology and virology, the study of liver diseases represents the cutting edge of science today.
ANATOMY
The segmental anatomy of the liver as outlined by the French surgeon Couinaud forms the basis of all liver surgery, and
is now the standard format used in all radiological and surgical descriptions.
The liver is in reality two livers - the right and the left - each having four segments, which are numbered serially from I to
VIII starting with the caudate lobe posteriorly and going from left to right. Each segment possesses its own arterial and portal
venous supply, and is drained by its own bile duct. The venous drainage to the inferior vena cava is, however shared by
adjacent segments: the left hapatic vein running between segments II and III of the left liver, and the right hepatic vein running
between the anteriorly located segments V and VIII, and the posteriorly located segments VI and VII of the right liver. The
middle hepatic vein runs in between the right and left livers, and its course can be marked on the anterior surface (at surgery)
by an imaginary line running from the gall bladder fundus in front to the inferior vena cava behind. The hepatic veins are
easily visualised on ultrasound scanning, and help to precisely localise focal lesions of the liver.
The importance for the surgeon of recognising the segmental nature of the liver, lies in the fact that while it is easy to
surgically remove portions of the liver, what is much more difficult is to ensure the viability of the liver tissue that is left
behind. It is deceptively easy, during a major liver resection, to “get lost" in the liver substance and end up compromising
the vascularity or the venous drainage of the remaining segments.
For the physician, a familiarity with the segmental anatomy is necessary fora meaningful surgical referral. A known cirrhotic,
for instance, who decompensates with the development of a liver tumour, would probably not be a candidate for surgery
if more than two segments are involved.
IMAGING
With the knowledge that most focal lesions of the liver are not amenable to medical therapy, the trend in the 80s has shifted
to diagnosis by imaging rather than histopathology. It is now possible to achieve a reasonably accurate pathological
diagnosis while delineating the anatomical and physical characteristics of the lesion by ultrasound and contrast enhanced CT
scan. Biopsies are at best a hit or miss affair, and even if successful in obtaining enough tissue for a pathologist to commit
himself are an academic exercise best reserved for patients who are not candidates for curative therapy. This philosophy
is outlined in Fig. 1.
96
VOL III No. 4-----
St. John’s Medical College Journal of Medicine
Fig 1 : Segments of the Liver
THE RESECTIONS
FOCAL LIVER LESION
I
ultrasound scan
T
CYSTIC
I
I----------- 1
patient
septic
I
HYDATID
CYST
± positive
serology
CONGENITAL
LIVER CYST/
POLYCYSTIC
LIVER
I
DISTANT
METASTASES
I
CT scan
I——
PYOGENIC/
AMOEBIC
ABSCESS
appropriate
treatment:
1. percutaneous
aspiration
2. antibiotic/
amoebicidal
therapy .
3. percutaneous/
surgical
drainage
symptomatic/
complicated
uncomplicated/
asymptomatic
heavijy
calcified/
asymptomatic
HAEMANGIOMA
I
angiography
asymptomatic/
little risk
* tumour
/
symptomatic/
circulation/
/
risk of rupture
avascular
lesion
? trial of
medical therapy
embolisation
surgical treatment
usually no treatment,
assess renal function,
occasional surgery
SOLITARY MULTIPLE
observ
appropriate
non-surgical
treatment
------ 1
IV cavogram
operative assessment
± resection
± biopsy
PATHOLOGICAL
DIAGNOSIS
biopsy
1. FNAC
± US/CT guidance
2. Laparoscopic
needle biopsy
_3. Percutaneous
needle biopsy
± US/CT/angio
guidance
Fig 2 : Investigation of a focal liver lesion
December 1990
97 —
St. John's Medical College Journal of Medicine
Based on the hepatic segmental anatomy, the liver resections are (Fig.2):
LEFT LOBECTOMY: Segments II and III, i.e. the liver tissue to the left of the falciform ligament.
LEFTHEPATECTOMY: Segments II, HI and IV, i.e. the liver tissue to the left of the cholecysto-caval line. Segment I (caudate
lobe) is included when required by the anatomical extent of the lesion.
RIGHT HEPATECTOMY: Segments, V, VIII, VI, and VII, i.e. the liver tissue to the right of the cholecysto-caval line.
EXTENDED RIGHT HEPATECTOMY (syn.: RIGHT TRISEGMENTECTOMY): Segments V, VIII, VI, VII, and IV, i.e.
the liver tissue to the right of the falciform ligament.
EXTENDED LEFT HEPATECTOMY (rarely performed and hazardous) Segments II, III, IV, V and VIII i.e., the liver tissue
to the left of the right hepatic vein.
Apart from the above mentioned standard resections, resection of segments both singly and in combination have been
described, especially in the mangement of cirrhotics who may have more than one tumour, and are unable to withstand a
standard resection.
Liver resection may also be required for bile duct tumours infiltrating the hilar structures supplying one half of the liver,
or for direct infiltration of the liver parenchyma at the hilum. The difference from the same resection performed for a primary
hepatocellular lesion is that in this situation the patient is jaundiced and the resection removes a sizable mass of normal
liver tissue. The physiological derangements in the operative and postoperative period are therefore much worse.
PERIOPERATIVE MANAGEMENT
Child’s criteria constitute a time honoured method of assessing the degree of disability of a patient with liver disease. While
Child’s C patients are an easily recognised group at major risk for any kind of surgery, risk allocation in better preserved
patients is an area of ongoing research. BSP retention, glucose tolerance test, measurement of Factor II and V levels
and estimation of the amount of “cytochrome a" in a liver biopsy specimen, each have their proponents. It is becoming
increasingly clear, however, that perhaps the most sensitive prognostic indicator is the patient’s history. Chronic liver
disease resulting in significant impairment of the patients lifestyle, with dimunition of intelligence and physical vigour carries
a grave prognosis.
Resection of a large mass of liver tissue is well tolerated only if at least 2 normal segments of liver are left behind. The
diseased liver is extremely sensitive to ischemic injury which may follow the impairment of liver blood flow under anaes
thesia or result from surgical interruption of the blood flow to whole or part of the liver. Clinical manifestations are subtle, and
may take the form of respiratory, renal and /or cerebral dysfunction. Hypoglycemia, hypoalbuminemia, hyperbilirubinemia,
abnormal clotting, alkalosis/acidosis and electrolyte abnormalities are associated. Intensive care after major liver surgery
involves monitoring of all haemodynamic and metabolic parameters.
Based on this mass of data decisions regarding the use of fluids, blood, blood products, dialysis and ventilatory support
and combinations ofdrugs like dopamine, dobutamine, nitroglycerine, nitroprussided and noradrenaline, to name only a few,
have to be made. Parental nutrition is often required since there may be problems associated with the use of the G.I. tract
for enteral feeding.
Perhaps the most dangerous of all complications in the acute phase is the rapidity with which these patients tend to develop
severe hyponatremia, and its dreaded sequel of cerebropontine myelolysis. The immunological impairment that
accompanies liver surgery requires a major input from the microbiologist - an important member of the clinical team
-who decides the antibiotic strategy, and the surveillance for viral and fungal and resistant bacterial superinfections, that
are associated with the use of broad spectrum antibiotics.
FUTURE TRENDS
There is now sufficient evidence on long term follow up to justify an aggressive approach to liver tumours - both primary
and metastatic. The future will see increasing attempts to offer resection to centrally located liver tumours, and to tumours
associated with cirrhosis, which are presently regarded as technically inoperable.
Initial attempts to resect massive central liver tumours in children under cardiopulmonary bypass with hypothermia have
been successful. The experience with liver transplantation has led to large and multiple tumours in adults being managed
by excising the entire liver, and on the back-bench resecting the tumour and reconstructing the liver before re-implantation.
98
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St. John's Medical College Journal of Medicine
There is renewed interest in transplantation for tumours of the liver and extrahepatic bile ducts. While the former is performed
under chemotherapeutic cover, the latter is being tackled with “cluster transplants” in which the liver, pancreas and
duodenum are transplanted as one complex following total and radical resection of the tumourwhich is usually slow growing
and slow to metastasis. Improvements in immunosuppressive drugs which selectively suppress organ rejection while
leaving unaffected the ability of the body's defences to cope with distant micrometastases would further open up this
field of surgery.
Orthotopic Liver Transplantation promises to find increasing application in the future. Congenital diseases like haemo
philia are cured by transplantation, and in future liver transplant may be offered to such patients despite the fact that the liver
is not “diseased". Fulminant and subhepatic failure irrespective of cause, are an increasingly common indication for
transplantation. To keep the patient alive till a suitable organ is available, the diseased liver is excised and the patient
supported with intensive care until transplantation, which is usually performed within 48 hours.
The chief limiting factor is the increasing shortage of cadaveric organs, and as the demand for liver transplants is only likely
to increase, attempts at xenografting are being made. The liver enjoying as it does an immunologically favoured status,
would be one of the first organs to be transplanted from other species if advances in immunosuppression permit.
Dr. Philip G. Thomas
Assistant Professor
Department of General Surgery
St John's Medical College Hospital
Bangalore
SELECTED REFERENCES
1. Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J.Surg. 1982;6:3-9.
2.
Di Bisceglie Am. et al. NIH conference : Hepatocellulaf carcinoma. Ann. Int. Med. 1988;108:390-401.
3. Lee CS, Sung JL, Hwang LY, et al. Surgical treatment of 109 patients with symptomatic and asymptomatic hepatocellular carcinoma. Surgery 1986;90(4):481 489.
4.
Bismuth H. Houssin D, Ornowski J, Meriggi F. Liver resections in cirrhotic patients : a western experience. World J Surg. 1986:10:311-317.
5.
Starzl TE, Demetris AJ. Liver transplantation : a 31 year perspective. Curr. Prob. Surg. 1990;Vols2-4:55-240.
December 1990
99 —
St. John's Medical College Journal of Medicine
DERMATOLOGY SYMPOSIUM - ALLERGY
FOREWORD
Allergy Diseases have not yet achieved their due importance. Although
Allergy Diseases, are rarely life threatening they have aconsiderable impact
on health and development. Further, there is increasing evidence that the
prevalence of these diseases is steadily increasing in the population. Allergy
Diseases are of high complexity both in their clinical manifestation and their
etiology. One of the main intentions of this symposium therefore is to present
information on various aspects of these diseases in order to understand the
causative factors. In addition, it is to demonstrate tests that help diagnose
some of them.
To this end we have an excellent faculty both invited and from our institution
to deliberate these matters. I do hope that the deliberations of this National
symposium will generate lasting interest among the participants. More
importantly I hope that for the future, efforts of this symposium will establish
a rational approach in the field of Allergy in our country.
I would also like to thank my colleagues for their support and co-operation
in making this symposium a success.
Dr. S.C. Rajendran, MD DVD
Organising Secretary
too
VOL III No. 4 —
St. John’s Medical College Journal of Medicine
ABSTRACTS
DERMATOLOGY SYMPOSIUM - ALLERGY
ETIOPATHOGENESIS OF BRONCHIAL
ASTHMA
Abstract
Bronchial asthma is a common cause of respiratory
morbidity. Central to the problem of asthma is reversible
airways obstruction which is triggered by a variety of stimuli
such as allergy, infection, excercise, climatic changes,
emotional factors, drugs and others. In recent years, there
has been rapid increase
in
understanding of
the
phenomenon of airway hyperreactivity both in terms of
physiology and immunology. The concept that asthma is
related more to inflammatory changes in the airways rather
than to 'bronchospasm’ alone has been appreciated. The
role ofthechemical mediators in the the immediate as well
as the Late Asthmatic Response (LAR) has been elucidated
elegantly. This aspect of improved understanding is
important not only academically but also at the clinical level.
The role of the cellular factors is demonstrated by the aid
of techniques such as, bronchoalveolar lavage.
Measurement of airway responsiveness and its
relationship to the severity of asthma has been important
in formulating therapies with improved outcome in cases of
patients.
whether such an epitope is in the soluable form or as part of
virus or bacteria, needs elucidation. On the other hand, T cell
receptor can ‘see’the antigen, only when it is processed
and presented in conjunction with major histocompatibility
complex (MHC) of class I or class II molecule. The antigen
processing and presentation is performed by macrophages
and B cells, in general called APC or antigen presenting cells.
One subpopulation of T cells-CD8 positive cytotoxic T cells
recognise the antigen (eg., cell surface bound viral antigen) in
conjunction with class I molecule, resulting in specific killing of
the target cells.
The major event in T cell biology is the clonal activation of T
cells by specific antigen. This phenomenon is MHC class
II restricted. As a result of the interaction between CD3/
Ti complex, and epitope-class II molecule, the T cell is
activated ultimately causing such T cells to proliferate. In this
process, new molelcules (lnterleukin-2 receptors) are
expressed and growth factors like lnterleukin-1 (IL-1), and IL2 and Interferon are synthesized by the interacting cell
populations. Further, we have been able to explain T-B
cooperation or T cell help at molecular level. The present
understanding on the T and B cell recpetoq antigen
processing and presentation by APC, early activation events,
growth factors will be described.
Dr. Om Prakash
Consultant Physician
St. Martha's Hospital
Bangalore
MECHANISM OF ANTIGEN RECOGNITION BY
LYMPHOCYTES
According to the Clonal Selection Theory, each lymphocyte
is precommitted to recognise a specific antigen. This is true
for both T- and B- lymphocytes and the phenomenon of
commitment takes place in thymus for T-cells and in bursa
of Fabricus/bone-marrow for B-cells, involving gene
rearrangements to generate diversity.
On B cells, membrance bound immunoglobulin-M (mlgM)
is the recognizing molecule. On T cells, the T cell receptor
is/the heterodimer or CD3/Ti complex. In both T and B cell
receptor molecule, the variable region is responsible for the
specificity of antigen recognition. In addition, accessory
molecules aid in antigen recognition for T cells.
There is a major difference in antigen recognition between
T and B cells. slgM behaves similar to serum IgM, binding
specifically to antigenic determinant or epitope. In other
words, B cell receptor binds to antigenic epitope directly,
December 1990
Dr. V.R. Mulhukaruppan
Department of llmmunology
School of Biological Sciences
Madurai Kamraj University
Madurai
PRINCIPLES AND STRATEGIES IN THE
CLINICAL MANAGEMENT OF BRONCHIAL
ASTHMA
When one considers strategies of any kind, the first step is
to make the participants fully aware of the action and its
consequences. This is of vital importance when one embarks
on the treatment of a disorder like Atopic Bronchial Asthma,
steeped as it is in myths and misunderstandings. The patient
must be educated as to the true nature of the disorder, the
present therapeutic options and their implications inorder to
ensure their utmost co-operation before embarking on any
kind of drug treatment.
The therapeutic options are few, but used judiciously can
control the symproms in virtually all patients. The available
drugs can be divided into the following groups.
1.
Phospho-diesterase inhibitors.
101—
St. John’s Medical College Journal of Medicine
2.
3.
4.
5.
Beta-adrenergic agonists.
Atropine derivatives
Corticosteroids
Others eg: Sodium cromoglycate and Ketotifen
The use of theophylline group of drugs (principal phospho
diesterase inhibitors) in bronchial asthma is controversial.
However, other functions ascribed to these agents have
recently revived their use, particularity as adjuvants to the
Beta-adrenegic agonists.
Beta-adrenergic
agnoists and ipratropium Bromide
(atropine derivate in common use today) are the most widely
used agents for treating bronchia asthma and for status
asthmaticus today because of the ability to deliver these
agents by the inhalation route as well as subcutaneous route
in the former. Aerosol therapy is preferred because of the
immediate onset of action and small quantities of the drugs
required which consequently produce negligible systemic
side effects - a strong plus point compared to the oral route.
Aerosols have revolutionised the treatment of acute and
chronic bronchial asthma and are today the firest-line drugs
in this disorder.
Corticosteroids are the prime drugs in acute exacerbations
where beta-agonists and theophyllines fail to control the
symptoms, and must be used rather than avoided. Their
usefulness far outweighs their unecessarily dreaded side
effects. These agents in the aerosol form or as rotacaps to
be inhaled are the major drugs for prophylaxis both in adults
and children, though personally I prefer
sodium
cromoglycate for prophylaxis in children. Ketotifen, though
orally administered, has no therapeutic advantages over
sodium cromoglycate and because of its tendency to
produce drowsiness has virtually gone out of favour of most
therapeuticians.
A brief therapeutic outline can thus be drawn as follows:
Occasional mild attacks - beta adregenic aerosols or
tablets with or without theophylline.
2. Occasional severe attacks - as above but with short pulses
of corticosteroids during the attacks.
3. Chronic perennial asthma - cortocosteroid aerosol
prophylaxis with beta agonists and theophylline to be
added during intermittent exacerbations. To the un
responsive Ipratropium bromide in aerosol form can be
added as well.
1.
Finally a word about diet and excercise. Apart from restricting
items with artificial colouring agents and preservatives and
certain food stuffs that cause dermal allergies in individuals,
no other diet restriction is really necessary. When free of
bronchospastic attacks, excercise to its optimum level is
permissable. Bronchial asthma should be regarded as a
disorder and not a disease and individuals suffering from it
should be encouraged to lead normal productive lives. With
102
ABSTRACTS
the therapeutic armamentarium at our disposal to-day this
is not a dream but a reality.
Dr. A. S. Chitnis
Senior Consultant. Jaslok Hospital
Bombay
SOME SELECTED TOPICS IN CUTANEOUS
ALLERGIES
A large number of skin diseases are based on allergic/
immunological mechanisms, but in a limited period of time, it
is not possible to have a detailed discussion on all these
diseases. It is therefore proposed to pick up a few selected
topics among these diseases and highlight the latest
developments/experience in the respective areas.
Urticaria is the commonest allergic disorder and it can be
caused by avarietyofagents. Food and drugs are well known
causes of urticaria, but a significant proportion of cases of
urticaria are caused by physical agents such as cold, heat,
sunlight, friction or excercise. We have developed two tests,
‘'Cryo-stimulationtest" for cold urticaria and “Dermograding”
for dermographic urticaria with which one can deliver
standardised and graded stimuli of cold and friction
respectively for confirming the diagnosis and grading the
degree of hypersensitivity in these two types of urticaria.
These tests are also useful for following the natural course of
the disease in these cases and also forobjectively
evaluating the effects of therapeutic procedures.
When the allergy is suspected to be caused by foods, the
most reliable procedure consists of the food elimination
and provocation test. This procedure consists of eliminating
the suspected foods (partial diet elimination) or sometimes all
the foods except glucose, salt and water (complete diet
elimination) for 2 days to see if the symptoms of the allergic
disease disappear or reduce by at least 50%. If the patient
improves during these two days, the eliminated foods are re
introduced one by one perdaytofind out which of these foods
would lead to recurrence of the symptoms. In case there is
no improvement even on complete diet elimination, one can
conclude that the allergic symptoms are not being caused by
any of the foods. This procedure may be time-consuming but
if carried out accurately it is very dependable for finding out
if the allergy is caused by a food.
Patients having allergy to a pollen often get their symptoms
only during a fixed period of the year and recover completely
or improve significantly when that period is over. They may
also recover if they move to another place where that plant
does not occur. Inhalant allergy can also be caused by dust
in the house, offices, liberaries and road-side. Such
patients
derive significant benefit if they prevent the
inhalation of pollen/dust by wearing nasal filters designed by
us. These filters are worn inside the nostrils and are thus not
VOL III No.
4—
ABSTRACTS
St. John's Medical College Journal of Medicine
visible from outside (like contact lenses). Soft nasal filters are
available in 9 different sizes so that the patient can pick the
size which fits his/her nostril,and a week’s training under the
care of the expert is enough to make the patient understand
the mode of its proper usage. There are patients now who
have used these filters formore than 10 years and derived
adequate benefit without any long side effects.
Contact dermatitis is a special type of a reaction in which the
dermatitis is caused by an agent coming in contact with the
surface of the skin. The causative agents generally include
cosmatics, wearing apparel, jewellry, tropically applied
medicines or other agents to which an individual gets
exposed during his daily activities. The areas of the body
involved by the dermatitis generally involve the causative
agents. To facilitate this test we have preapered ready
made materials in the form of antigen-impregnated discs
and antigen-containing saucers which make the procedure
far easier and quicker. We have also established a
procedure by which the degree of contact hypersensitivity
to a particular antigen in a patient can be determined in the
same way as the levels of antibodies in antibody-mediated
diseases.
Cutaneous reactions to drugs are another important field
because some of the drug
reactions especially
anaphylaxis, toxic epidermal necrolysis (TEN) and StevensJohnson syndrome (SJS) can be rapidly fatal. The
aetiopathogenesis of anaphylactic reactions to penicillin and
their management are well known, but TEN and SJS are still
reported to be highly fatal. We have developed a treatment
schedule with which the fatalities can be prevented almost
completely. This schedule is based on, (1) withdrawing all the
drugs being given to the patient at the time of the drug
reaction,
(2) using an adequate dose of systemic
corticosteroids to control the reaction within 24 hours and
(3) rapidly withdrawing the corticosteriods after the drug
reaction has been controlled.
Another disease in which we have achieved remarkable
success is pemphigus. This is an autoimmune disease
in which IgG autoantobodies circulate in the blood and react
with a protein covering the epidermal cells to produce
blisters all over the skin and mucous membranes. The
disease is potentially fatal in almost all patients within a few
years. By using an arbitrarily designed schedule called
dexamethasone cyclophosphamide plus (DCP) therapy
consicting of 100 mg dexamethasone on 3 consecutive days
along with 500 mg cyclophosphamide on 1 day, repeated at
4 weeks intervals and 50 mg cyclophosphamide orally daily
in between the DCP, we have been able to induce permanent
remissions in almost every patient under our care.
Or. J. S. Pasricha MD. PhD
Professor of Dermatology
AllMS
New Delhi
December 1990
ALLERGIC RHINITS
Allergic Rhinitis has been defined as, an IgE mediated
hypersensitivity disease of the mucous membranes of the
nasal airways characterized by sneezing, nasal blockage,
and discharge. However, classical IgE mediated allergic
rhinitis is not always seen. This is because many allergens
induce not only IgE, but also a complex array of
inflammatory mediators. Also, both Allergy and Infection
both may coexist, each potentiating the other. Consequently
there are two different classifications of RHINITIS.
Infectious and non infectious (Allergic and non allergic)
Allergic further subdivided into Seasonal & Perennial
II) As being due to mechanical, allergic, mucociliary clear
ance abnormality, granulomatous disease, autonomic
imbalance, hormonal imbalance and iatrogenic causes.
I)
It should be borne in mind that the lining of the nose and the
paranasal sinuses is continuous and inflammation of one
invariably affects the other. Also the upper and lower
respiratory tracts are closely related, in anatomy, in
physiological functions and in responses to the environment.
The
incomplete nature of our knowledge of
its
pathophysiology, the plethora of investigations, and
unpredictable nature of response to therapy, makes
formulation of a scientific approach to the management of
these patients difficult.
Dr. Ravi ,C. Nayar
Department of Otorhinolaryngology
St. John's Medical College and Hospital
Bangalore 560 034
OCULAR ALLERGY
Ocular allergic disorders are among the most commonly
encountered eye problems. Conjunctiva is the most
frequently affected. Ocular allergy and conjunctivitis are
often considered synonymous. Allergic conjunctivitis may
manifest as seasonal allergic conjunctivitis, perennial
allergic
conjuntivittis,
vernal conjunctivitis and gaint
papillary conjunctivitis.
Phlyctenular conjunctivitis
is
considered as a manifestation of endogenous allergy.
Among the deeper inflammations uveitis has a presumed
immunological basis. Transparent structures like cornea, lens
and vireous being avascular, are not frequently involved in
allergic disorders.
Dr. Mahabaleswar MD. DO. MNAMS
Professor and Head
Dept of opthalmology
St. John's Medical College Journal of Medicine
ABSTRACTS
IN VIVO AND IN VITRO METHODS FOR
THE DIAGNOSIS OF ALLERGY
Antibodies are generally viewed as desirable agents
endowing protection against infectious diseases. However,
immunologic injury mediated by undesirable or harmful
properties of antibodies can lead to hypersensitivity resulting
in tissue damaging reactions. Among the four types of
hypersensitivity, type I is mediated by IgE class of antibodies
resulting in the manifestation of atopic allergy, the clinical
consequence of which may range from bronchial asthama,
allergic rhinitis, allergic conjunctivitis, gastrointestinal allergy,
sytemic anaphylaxis to atopic dermatitis.
The methods currently available for the diagnosis of atopic
allergy can be categorised into three tyeps, viz. (1) skin tests
(prick and intradermal) (2) provacation tests (nasal, bronchial
or conjuctivial challenge with the offending allergen or oral
challenge for foods) and (3) in vivo tests for the quantitation
of total and allergen-specific IgE antibodies.
Elevated levels of IgE antibodies are often associated with
atopic allergy and an in vitro test for total IgE is an useful
indicator in the diagnosis. Positive skin tests together with the
demonstration of specific IgE antibodies in the serum of an
individual will aid in the identification of the offending
allergens.
IgE antibodies specific for an allergen can be demonstrated by
radioallergosorbent test (RAST) or ELISA or by quatitating the
release of histamine by passively sensitized normal
leucocytes after incubating with atopic patient's serum and
subsequent challenge with the offending allergen. A
combination of the in vivo and in vitro methods are crucial not
only for determining the atopic status of an individual, but also
to accurately identify the offending allergen(s) which will help
in effective disease management and immunotherapy. The
various in vivo and in vitro methods currently available for the
diagnosis of atopic allergy will be discussed.
Dr. P V. Subba Rao
Laboratory of Immunology and
Allergic Diseases,
Department of Biochemistry
Indian Institute of Science
Bangalore - 12
104
VOL III No. 4----
DERMATOLOGY- SYMPOSIUM
St. John's Medical College Journal of Medicine
FOOD ALLERGY
P.S. KA MA TH
Food allergy is a diagnosis often entertained, seldom
investigated and rarely confirmed. Food allergy is defined as
an immunologically
medicated clinical syndrome that
develops after ingestion of a dietry product. The definition
thus must fulfill two criteria : (1) The demonstration of a
reproducible reaction to a specific food and (2) evidence
that this reaction is immunologically medicated.
PATHOPHYSIOLOGY
There is so much confusion regarding terminology to be used.
The following is a list of definitions which are used for
uniformity:
The intestinal mucosal barrier protects against dietary
antigen. Disruption of this barrier as in the newborn period or
after an intestinal infection can lead to the development of
food allergy. The integrity of the mucosal barrier is
contributed to by both immunologic and non immunologic
factors. These factors are outlined in Table 1, and include
pH, peristalsis, proteolytic activity and intestinal epithelial
membrane factors as non immunologic factors; the
immunologic comopnents comprise the gut associated
lymphoid tissue. Factors which increase macromolecular
absorbtion by the gut are listed in Table 2.
Adverse immunological response to
ingested food.
Table 1 : Factors controlling Macromolelcular Transport
in the Gut
Food allergy
Synonymous with food sensitivity.
Non immunologic Factors
Food anaphylaxis :
Acute food sensitivity involving IgE
antibody.
Food intolerance :
Synonymous with food poisoning.
Indicates non-immunologic action of
ingested food or food additives either
as contaminants or released by
organisms which are contaminants of
food.
Anaphylactoid
Nonimmunologic release of chemical
mediators Reaction mimicing food
anaphylaxis.
Pseudoallergy
Encompass anaphylactoid reaction
as well ass adverse pharmacological
and adverse metaboric reactions.
DEFINITIONS
Food sensitivity
:
EPIDEMIOLOGY
Food allergy is reported to occur in upto 7 percent of the
pediatric population. Immaturity is an important factor in the
pathogenesis of the condition and a family history is a major
predisposing factor. Breast feeding during the first few
months of life probably decreases the infant's risk for the
development of food allergy.
P.S. KAMATH MD, DM
PROFESSOR AND HEAD
DEPARTMENT OF GASTROENTROLOGY
ST JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE 560 034
December 1990
Indigenous intestinal flora
Secretions
Gastric barrier
Peristaltic movement
Liver filtration
Miscellaneous
Pancreatic snzymes
Goblet cell mucus
Local immunologic defenses
Secretory IgA
Cell-mediated immunity
Other immunoglobulins (IgG.M.E).
Table 2
Factors leading to Enhanced macromoleculte uptake in
Gut
Local antibody deficiency
Secretory IgA deficiency
Altered mucosal barrier
Changes in surface membrance
charge Inflammation
Ulceration
Lysosomal dysfunction
? Storage diseases
? Corticosteroids
Intraluminal factors
Decreased gastric acidity
Pancreatic insufficien
The mechanism of intestinal production of committed B cells
is not completely understood. Lymphocytes within Peyer's
patches are stimulated by intestinal antigens by means of
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St. John’s Medical College Journal of Medicine
specialized epithelial cells.
Lymphoblasts migrate to
mesenteric nodes for further maturation, enter the systemic
circulation, and then migratebacktothelamina propria. Here
they produce secretory IgA in response to intestinally
absorbed antigens. While helper T cells mediate a local
intestinal B-cell response, the systemic immune response
to dietary antigen is in general subded or absent. This is
because while the local IgA response is stimulated by local
antigens the IgG and IgE responses are suppressed. This
suppressed response to dietary antigen is called oral
tolerance. Tolerance is mediated by suppressor T cells which
are activated in Peyer’s patches in response to antigen
presentation. Once induced, these suppressor T cells
migrate to pheripheral lymphoid tissue where they mediate
tolerance by supressing systemic humoral (IgG, IgE, IgM)
and cell-mediated responses to specific dietary antigens.
In the newborn the intestinal mucosal barrier is immature.
The impaired barrier which facilitates macromolecular
uptake is contributed to by changes in the composition of the
microvillous membrane low gastric acid output, decreased
proteolytic activity and altered mucin production. The
intestinal immune mechanisms are also poorly developed
and the newborn intestine lacks the capacity to produce
immunoglobulins. IgA concentrations in saliva, stool and
serum of neonates are lower than in adults.
CLINICAL FEATURES
The clincial features of food allergy are influenced by factors
such as age, thequantity and qualityoffood ingested and the
presence of coexisting medical conditions.
Two general types of food sensitivity
reactions are
encountered. Immediate and intermediate reaction which are
IgE - mediated and delayed responses which are non-lgEmediated. The immediate or anaphylactic reactions present
as urticaria, laryngeal edema, asphyxia and sometimes
death. The intermediate reactions occur within two hours of
antigen exposure, are less dangerous than immediate
reactions and present with gastrointestinal symproms,
urticaria, asthma and rhiunitis. Delayed reactions which are
non-lgE-mediated occur more than two hours after antigen
exposure,are difficulttodiagnose andproduce symptoms as
non-specific
and migraine. Other features are recurrent
abdominal pain, joint pains and apthous ulcers. The
symptoms
are
either gastrointestinal or extra
gastrointestinal.
GASTROINTESTINAL TRACT
The oropharynx is the site of initial exposure of food antigen.
Thus, edema and pruritis of the lips, mouth and hypopharynx
may be the initial symptoms of food allergy. Because of
repeated episodes of swelling of the mouth, lips and tongue
chronic mucosal fissuring of the mouth may occur.
With
the passage of the antigen into the stomach and
106
intestine a acute onset of nausea, vomiting, abdominal pain,
diarrhea or even bloody diarrhea may occur. At upper
gastrointestinal endoscopy gastric edema and petechial
hemorrhages may be seen.
The pathologic changes in the intestine in children with allergy
to cow's milk have been well characterized. The mucosa is
thin with patchy areas of villous atrophy. Because of this
mucosal injury infants have diarrhea,
protein-losing
enteropathy, iron deficiency anemia due to chronic intestinal
blood loss and weight loss. Cow’s milk allergy is an important
cause of failure to thrive in infancy.
In children younger than 2 years of age proctocolitis can result
from cow’s milk allergy. The primary manifestation is bloody
diarrhea. Sigmoidoscopy and biopsy reveal a focal or
diffuse colitis with eosinophilic infiltrate. Of interest, this
condition can occur in strictly breast-fed infants. In these
infants the allergic colitis results from maternally derived
cow’s milk protein antigens that are transmitted to the infant
in breast milk. Elimination of cow's milk from the mother's diet
results in resolution of symptoms.
Eosinphilic gastroenteritis. The relationship of this condition
to food allergy is not clear. Many areas of the gastrointestinaL
tract are inflamed and diffusely infiltrated with esinophils,
particularity in the gastric antrum. Thickening of the intestinal
wall may occur resulting in bowel obstruction. Serosal
disease results in eosinophilic ascitis. The mucosal form
may be triggered by specific food antigens.
RESPIRATORY TRACT
Rhinorrhea and sneezing are manifestations of food allergy
which may occur in association with gastrointestinal or
cutaneous symptoms. Bronchoconstruction may also occur.
An unusual syndrome has been described in infants fed on
cow’s milk and is characterised by recurrent pneumonia,
pulmonary hemosidserosis, anemia, failure to thrive and
gastrointestinal blood loss. IgE rather than IgE has been
implicated.
Skin. Urticaria and angioedema are frequenct manifestations
of food allergy. In infants food sensitivity is considered to play
a pathogenic role in atopic dermatitis. Characteristic features
are an erythematous maculopapular eruption most often
involving the head and neck, the cheeks and creases behind
the ear. A family history of atopy exists in most cases.
Positive skin and radioallergosorbent tests to food products
are frequently found.
DIAGNOSIS: The definitive diagnosis for food allergy is
based on the demonstration of a clinical reaction to a food
challenge, with elimination of the symptom complex on
removal of the offending food product. Thus, the criteria for
diagnosis of milk allergy are : 1. Symptoms subside on
ellimination of milk from the diet. 2. Symptoms recur within 48
hours after refeeding. 3. Three sequential challenges are
VOL III No. 4 —
St. John’s Medical College Journal of Medicine
positive. 4. Symptoms abte after each challenge. While the
criteria seem straigh-forward they are often difficult to satisfy.
The initial approach to the patient with a suspected food
allergy should
include a careful history and physical
examination. The important questions to be asked should
relate to the severity of the food reaction, the timing of the
reaction after ingestion of food, the type of foods involved,
and a family history. It is known that patient’s histories are
often unreliable. In such cases an elimination diet may be
useful for diagnosing untoward reactions to food.
Skin tests with food extracts are performed by the prick or
scratch method. A positive skin test is defined as a wheal with
a diameter of 3 mm or greater than that produced in a
negative control test. Fasle positives are common; -a
negative test ususally indicates absence of allergy to the food
product. Skin tests are unreliable in children younger than 3
years of age. The radioallergosorbent test is more expensive
but not superior to skin testing.
population especially, adequate calorie, vitamin and mineral
replacement must be ensured. About 30 to 40% of children
lose their sensitivity to some foods after several years.
Antohistaminics may be useful for the control of rhinitis or
urticaria. The ideal approach, of course, is to prevent the
development of food allergy.
SUGGESTED READING:
1. Heyman MB. Food sensitivity and eosinophilic gastroenteropathies.
In Gastrointestinal Disease: Pathophysiology Diagnosis
Management.
Sleisenger MH, FordtranJS Eds. Fourth Edition, Philadelphia WBSaunders
1989; 1113-34
2. Schreiber R A. Walker WA. Food allergy. Factsand fiction. Mayo Clin Proc
1989;64:1381-91.
3. Walker WA. Antigen handling by the smal intestine Clin Gastroenterol
1986;15:1-20
4. Walker Smith JA: Food sensitive enteropathies.
1986;15:55-6.
Clin Gastroenterol
TREATMENT
5. Stern M, Walker WA. Foody allergy and intolerance. Pediatr Clin North Am
1985;32:471-84.
The only proven effective therapy is an elimination diet. It is
important
to avoid malnutirition and in the pediatric
6. Alpers DH, Clouse RE, Stenson WF. Manual of Nutritional therapeutics
2nd Ed. Boston. Little Brown and Co. 1988.
December 1990
107—
DERMATOLOGY- SYMPOSIUM
St. John's Medical College Journal of Medicine
PRACTICAL SKIN TEST, PROCEDURES IN ALLERGY
I- PATCH TESTING
ANIL ABRAHAM
THE PRINCIPLES OF PATCH TESTING
SITE FOR PATCH TEST
INTRODUCTION
a)
Patch testing is based on the principle that in an allergic
individual, the whole skin is capable of reacting with the
causative allergen. Therefore if the antigen is applied on an
apparently
normal skin area, it could provoke . a
representative reaction on the area tested.
Upper back is the best site; lower back, flexor aspects of
arm and forearm and extensor aspect of thigh are
alternatives.
PATCH TEST UNITS:
Several patch test units have been used. The more popular
ones have been listed :
a) Al-test unit
b) Finn chamber
c) Duhring chamber
d) Pasricha patch test unit
e) Indigenous Finn chamber (Kaur & Sharma)
f) Pre-packed units (PA patch)
The simplest patch test unit which can be implemented with
minimum materials is described in Fig.1.
Allergen
2.5 Cm2 Gauze
b) Avoid mobile areas such as over the spine or the medial
border of the scapula (Fig.2).
c) Avoid areas with active dermatitis.
d) Avoid hirsute parts of the body
TIMING OF PATCH TEST
a) Preferably after active dermatitis has settled.
b) To be avoided when the patient is on systemic steroids
or other immunosuppressive drugs. ( Not > 20 mg
Prednisolone).
4 cm Sq.
Adhesive Tape
Filter Paper
Fig. 1 : Patch Tost Unit
EQUIPMENT AT HAND DURING TESTING
a) Patch test kit
b) Allergens in appropriate vehicle and concentration
c) Marker pen.
PRACTICAL STEPS IN PATCH TESTING
DR. ANIL ABRAHAM
MD, DNB
DEPT. OF DERMATOLOGY,
ST.JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE 560 034
108
a) Detailed history for possible allergens.
b) Review treatment history
c) Examine back for suitability lor patch testing
d) Clean area for proposed patch
e) Transfer allergens to patch test unit
VOL III No. 4 —
St. John's Medical College Journal of Medicine
f) Record and number allergens on proforma
g) Transfer patch test unit to patient’s back. (Fig.2).
INSTRUCTIONS TO PATIENT
a)
b)
c)
d)
e)
Do not bathe/indulge in strenuous activity for 48 hours.
Report for reading after 48 hours.
If there is severe itching, report to the doctor early.
Do not ingest/apply medication during this period
Do not remove patch for 48 hours.
READINGS OF RESULTS
?
Doubtful reaction
+ Weak (Non-vesicular)
++ Strong (vesicular)
+++ Extreme
Negative
IR Irritant reaction
NT Note tested
Faint Macular Erythema only
Erythema, Infiltrn, Papules
Above + vesicles
Bullous reaction
Nothing to see
Well demarcated, severe
MODIFICATIONS OF PATCH TESTING
a)
b)
Photopatch test: Where the sun may play a contributory
role the patch test is modified to include sun exposure of
a duplicate set of allergens.
Usage test: This is common practice in the case of hair
dyes and perfumes and consists of direct non-occlusive
application of the suspected offender.
FALSE POSITIVE PATCH TEST RESULTS
a)
b)
c)
d)
Concentrated/lrritant Test substance
Active dermatitis
Angry-Back Syndrome
Plaster reaction
FALSE NEGATIVE PATCH TEST RESULTS
a)
b)
c)
d)
Incorrect diluent/weak test substance
On topical or high dose systemic steroids
Poor occlusion of Patch
Reading too early/too late
RELEVANCE OF PATCH TESTING
Calnan states that the greatest abuse of the patch test is
failure to use this test! It is a unique direct in-vivo test, and
when properly applied and correctly interpreted it is the only
scientific proof of contact allergic dermatitis. A good history
and appropriate clinical correlation with environmental
allergens are invaluable in optimally utilizing the Patch Test in
allergic skin disease.
RECOMMENDED READING
1. Calnan CD: The use and abuse of Patch Tests' In HI Maibach and GA
Gellin (eds): Occupational and Industrial Dermatology, Chicago, Yr. BK.
Medical Publishers 1982 p35.
2. Arndt KA : ‘Patch Testing' in Manual of Dermatologic Therapeutics.
Boston, Little Brown & Co. 1989 p 184.
COMPLICATIONS OF PATCH TESTING
3. Fischer AA: The Role of Patch Testing in Contact Derm. Philadelphia,
Lea & Feblger, 1986 pp9-29.
a)
b)
4. Pasricha JS : 'Testing Procedures' In contact Dermatitis in India. Survey
of the causes of contact Dermatitis in India. 1988;1:6-20.
Sensitization to new allergens
Rarely, flare of dermatitis, secondary infection pigmenta
tion, scars, keloids.
December 1990
109—
DERMATOLOGY- SYMPOSIUM
St. John’s Medical College Journal of Medicine
PRACTICAL PROCEDURES IN SKIN TESTS FOR ALLERGY
II - PRICK TESTING
ELIZABETH JAYASEELAN, S.C. RAJENDRAN, ANIL ABRAHAM
INTRODUCTION
EQUIPMENT AT HAND DURING PRICK TESTING
Skin tests are the fundamental tools in the investigation of IgE
mediated allergic diseases. The origin of these tests can be
traced back to Harrison Blackley in the 1860's who first
attempted scarification for the diagnosis of Hay Fever. The
procedure was improved and made more scientific by Noon
and Freeman in 1911.
a) Allergen Extracts : A standard extract is defined as one
which contains a measured amount of specific antigen. Most
of the presently available commercial extrats have labels that
specify the volume of protein nitrogen units (PNU) or state
the weight to volume ratio of the extracted ingredients.
Squeezed juice, beer, wine or milk can be safely used for skin
testing.
PATHOGENIC BASIS
The antigen in the extract used reacts with the specific IgE
antibodies fixed to the most cells of the skin, triggering off their
degranulation. In those who have never been exposed to the
allergen, orthose who have not developed IgE to the provoca
tive extract, the reaction will be negative.
Similarly following immunotherapy by desensitisation, block
ing antibodies or IgG will bind to the antigen, thus impending
an IgE moderated most cell response.
Types of skin tests :
There are two approaches to allergy skin testing
A. Cutaneous or Epicutaneous
a) Scratch test
b) Puncture test
c) Prick test
B. Intradermal
- In this method the extract is injected into the superficial
layers of the dermis.
COMPARITIVE ADVANTAGES OF THE PRICK TEST
The Present discussion concentrates on the prick
method because of it’s relative advantages.
a) Safety, speed and simplicity
b) Numerous antigens can be tested simultaneously
c) Negligible risk of anaphylaxis
d) Minimum discomfort
DR. ELIZABETH JAYASEELAN
DR. S.C. RAJENDRAN M.D
DR. ANIL ABRAHAM M.D
DNB
DEPARTMENT OF DERMATOLOGY
ST.JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE
i io
test
b) Controls : Skin testing employs a negative control in the
form of saline or diluent and a positive control, 0.1 mg/ml
histamine hydrochloride. The positive control is the standard
against which positivity is graded and is also useful in detect
ing suppression of the test reponse by medication.
FACTORS INFLUENCING TEST RESULTS
a) Medication
Antihistamines affect the degree and duration of suppresion
of wheals induced by prick testing with histamine.
The mean suppression following diphenhydramine was 1.9
days, chlorpheniramine 2.5 days, hydroxyzine 4.3 days, terfenadine 6 days and aztemizole 27 days. Anti-emetics and
tranquilizers of phenothiazine and imipramine class also have
antihistaminic activity. Hence routine antihistaminic drugs
should be discontinued fora week before skin tests and longer
acting drugs like astemizole should be stopped at least two
and a half weeks before. The positive control with histamine
during skin testing therefore, has an important role to play in
determining whetherdrugs have dulled the allergic response.
Bronchodialators like epinephrine, theophylline and beta-2
specific adrenergic agonists do not interfere with the skin
reaction and can be continued safely. Corticosteroids upto an
equivalent of 30 mg prednisolone daily have also been
considered admissable.
b) Site of testing
The most reactive parts are the upper and mid-back and these
sites have the additional advantage of furnishing a wide area
to test a large number of allergens simultaneously.
The forearm is commonly chosen for convenience and at this
site the ulnar border is most reactive while the wrist is the least
reactive.
c) Timing of Testing
Early morning is the least reactive time of the day while the
VOL III No. 4 —
St. John's Medical College Journal of Medicine
period between 1900 hours and 2300 hours has been found
to elicit the maximum response.
d) Age of the Patient
The reaction in infants is smaller than in adults and the
maximum response has been elicited in individuals in the third
decade. There is a steady decline in responsiveness after the
age of fifty which possibly corresponds to a decrease in total
and specific IgE levels with age.
PRACTICAL STEPS IN PRICK TESTING
1. Historical review for possible allergens.
2. Advice regarding prior discontinuation of medication that
may interfere with result.
3. Test site cleaned with spirit and allergen sites marked.
4. Allergen extracts placed as drops near the marked sites
with at least 4 cms. distance between adjacent allergens.
5. Positive control (saline) also positioned.
6. Standard lancet used at 45°angle to cause a small break
in the epidermis without bleeding at the site of extract. Saline
is pricked first and histamine last. The same lancet is used
throughout the test by wiping the tip with a moist gauze after
each allergen.
7. Extracts are mopped with filter paper.
8. Readings are carried out at 10 minutes, 15 minutes and 20
minutes.
9. Equipment is at hand to deal with a severe reaction.
FALSE NEGATIVE TESTS
CONCLUSION
The prick test is a safe, sensitive and economical means of
obtaining information regarding allergy, upon which a clinical
judgement can be based.
GRADING OF RESULTS
Grading depends on the size of the wheal in relation to the
wheal produced by the positive control 0.1 mgm/ml histamine
hydrochloride the measurement usually used is the average
of the longest diameter, and the diameter perpendicular to it.
Unfortunately there are several methods of grading the
response, the Scandinavian society of allergologists have
proposed an acceptable grading which is implemented at the
allergy clinic of St. John's Medical College Hospital.
Grade
4+
3+
2+
Description
Wheal twice the size of positive
control / or pseudopods
Wheal equal to the size of positive
control
Wheal half the size of positive control
Positive control
Negative control
Negative result
: Histamine
: Saline
: less than 2 +
FALSE POSITIVE RESULTS
1. Lack of stability or deterioration of stored extract.
2. Localized allergy is a phenomenon where skin tests may
be negative because the allergic response is only at the
trigger anatomic site eg. the nose or bronchus.
3. Skin sensitivity in children may be delayed by 1-2 years
after onset of symptoms.
1. Concentrated extract
2. Inadequate distance between extracts : - If 4-5 cms
distance is not maintained, a strong positive can cause non
specific enhancement of neighbouring tests.
3. Histamine control too close to allergens
RELEVANCE OF THE PRICK TEST
RECOMMENDED READING
1. The test correlates well with clinical disease and can be
performed rapidly and safely.
2. It can be used to test a large number of suspected
allergens simultaneously.
3. There is a good correlation between a positive prick test
and a positive RAST.
4. The test is useful as an indicator of the response to
immunotherapy by hyposensitisation.
5. However the skin test MUST be correlated with the
patient's history and environmental exposure. Irrelevant
positives to unrelated food or environmental allergens can be
totally misleading for the unwary practiconer.
6. In addition discontinuing antihistaminics in patients with
active disease may be a hurdle in practice. So also allergy skin
tests without relevant advice on how to avoid the allergent,
and without desensitisation facilities would be a farce.
1. Diagnostic Procedures in allergy - Allergy skin testing : Harold S. Nelson
Annals of Allergy 1983 Pg 411-416
December 1990
2.
Allergy skin testing : Imber We. Journal of Allergy and Clinical Immunol
ogy 1977;60:47.
3. Immediate (IgE mediated) skin testing in diagnosis of allergic disease.
Annals of Allergy 1978:41:211.
4. Skin test reactivity and clinical allergen sensitivity in infancy : p p
Asperen Journal of Allergy and clinical Immunology 1984;73:381-382.
5. Duration of inhibition of skin reactivity by antihistamines : Annals of Allergy
1989 vol.62:525.
6. Clinical evaluation of a new Enzyme - Assay for allergen - specific IgE.
Joel Du et al Annals of Allergy. 1989,Vol.62:503.
7. Is the choice of allergy skin testing versus in vitro determination of specific
IgE, no longer a scientific issue? Annals of Allergy 198962:373.
REVIEW
St. John's Medical College Journal of Medicine
AUTOLOGUS BLOOD TRANSFUSION : ITS ROLE IN
ORAL & MAXILLOFACIAL SURGERY
P.K.NAYAK, K.S.LIM, R.P. WARO-BOOTH
Oral cancer in the U.K. represents about 2% of all cancers.
In India this figure is elevated to about 30% of all cancers.
Many patients present too late for any effective treatment.
Others suitable for treatment receive radiotherapy. This
leaves a substantial number of patients with oral cancer
who require surgery as a primary modality or as salvage after
radiotherapy. This latter group may have their surgery antici
pated as part of a planned combined treatment. These
patients therefore present a significant surgical problem to
maxillofacial surgeons.
The highly vascular anatomy of the head and neck region
makes it necessary to cross-match and often transfuse blood
to patients undergoing this type of surgery. Although it is
not always necessary to undertake the extensive recon
structive procedures seen in western maxillofacial surgery,
the ablative surgery normally requires the patient to be
cross-matched.
Maintenance of well stocked blood banks is a problem in
any country, but is considerably more difficult in the third
world countries. Many patients are concerned, albeit errone
ously, that blood transfusion may be associated with the
risk of cross-infection, particularly from A.I.D.S. (Acquired
Immune Deficiency Syndrome).
It has been proposed’ that autologous blood transfusion the recycling of the patient's own blood, this being pre
deposited during the days/weeks that precede the operation
- may alleviate these fears. It will also have other benefits
which are probably more significant. The development of
an effective blood substitute has not yet materialised.
P.K.NAYAK, MDS, FDS,RCS (ENG), FDS, RCPS
(GLAS), FFD, RCS(IRE)
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
CENTRAL MIDDLESEX HOSPITAL
LONDON. 10 7NS
K.S.LIM, BDS, LDS, RCS (ENG)
R.P. WARD-BOOTH, MBCHB, FDS, RCS (ENG),
FRCS(ED),
CONSULTANT ORAL & MAXILLOFACIAL SURGEON
SUDERLAND DISTRICT GENERAL HOSPITAL
KAYLL ROAD SUNDERLAND. SR4 7T0
112
Autologous blood transfusion (ABT) eliminates virtually all
the hazards of homologous blood transfusion. Cross
matching is not essential, no disease is transmitted, the
presence of drugs is less important and the risk of isoimmu
nization to foreign proteins present in donor blood is ex
cluded. Patients with religious objections to blood
transfusions may accept ABT with certain safeguards. It must
be stressed, however, that the risk of transmission of the
H.I.V. is very low, estimated at less than one in a million.2
TECHNIQUE OF AUTOLOGOUS BLOOD
TRANSFUSION
The technique of ABT is well established in the United States
and Australia 3-4-5. Increasing sophistication of surgery indi
cates that the need for blood has reached a stage when
demand is in the danger of out-stripping supply. Most forms
of elective surgery may be covered by pre-operative
donation, and may orthopaedic, vascular and gynaecologi
cal procedures can be carried out using autologous blood.
Results show that about 25% require no blood at all, and in
two third of the operations, autologous blood sufficed 6J.
There are threee methods for collecting blood for ABT :
1. Salvage of blood during and after cardiopulmonary
bypass surgery. Blood scavenging
machines8-9 are not
widely used in the U.K. but can be helpful for patients with
ruptured aortic (thoracoabdominal) aneurysm, ectopic
pregnancy, liver transplantation and trauma.
2. Peri-operative collection and haemodilution in theatre
provides a ready supply of fresh blood for retransfusion at
completion of surgery.
3. Pre-operative donation and storage'0-” is cheap, effec
tive and provides economy of homologous blood usage.
This is the method to be discussed in this paper. In the U.K.
the blood transfusion service does not recognise the
particular need for ABT, and therefore it is not routinely
available. In Sunderland, however, whilst there is no routine
service provided a limited number of patients are able to
receive ABT on an experimental basis. This service has
been extended to provide a regular supply.
ABT needs careful and separate identification of blood for
autologous use. Clearly, the blood will not be screened and
cross matched in the conventional manner of homologous
transfusion, and hence it must be strictly segretated from
normal blood bank sources. There are no definite limits as to
VOL III No. 4 —
St. John's Medical College Journal of Medicine
the age at which the blood can be collected from the donor,
but children would
normally be unco-operative. It is
suggested that anyone who has normal marrow function and
who is fit for general anaesthesia andsurgery, is fit to donate
blood in an ABT program12. A patient who is medically eligible
for ABT must be fully informed of the risks and requirements
of the procedure and should sign a specified consent form
for this purpose.
The patient must present with a haemoglobin greater than
11 gms/dl, orapacked cell volume of 34%ormore. Inaddition,
no more than 12% of the estimated blood volume of a patient
should be drawn at any one visit. The autologous blood is
available for approximately 35 days after collection with the
blood stored in the liquid form with citrate phosphate dextrose
and adenine. Upto 8 units of blood (405-495 mis. each) can
be withdrawn altogether. In the experience of oral surgeons
in the United States-1 a predeposit of 2 units was required in
most of their cases of combined maxillary and mandibular
orthognathic surgery.
The blood should be collected at no more than 3 day intervals
and last phlebotomy should take place no less than 72 hours
before surgery. 72 hours is the maximum time required for
mobilisation of protein to return the plasma volume to
normal. Iron availability is the limiting factor in haematopoiesis
following phlebotomy, and chronic phlebotomy of one unit
every two days is well tolerated as long as adequate iron
replacement is available. Ferrous sulphate (300 mgs 3 times
daily) is prescribed and increased marrow activity achieves
an increase in haemoglobin concentration of 1 gm/dl, replacing
one unit every 3 to 5 days.
Under such management the patient should have at opera
tion, a haemoglobin above 10 gm/dl, a level considered safe
by the majority of anaesthetists. The drop in packed cell
volume following the operation may have the following advan
tages.
1.
2.
3.
Reduced possibility of thrombosis
Improved capillary perfusion
Reduced whole blood viscosity
Additionally, the marrow is maximally active at the time of
operation and is better able to replace any blood loss above
that provided by autologous transfusion.
Remaining blood may, if necessary, be returned to the blood
bank and subsequently used for homologous transfusion. If
transfusion of autologous units does not occur within the
dating period of the oldest unit, loss of this unit may be
prevented by returning this Blood to the donor just after
draining a fresh unit - the ‘leap frogging’ technique.
DISCUSSION
Autologous blood transfusion is a technique popularised in
the west for essentially healthy, well nourished patients under
December 1990
going elective surgery. Transporting this technique to
India, despite all its potential advantages requires careful
consideration.
In India maxillofacial surgery rarely involves the elective
surgery seen in the U.K. For example, facial osteotomies
are rarely carried out, although large jaw cysts, benign
salivary lesions will present. Naturally it is estimated that
even in the U.K. patientswill have pre-surgical radiotherapy
up to 40 Gy. As mentioned before the reconstructive
surgery is frequently minimal and blood loss correspond
ingly less. Onlytwounitsarenormallyrequiredforresection
of the tumour and neck dissection.
It thus seems highly likely that the small amount of blood
required for transfusion coupled with the inevitable delays
before the patient will get to surgery make ABT a viable
option. The indications'for ABT in the west also apply to
India.
The indications for transfusion of blood products remain
the same, but are not always strictly applied. This may on
occasions lead to excessive transfusions. These indications
are transfusion of packed cells or whole blood to replace
blood loss, and the transfer of specific blood products,
e.g. Facter VII in haemophiliacs.
There are clearly many good reasons for avoiding
unnecessary blood transfusion. The most significant
reason are the immunological factrs19.
Alloimmunisation
Incompatibility
Red cell, leucocyte and platelet
antigens.
Plasma protein antigens
a. Red cell incompatibility
Intravascular haemolysis - ABO
incompatibility
Extravascular haemolysis Immediate/delayed
b. Leucocyte and platelet
incompatibility
Febrile reactions (granulocytes)
Pulmonary reaction (granulocytes)
Post-transfusion purpura (platelets)
Poor survival of transfused
platelets and granulocytes
Graft vs. Host reactions
(lymphocytes)
c.
Plasma protein incompatibility
Urticarial and anaphylactic
reactions.
Post-transfusion hepatitis is a possible sequel of blood
transfusion20, and may be caused by the Hepatitis B virus,
St. John’s Medical College Journal of Medicine
agent(s) of Non-A Non-B Hepatitis, Epstein-Bar virus and
Cytomegalovirus. Bacterial Syphilis, Brucellosis, Rickettsial
disease and parasitic (Malaria, Fillariasis, Trypansomiasis,
Leishmaniasis ad toxoplasmosis) infections may also be
transmitted by blood transfusion.
In young, fit and healthy patients, it is quite acceptable for
them to lose 10-30% of their total blood volume during
surgery. If however, blood transfuion is anticipated, then
there are several advantages in offering the patient the
option of ABT. The advantages of ABT are summarised as
follows21
10
9
*.
1. Blood is available in areas remote from donor banks,
under all conditions with no limitations due to time,
geography or catastrophe.
Therefore in view of the distinct advantages, in terms of
safety and effectiveness, offered by the technique of ABT
as compared to homologous blood transfusion it would seem
particularly relevant to this type of oral and maxillofacial
surgery. The logistics and need to establish this service in
India requires further evaluation.
It must be emphasised however, that any discussion on
the role of ABT does not imply any doubts about the
competence or effectiveness of the screening procedures
by the Blood Transfusion Service. Above all, this paper
aims to stimulate greater consideration to the role of
Autologous Blood Transfusion in third world countries.
REFERENCES
1.
2. In instances of rare blood types, the autologous may be
the only possible donor.
Marciani R.D.J. Oral & Maxfac. Surg. 1985;43:201-204.
2. Barbara J. A J Contreras M and HewitP. Brit. J. Hosp. Med. 1986;36,3:178184.
3. The possibility of errors in typing or cross-matching are
eliminated.
3. Zuck T. Introduction in : Amerdan Assodation of Blood Banks, ed. Autolo
gous transfusion. Washington DC : Amerdan Assodation of Blood Banks
1976.
4. No incompatibility reactions or sensitization to other
human antigens will occur.
4. Ibister J P. Strategies for avoiding or minimising homologous blood transfu
sion. A sequel to the AIDS scare Med J. AusL 1985;142:596-598.
5. Pyogenic or allergic reactions due to blood factors are
eliminated.
5. American Assodation of Blood Banks. Standards for blood banks and
transfusion services. Washington, DC : American Association of Blood Banks
1981.
6. There is no risk of exposure to carrier transmitted
diseases.
6. Nicholls M.D. Janu MR. Davies V.J. and Wedderbrun D E. Autologous
blood transfusion for elective surgery. Med. J. AusL 1986;144:396-399.
7. Religious priniciples may be respected in instances when
homologous blood is unacceptable.
8. In cases of shock, better volume expansion has been
reported with autologous rather than homologous transfu
sion.
9. Labile coagulation factors are preserved with immediate
reinfusion.
10. Erythropoiesis is stimulated by donation at short intervals.
The possible disadvantages are that there is clearly a need
for time to be available prior to surgery for the blood to be
collected. The patient must be relatively fit and well, with no
significant anaemia, coagulopathy or presence of microem
boli or bacteraemia. In recent years, claims have been made
concerning the effect of homologous blood on the recurrence
of colonic cancer 22'23-24. in terms of cost effectiveness, it
would seem that there is an initial “setting up" cost because
ABT is normally provided at the centres where the oeprations
are to be performed, rather than at centralised transfusion
laboratories. Eventually, the unit cost should fall and be
offset by reduced patient morbidity, and diversion of
unusedblood foruse by other patients. Inaddition, individuals
may be recruited into the population of blood donors.
114
7. James S.E. and Smith M.A. Autologous blood banks transfusion in elective
orthopaedic surgery. J. Royal Soc. Med. 1987;80:284-285.
8. Propovsky M A. Devine P.A. and Taswell H.F. Intraoperative autologous
transfusion. Mayoclin. Proc. 1985;60:125-134.
9. Saarela E. Autotransfusion. A review. Ann. Clin. Res. 1981 ;(suppl 33) :4856.
10. Cable R.G. Implementation of a predonation system. InL Anaesthesiol
Clin. 1982;20 59-76.
11. Kruskall M.S. Glazer E.E. Leonard S.S. etal. Utlisation and effectiveness
of a hospital autologous preoperative blood donor program. Transfusion
1986;26:335-340
12 Miles G. Langston H. and Delassandro W. Experience with autotransfu
sions Surg Gynaecol Obstet. 1982:115:589-694.
13. Kay L A. The need for autologous blood transufion. Brit Med.J.
1987;294:137-139
14. Ammann A. J. Cowan M.J. Wara D.W. etal. Acquired immunodefidnecy in
an infant: Possible transmission by means of blood products. Lancet
1983;1:956.
15. Curran J.W. Lawrence D.N. Jaffe H W. et al AIDS associated with
transfusions. N.Engl.J.Med 1984;310:69
16. Peterman T.A. Jaffe H.W Feorino P.M etal. Transfusion associated with
AIDS in the United States. J.A M A 1985:254:2913
17.
Rouzioux C. ChamaretS. Montagnier I. etal Absence of antibodies AIDS
VOL III No. 4----
St. John's Medical College Journal of Medicine
virus in haemophiliacs treated with heat treated FACT VIII concentra. Lancet
1985;1:271.
18. Wells M.A, Wittek A.E, Epstein J.S. et al. Inactivation and partition on HTLV
III during ehtanolfractionation of plasma. Transfusion 1986;26:210.
19. Walters A.H. and Murphy M.F. Haematology Seminar: Adverse immunol
ogical reaction to blood transfusion. Hosp. Update 1986;12.7:565-574.
20. Seidl S. and Kuhnl P. Transmission of disease by blood transfusion. World
J. Surg. 1987;11:30-35.
21. Kuban O. J. Autologous blood transfusion in American Association of Blood
Banks. Autologus transfuion - A technical workshop Washington DC. Ameri
can Association of Blood Banks. 1976;2-25.
22. Burrows and Tartter P. Effects of blood transfuions on colonic malignancy
recurrence rate. Lancet 1982;2:62.
23. Blumberg N, Agarwal M.M. and Chuang C. Relation between recurrence
of cancer of the colon and blood transfusion. Brit. Med. J. 1985:290:10371039.
24. Fielding LP. Red for danger: Blood transfusion and colorectal cancer. Brit
Med. J. 1985291:841-842.
December 1990
11
ST. JOHN’S MEDICAL COLLEGE
ALLERGY
ALUMNI ASSOCIATION
ST. JOHN'S MEDICAL COLLEGE
BANGALORE
Dear Doctor,
- PANEL DISCUSSION
IMMUNO THERAPY
Moderator - •Dr. Om Prakash, MD,
Panelists — Dr. Swarna Rekha, MD,
Dr. Moire Jacob, MBBS,
DCH, FRCP, LMCC,
Dr. P.V. Subha Rao, PhD,
4 15 - 5.30 PM
This notice follows our first circular in which we announced the
National Symposium on Allergy being organised by the Alumni
Association of S.J.M.C. on Friday 7th December 1990.
This symposium is sponsored by the Indian Council for Medical
Research (ICMR) and forms a part of the Continuing Medical
Education Programme of St. John’s Medical College, Bangalore.
5 30 - 6.30 PM
PROGRAMME
The detailed programme of the Symposium is as follows:
Venue: Room 117, Ground Floor, St. John’s Medical College.
- INAUGURATION
9.15 - 9.45 AM
- REFRESHMENTS
9.45 - 10.00 AM
10.00 — 11.45 AM
— Morning Session
Topic
Venue: OPD Dermat & Medicine Dept
SJMCH
Prick test — Dr. Elizabeth Jayaseelan,
DNBE,
Patch test —
Dr. Anil Abraham, MD, DNBE,
Lung functions test —
Dr. George D’souza, MD
Speaker
Immunology”
“Invivo & Invitro
Techniques
in Allergy”
“Eitopathogenesis of
Bronchial Asthma”
Dr. V.R. Muthukkaruppan, PhD
Madurai Kamaraj University, Madurai
Dr. P.V. Subba Rao, PhD
Indian Institute of Science, Bangalore
Organising Committee
CHAIR PERSONS
Dr. Thangam Joseph, MD
Prof. & H.O.D. — Pharmacology
S.J.M.C., Bangalore
Dr. Dara S. Amar, MD
Prof. & H.O.D. — Community
Medicine
S.J.M.C. Bangalore
PRESIDENT
Bombay
Dr. Mahabaleshwar.MD, DO, MAMS
Prof. & Head
Dept, of Ophthalmology
St. John’s Medical College Hosp.
Dr. Arun B. Kilpadi, MS
Associate Prof. — Surgery, SJMCH
President, S.J.M.C. Alumni Association
Bangalore
ORGANISING
SECRETARY
CUM TREASURER
- LUNCH
JT. ORGANISING
SECRETARY
Dr. S.C. Rajendran, MD, DVD,
Asst. Prof. & Incharge
Dept, of Dermatology & Venereology
Treasurer, S.J.M.C. Alumni Association
Dr. J.J. Alapatt, DLO,
Lecturer - ENT, SJMCH
Gen. Secretary, S.J.M.C.
Alumni Association.
Dr. Om Prakash, MD
St. Martha’s Hospital, Bangalore.
11.45 - 12.00 Noon
— Coffee Break
12.00 — 1.10 PM
Topic
— Pre Lunch Session
Speaker
“Principles of Management Dr. A.S. Chitnis, MD
Jaslok Hospital & Research Centre
of Bronchial Asthma’
‘Ocular Allergies’
1.10 - 2.15 PM
2.15 - 4.00 PM
— Post Lunch Session
T<A
"SWAllergies"
Speaker
Dr. P.S. Pasricha, MD
Prof, of Dermatology & Venereology
All India Institute of Medical Sciences
New Delhi
Dr. Patrick S. Kamath, MD, DM,
Professor
Dept, of Gastroenterology
St. John’s Medical College Hosp.
“Food Allergies”
PRACTICAL DEMONSTRATION
Prick test, Patch test, Lung functions
test
“Nasal Allergies”
Dr. Ravi C. Nayar, MS, DNBE,
Asst. Prof, of E.N.T.
St. John’s Medical College Hosp.
4 00 - 4.15 PM
-Tea Break
SCIENTIFIC
SUBCOMMITTEE
Dr. Ashley L.J. D’Cruz, MS, MCh,
Asst. Prof. & Incharge
Dept, of Paediatric Surgery, SJMCH
Academic Secretary, SJMC
Alumni Association
Dr. Anil Abraham, MD, DNBE
Lecturer
Dept. ofDermatology & Venereology
Bulletin Secretary, SJMC
Alumni Association
Dr. George D’Souza, MD,
Lecturer, Dept, of Medicine, SJMCH
P R O' G R A H fl £
T iminqa
Topic
9.15 AH
to 9.45 AH
Spaakar
9.45
tolO.OO
10.00
ta
10.30
to 10.35
DISCUSSION
Dr. VR• Huthukkarruppan, PhD
Madurai Kamaraj UnlvarAAty
Madurai.
10.35
to
11.05
1105
to
11.10
■ INVIVO A INVITRO TECHNICS
IN ALLERGY "
DISCUSSION
Dr. P.V. Subb. R.o, PhD
Indian Institute of Science
Bangalore.
• ETIO PATHOGENESIS OF BRONCHIAL ASTHMA ■
DISCUSSION
Or. On Prakash, HD
St. Martha’s Hospital
Bangalore.
10.30
11.10
to 11.40
11.40
to 11.45
11.45
REFRESHMENT
■ Basic Immunology ■
to
12.do PH
BREAK
12.00 PH to
12.30 PH
12.30
to
12.35
■ PRINCIPLES OF MANAGEMENT
OF BRONCHIAL ASTHMA «
DISCUSSION
Dr. A.S. Chitnis, MO
Jaslok Hospital & Research Centre
Bombay.
12.35
to
1.05
" OCCULAR ALLERGIES ”
1.05
to
Dr. Mahabaleshuar, HD DO HAHS
Prof. 4 Head
Dept, of Ophthalmology, S3HCH
1.10
DISCUSSION
1.10 Prt to ’.45 PM
l’ u n
2.15 PH to
2.45 PH
" SKIN ALLERGIES ■
2.50
DISCUSSION
2.45
to
C M
2.50
to 3 .20
« FOOD ALLERGIES "
3.20
to 3.25
DISCUSSION
3.25
to
3.55
• NASAL ALLERGIES ■
to
4.00“
DISCUSSION
4.00 PH to
*.is Pn
r.cf’reshment
4.15 PH to
5.30 PH
PANEL DISCUSSION
5.30 PH to
6.30 PH
3.55
Sponsored by
INAUGURATIO N
PRACTICAL PROGRAMME
Prick test. Patch test.
Lung functions test
Dr. 3.5. Pasricha, MO
All India Institute of Medical Sciences
New Delhi.
Dr. Patrick S. Kamath, HO DM
Assoc. Prof. & I/c Head
Dept, of Gastooenterology, SJMCH
Dr. Ravi Nair, MS DNB
Asstt. Prof, of ENT
S3MCH
~ Moderator - Dr. 0* Prakash
Panelists - Dr.'^warna Rokha, Dr. Moire Jacob
. Venue: OPO Dermat 4 Medicine Dept., SJMCH
Prick test - Dr. Elizabeth Jayasselan
Patch test -.Dr. Anil Abraham
Lung functions task - Of. Georgs DeSouxa
BECAUSEOFME^
The Alumni Association of St. John's Medical College & Hospital
Bangalore
THE NATIONAL SYMPOSIUM ON ALLERGY
ON
FRIDAY 7TH DECEMBER 1990
IN ROOM 117, Robert Koch Bhavan, S. J. M. C.
Sponsored by : ICMR & National hcademy of Medical Sciences
Dr. S. C. Rajendran, M. D. , D V. D.,
Organising Secretary Cum Treasurer
Programme Overleaf
Or. Arun B. Kilpadi, M. S.
President
PROGRAMME
09 15 Hrs
-
Welcome Address
Dr. S. C Rajendran, M. D. ,D .V. D.
Organising Secretary
09 20 Hrs
-
Inauguration
Fr. B. Moras
Administrator
St. John's Medical College Hospital
09 30 Hrs
-
Lighting of lamp
and release of
souvenir
Fr. Percival Fernandez, Ph.D
Director
St.John's Medical College &
Hospital
09 35 Hrs
-
Vote of thanks
09 45 Hrs
-
Light refreshment
10 CO Hrs
-
Scientific Programme Commences.
Di. J. J.AIapatt, MBBS, D.L.O.
Hon. Gen. Secretary
READER’S DIGEST • FEBRUARY 1995
tury, and that the next generation
of aircraft, 600- and 800-seaters,
will pick up where the 747 left off.
"It surprised even the optimists
among us," Malcolm Stamper says.
Thirteen hours after takeoff, the
grey and blue 747 lines up with the
runway at Tokyo's Narita Airport
and gently touches down. In a few
minutes the passengers are gone,
and both crews soon after. A le
gion of cleaners and caterers
swarms aboard, then new crews.
By evening, the plane is ready to
go back to work.
Small Surprises
When his wife was expecting their third child, a father decided to
tell his two sons, ages seven and nine, the facts of life. I le checked
out several books from the library on how parents should approach
the subject. After stumbling through an explanation, he took a deep
breath, and said, “Now, boys, do you have any questions?"
“Yes," the younger boy answered immediately.
“Go ahead,” said the man nervously.
“Can we,” his son asked, “have new baseball gloves?”
— Quoted by James Dent in Charleston Gazette
In my class of seven-year-olds I always teach the students not to
intermpt when I'm working with a reading group. The day Jessica, a
conscientious child, approached the reading table, I knew she must
be coming about a serious matter.
Visibly upset, she whispered, “Mrs Cerrone, David called me the
‘E’ word." Having taught for several years, I knew a lot of unspeak
able words, but I couldn't recall any that began with that letter.
Finally I asked, “Jessica, just what is the ‘E’ word?"
After a dramatic pause, she said with great seriousness, “Ignorant."
— Janet Cerrone
Waiting for his first orthodontist appointment, my 12-year-old son
was slightly nervous. He was completing a patient questionnaire and
apparently had hopes of winning the dentist's favour.
I noticed that in the space marked “Hobbies” he had filled in
“Swimming and flossing."
— Annalyn Smith
My 16-year-old son’s room was always a mess. I told him he
couldn’t go out with his friends until he had cleaned half of it.
Just a few minutes later, he was heading for the front door, whis
tling. When I confronted liim, he said, "But, Mum, you told me it
didn’t matter which half I cleaned. So I cleaned the top half!”
— B. L. Stumbaugh
74
JH3HE panicked 2am phone call
B woke Dr Suzanne Corrigan of
■ the American Academy of Pae
diatrics. A woman cried, “My child
has a high fever. What should I do?”
The
paediatrician
quickly
asked: How old is the youngster?
How high is the fever? What are
the other symptoms? “It turned out
that the fever measured
101 degrees F* rectally —
the equivalent of 100 de
grees orally,” says Corri
gan. “And the baby, a 15month-old,
had fallen
back to a peaceful sleep.”
The mother had wor
ried that the fever might
shoot up if she didn’t wake
the child to give medica
tion. Corrigan reassured
her that the fever was mild
and simply the body’s
natural response to fight
ing off an invader, most
likely a virus. The doctor
advised her to let the baby sleep,
unless other symptoms appeared.
“Like many people, this mother
mistakenly, assumed that having
a fever means you’re seriously
ill,” says Corrigan. “I tell pa
tients that fever itself isn't
an illness. It’s how the
body revs up the im
mune system to de
fend against in
fection."
An unwar
ranted fear
vated temperature — a common
reaction — is called “fever phobia”
by Dr Barton Schmitt, a professor
of paediatrics. Few people, says
Schmitt, realize that fever itself is
rarely dangerous, and by treating it
aggressively with
aspirin or
• All body temperatures in this article use the Fahr
enheit scale.
Whera
Wor
Abo
EF@w®[?
As that
little silver line
creeps higher,
we start to panic.
But doctors have
some surprising news
BY CAROL KRUCOFF
WHEN TO WORRY ABOUT A FEVER
READER'S DIGEST • FEBRUARY 1995
paracetamol, they may actually
slow down recovery.
Here are six surprising facts
about fever you should know to
protect yourself and your family.
The concept of 98.6 degrees F as the
body's "normal" temperature is out
of date.
Says University of Maryland’s Dr
Philip Mackowiak: “The normal
temperature is actually a range
rather than one single number.
And there’s a great deal of indivi
dual variation.”
The body’s natural circadian
rhythms prompt daily tempera
ture fluctuations of about one
degree Fahrenheit, but some peo
ple have oscillations as wide as
2.4 degrees or as narrow as 0.1
degree. Children tend to have
slightly higher normal tempera
tures than adults and are more
likely to run high fevers in re
sponse to infection.
Elderly
people tend to have lower body
temperatures than younger adults.
Ordinary actions can raise tem
perature: digesting a big meal, be
ing in the sun, prolonged crying in
babies, exercise. But body tem
perature rarely rises higher than
about 106.5 degrees — with two
main exceptions: a trauma or tu
mour that damages the hypothala
mus (the part of the brain control
ling temperature), and, more com
monly, heat stroke, which must be
treated immediately to prevent
damage to body organs, or death.
76
I
Taking medication to lower a fever
may prolong illness.
Here’s how fever works:
When white blood cells recognize
an intruder, they release proteins
that travel to the hypothalamus
and prompt it to raise the body’s
thermostat. The body reacts to this
by generating heat, often through
shivering. “Many immunological
functions appear to be more effi
cient at a higher temperature,"
says paediatrician Timothy Doran
of Johns Hopkins University. “And
some bacteria and viruses don't
grow as well at higher tempera
tures."
Recent studies show that when
animals are exposed to bacteria
but prevented from running a fe
ver, many die of infections they
might have survived. Doran re
searched children with chicken
pox, and found that “it took those
who were given paracetamol
about half a day longer to recover”
than it did those whose fevers
were untreated.
While most people are probably
better off not suppressing fevers
that cause no discomfort, there are
exceptions. Coronary patients and
those with such chronic conditions
as arthritis and diabetes should
contact a physician immediately.
To balance the risks and bene
fits of treating fever, a lot depends
on the patient's comfort. “Data
show that fever does good, but it
also can cause real discomfort —
usually beginning at around 101.5
degrees," says Dr Allen Mitchell of
Boston University. “If a fever is
making you achy and miserable,
many doctors recommend taking a
medication
such
as
aspirin,
paracetamol, or ibuprofen.” But,
cautions Mitchell, never use aspi
rin to treat fever in children or
adolescents, since it increases the
risk of the rare, potentially fatal
condition called Reye's syndrome.
2
4 fever doesn't necessarily mean a
3
!
serious illness.
“I’m much more concerned
about a non-responsive child with
a temperature of 101 degrees than
a playful child with a temperature
of 104,” says Dr Daniel Hyman, a
paediatrician. “Watch how the pa
tient looks and acts, instead of re
lying only on the thermometer.”
This is particularly important
with newborns and the elderly,
since their immune systems may
not be fully functional and they
often won’t run a fever even when
very ill. Fortunately, nature gives
other indicators of infection. A sick
infant may stare and have greyish
skin or cold limbs. In the frail eld
erly, look for lethargy and mood
change.
"High" fevers rarely cause brain
damage or death.
A temperature needs to soar
over 106.5 degrees, and that’s un
likely, before there is risk of brain
damage. Yet when Dr Schmitt sur
veyed parents, he discovered that
4
most thought a temperature of 104
degrees or less can cause serious
neurological side effects, including
brain damage. His study revealed
that more than half the parents
gave fever-reducing medicine for
temperatures of 98.6 to 100 degrees
— which are possibly normal.
“Some people get frantic,” says
Schmitt, “if medication won’t get
the temperature down to 98.6 F.
Yet a correct dose will only bring a
temperature down by two or three
degrees, so if you start at 103 de
grees, the most you can expect is
to bring it down to 100.”
To counter fever phobia,
Schmitt says physicians and nurses
“need to tell parents the main rea
son for treatment is to help the
child feel comfortable, not to pre
vent harm.” If you're sick, there's no need to
take your temperature frequently.
“The time to take a tem
perature is when your health-care
provider asks you,” says Dr Mi
chael Rothenberg, co-author of
Dr Spock’s Baby & Child Care.
For a doctor, a temperature read
ing is one of the diagnostic
markers used to determine over
the phone whether you should
come to tire clinic.
To find out if you have a fe
ver caused by illness, wait until
you’ve been quiet for an hour or
so before using a thermometer.
Rectal temperatures are the most
accurate and recommended for
77
5
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young children; oral temperatures
are preferred for older children
and adults.
A rule of thumb from another
expert, Dr Boyd Shook: “Unless
your doctor tells you, never
wake someone up to take a tem
perature
or
give
a
fever
medication. Sleep is very valu
able to someone who is sick.”
If you have a fever, you don't need
to stay in bed.
Sleep if you want to,. but
don’t feel compelled. "Getting in
bed and covering yourself with
blankets can accentuate a prob
lem," says medical editor Charles
Kennedy. “While it’s good to rest
and avoid undue fatigue, being su
pine isn’t necessarily beneficial."
Rather than forcing yourself or
your child to lie still, just relax qui
etly around the house.
•
t
|
I
:
Also call a doctor for fevers accompanied by: severe headache or
stiff neck, mental confusion, sore
throat, bad aches and pains,
coughing that brings up sputum or
blood, inconsolable irritability or
excessive sleepiness, rash or vomiting, difficulty breathing and
bloody diarrhoea or blood in
stools.
Have infected wounds exam
ined promptly. Consult a doctor
about fevers over 102 degrees
when infections are evident.
Drink plenty of fluids to avoid dehy
dration. This is particularly impor
tant for elderly people, who have
a greater risk of complications,
such as stroke, when they are de
hydrated. Drink frequently enough
to pass clear urine every two
hours. But heart and kidney pa;
ticnts should check with their physician before forcing fluids.
[at moderately. It’s wise to avoid
heavy meals, but you should eat
if you’re hungry. If you have di-
f
|
1
i
,
j
6
When fever strikes, here’s what
doctors do advise:
(all your physician when: an infant
three months or younger has a tem
perature of 100.2 degrees or more;
a baby between three and six
months has a fever of 101 degrees
or greater; a child older than six
months has a fever of 103 degrees.
For adults, call the doctor if: a
fever is 103 degrees or more; a
temperature of 101 degrees lasts
more than three days — even if
there are no other apparent
symptoms; a low-grade fever
continues for several weeks.
78
-
t
'
WHEN TO WORRY ABOUT A FEVER
arrhoea or have been vomiting,
avoid dairy products and stick to
bland foods like rice and dry
toast.
Try a gentle sponge bath. Children
with a 104-degree temperature or
higher may be more comfortable
if their fever is lowered with a
sponge bath. But if the child has
been given paracetamol, wait 30
minutes to an hour before the
bath. This will avoid chilling the
youngster whose temperature is
already coming down because of
the medicine. Use lukewarm
water, since cold water can cause
shivers and elevate temperature.
Avoid alcohol rubs — children
may absorb toxic amounts of al
cohol through their skin.
Finally, don't panic. Remember: fe
ver is a normal response to infec- ■
tion, and no major problems gen
erally come from fever itself. As
paediatrician Suzanne Corrigan
puts it: “In many ways, fever is a
friend, not a foe.”
What Was That Again?
From a news item on a cricket match in The Times of India,
Bombay: “Seam bowler Pringle... said he may have to take a corti
sone injection to boot his chances of being fit ia time.”
— S. Krishnan, Baroda
From a,report in The Hindu, Madras, on a power crisis: “The chief
minister has said his proposed tour abroad was to seek investment
for augmenting power shortage...”
— B. Ram;ee, Bangalore
From a job vacancy ad in Deccan Chronicle, Hyderabad: “Wanted,
electronic lady typist... ”
— Sarosh Koshy, Secunderabad
79
,*r*"
< FLUENCY
’ *'
j
- Media
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