CORONARY ARTERY DISEASE SOME ASPECTS OF MEDICAL TREATMENT
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- Title
- CORONARY ARTERY DISEASE SOME ASPECTS OF MEDICAL TREATMENT
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July 1985
* Coronary artery disease
* Coronary artery bypass surgery
* Bloodless operation in blood vessels
* Stroke
* Rheumatic heart disease
"'Combating rheumatic;diseases effectively ?
* Let us talk about salt
* A year for the youth
._____ 1
HEART DISEASE
Page No.
In this Issue
Coronary artery disease - some aspects of
medical treatment
153
Prof. M. L. Bhatia
jujy ^985
Asadha-Sravana
Saka 1907
Vol. XXIX No. 7
158
Coronary artery bypass surgery
Prof. P. Venugopal
161
Bloodless Operation in blood vessels
OBJECTIVES
Iosif Rabkin
163
Swasth Hind (Healthy India) is a monthly journal
Stroke
Published by the Central Health Education Bureau*
Directorate General of Health Services, Ministry of
Health and Family Welfare, Government of India,
New Delhi. Some of its important objectives and aims
arc to :
Dr M. C. Maheshwari
REPORT and interpret the policies, plans, pro
grammes and achievements of the Union Ministry of
Health and Family Welfare.
Dr Rajen Tandon
ACT' as a medium of exchange* of information on
health activities of the Central and State Health
Organizations.
FOCUS attention on the major public health
problems in India and to report on the latest trends
in public health. •
KEEP in touch with health and welfare workers and
agencies in India and abroad.
Coronary bypass surgery— some patients
require re-operation later
165
Rheumatic heart disease
166
In point of fact.. •
Rheumatic fever and rheumatic heart disease
169
Combating rheumatic diseases effectively
170
K. R. Swadeshi
172
Let us talk about salt
Smt. Aruna Palta
A year for the Youth
176
Major advance in Thyroid research
180
John Newell
REPORT on important seminars, conferences, dis
cussions, etc., on health topics.
Third inside cover
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Kotla Marg, New Delhi-110 002.
The contents of the Journal are freely reproducible.
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Heart disease is an important cause of disability and deaths in our country. It is
estimated that more than 5 percent of registered deaths in India are due to heart
disease and that 6,43,625 Indians died of heart disease in 1978. The percentage
distribution of death is more than that of all categories of cancer, which is
2.5 per cent.
CORONARY ARTERY DISEASE
Some Aspects of Medical Treatment
Prof. M. L. Bhatia
of heart disease exist. One of these
is coronary artery disease, i.e., disease of the heart
consequent to disease of the coronary arteries. The
conservative estimates of its prevalence in our country
in the general population above the age of 40 arc
2.5%. If this is so. then the risk group consists of
136.9 millions, of which 3.42 millions have the disease.
At the estimated population growth, the number of
such persons in 2000 A.D. will be 10.13 millions—
a large number indeed. The number could be much
more keeping in view the rapidly increasing number of
patients with this disease seen by doctors ail over
India.
M
any types
Coronary artery disease, as said earlier, is conse
quent to the disease of the coronary arteries. Coro
nary arteries are the blood vessels which provide the
heart with the oxygen and other nourishment it needs.
The heart is basically a hollow pump which by its
action of contraction and relaxation pumps blood
throughout the body providing nourishment to all
organs and cells. Blood flows out from the heart
through the arteries and returns to it through veins.
As blood leaves the heart, the first artery it passes
through is the aorta, and the coronary arteries branch
off from it. These arteries wrap around the heart
and carry blood into every part of the heart muscle.
july
1985
Cause of coronary artery disease
Many diseases affect the coronary arteries. Of these
atherosclerosis or hardening of the coronary arteries is
the commonest cause accounting for more than 90%
of coronary artery disease. In course of time, fatty
materials (specially cholesterol, a waxy looking fat
commonly present’in animal fats and oils, in yolk of
egg and in many other foods) stick to the inside walls
of the arteries. They may start forming plaques.
The process starts early in life and progresses slowly
over a lifetime. When the lumen of the artery becomes
significantly narrow (50% or more) by this cloggins the
flow of blood through the artery is markedly reduced,
affecting blood flow to the heart muscle. 1 he result
is coronary artery disease.
Risk factors
There is still much to learn about the causes of
coronary artery disease, in other words, about the
causes of atherosclerosis.
Available information
suggests that certain factors in a person’s background
or life style make the likelihood of developing coro
nary artery disease greater. These are called risk
factors.
Many such risk factors have been identified.
In
general it seems that the combination of several risk
153
factors rather than any particular risk factor increases
someone’s chances of developing coronary artery
disease.
Some risk factors cannot be helped, and therefore
cannot change. These are called the unmodifiable
risk factors, which include a family history of coronary
heart disease, the male sex and age above 40 years.
More important are the modifiable risk factors which
are controllable. These often result from one’s life
style, the things one eats and the things that one does.
The important ones of these factors are:
Angina is the important aspect of this serious heart
disease. It is medically called, angina pectoris.
Angina
Angina is one of the several possible results of
coronary artery disease. It is the name given to the
discomfort which results when the heart muscle tem
porarily does not get enough blood and oxygen; when
the supply of blood and oxygen are not adequate to
the heart muscle’s requirement. This discomfort is
the heart’s “distress signal”.
•
High blood pressure
Presentation of angina
•
Cigarette smoking
•
Raised levels of blood cholesterol
•
Overweight
•
Increased stress and tension in life
•
A sedentary life style
Anginal discomfort is often called ‘pain’ but it may
be felt differently by different persons. It may thus be
felt as a mild discomfort, a dull ache in the chest or
something else entirely like extreme tiredness, indiges
tion, burning, squeezing, heaviness, fullness, or tight
ness in the chest, upper stomach or throat, or as
heaviness and a sensation of weight in the arms,
specially on the left. It is described by some as a
choking sensation, shortness of breath or pain in
jaw, gums, teeth, throat or in the neck between the
shoulders.
Of course not everyone with some or even all these
factors will develop coronary artery disease, and some
people with coronary artery disease may not have
any of these factors. In fact only about 50% of the
people with coronary artery disease have one or more
such risk factors. But the risk of developing coro
nary artery disease is greater if the risk factors arc
present and the more the risk factors, the greater the
risk. Combination of risk factors is not simply add
ing them; it is more like multiplying them.
While a lot is known about coronary artery disease
and risk factors, even more remains unknown. How
ever, there is much evidence that by lowering the risk
factors the disease may be kept from progressing.
These are the precautions one can take, which will
make a difference,.
Presentation] of Coronary Artery Disease
Coronary artery disease affects a person in many
ways. There is no standard set of presentation of
coronary artery disease (CAD) for every
patient.
However, the usual ways in which its presence is felt
are:
The location of the anginal discomfort and its seve
rity also varies from person to person. It may
occur in one or several places. It may start at one
location and travel to others. The anginal episode is
generally short, lasting for 2 to 5 minutes. Its fre
quency may vary from once in several weeks to many
attacks per day.
The types of activities which bring an angina attack
vary from person to person. Most of these activities
make the heart work harder (increasing heart rate and
blood pressure), and thereby incease its requirements
of blood supply which cannot be met because of
restricted blood flow through the clogged arteries.
Some common activities which may present angina
are:
•
Exercise or exertion
•
Heavy meals
•
Walking uphill or up a staircase or walking in
cold weather or against a strong cold wind.
•
Angina
•
Heart attack (myocardial infarction)
•
Irregularity of the heart
•
Stress, fight, anger and other emotional conditions.
•
Heart failure
•
Sexual intercourse.
•
Sudden death
•
Being in a higher altitude.
154
SWASTH HIND
One of the important risk factors of coronary artery disease is high blood pressure.
by drugs or without drugs,*Jts is required
“Angina” and “heart attack” arc different
Angina and heart attack arc not the same thing
although the under lying cause, viz., disease of the
coronary arteries, is common to both.
Angina is
caused by a temporary reduction in the amount of
blood and oxygen that reaches the heart, most com
monly due to a narrowed coronary artery. An angi
nal episode is not life threatening and it docs not
permanently damage some part of the heart muscle.
On the other hand, a heart attack results from a
complete or almost complete deprivation of blood and
oxygen supply to a part of the heart for a long period
(generally for more than 30 minutes). After this
july
985
It must be controlled
period the stoppage is complete and sustained. the
part of heart muscle so affected dies, and is later
replaced by scar tissue.
A heart attack is a ‘life
threatening' situation.
Diagnosing angina and coronary artery disease
It is common to begin with a history of the symp
toms and then perform a physical examination. 1 he
history provides the most useful information and helps
not only in diagnosis but also the identification of its
severity, degree of incapacity suffered, other disease
factors present, etc. Such a history includes not only
the patient’s problems but also a detailed family
history.
Physical examination is detailed andV
155
is lay man’s term for coronary oc
clusion, thrombosis or myocardial infarction in
medical terms.
eart attack
H
Heart attacks occur when the blood vessel (Coro
nary artery) supplying fresh blood to the heart for
its nutrition is suddenly blocked off, thereby cutting
off the blood supply to a part of the heart muscle.
Cause of a heart attack
The commonest disease leading to such situation is
atherosclerosis wherein fat (cholesterol) is deposited
on the inner lining of the coronary artery. The gra
dual accumulation of the fat may ultimately com
promise the lumen sufficiently enough to interfere with
blood flow. When the blood flow ceases suddenly
due to the obstruction, the result is a heart attack.
Warning signals of a heart attack
The usual warning signals are :
Uncomfortable pressure, pain, fullness or burning
sensation in the centre of the chest for several minutes
or longer, generally at rest.
It may be shortlasting
or persist for hours.
Discomfort and pain may spread to the shoulders,
arms, jaw and sometimes to the upper part of the
abdomen.
Severe pain, dizziness, fainting, vomiting, sweating,
or shortness of breath may accompany the above
feelings. Sometimes these may be the only sensations
without any significant chest symptoms.
The signals may not always be present or severe.
In many instances they may subside to return hours
or days later.
The signals of heart attack are not the same for
everyone and may vary from very intense for one to
mild symptoms for another. These are not infrequen
tly misinterpreted as indigestion.
What to do in case of a heart attack
Heart attack can strike anyone. When it occurs
there is no time for delay. Most heart attack victims
survive if they recognise the early warnings of heart
attack and get prompt medical attention. Therefore,
get help immediately. Reach your doctor or a hos
pital casualty department as soon as you can. Till
you gel, medical attention:
156
—Avoid physical exertion.
—Rest in a comfortable position,
—Loosen tight clothes, and
—Avoid chill or excessive heat.
Emergency care
Hospital care is the safest for a heart attack victim.
Most modern hospitals treat such patients in a coro
nary care area where special equipment, drugs and
trained medical, para-medical personal are available
io look after the patient. With prompt and proper
care, the heart begins to heal. New blood supply to
the demaged part is established. Later scare tissue
forms al the site of the damaged area. The process
of healing varies from person to person.
What is to be done later
Rehabilitation can begin sometimes after the heart
attack. It requires the full cooperation of the patient
as well his
family with the doctor-nurse-dictition
and physical instructor team. The patient may re
quire medication, changes in diet and physical acti
vity and other measures. A firm family support is
essential and a positive outlook is of great import
ance. Patients who recover from a heart attack some
times have to change their lifestyles. Most of them
return to work. Continued guidance and follow-up
by the doctor is important. It varies from each indi
vidual, varying according to a long term health plan
drawn by the doctor for the patient.
Prevention is best
Everyone can reduce the risk of a heart attack
since atherosclerosis can be prevented or slowed by
decreasing coronary risk factors. High blood pres
sure, a diet high in cholesterol and saturated fats and
cigarette smoking are important risk factors of heart
attack. Daily stress, obesity and lack of exercise are
also disadvantageous. Most of these are correctable.
Unchangeable risk factors include age above 45 years,
male sex and heredity.
By changing one’s lifestyle and correcting the risk
factors that one can control and improve the chance
of living a longer, healthier life.
Prevention of a heart attack is the best way of
dealing with it. It is never too late to change harm
ful habits. Decide today.
SWASTH HIND
< includes checking of weight, blood pressure, pulse.
listening to the heart and lungs etc. to determine the
state of general health and signs of heart disease and
its complications.
Diagnosis also includes conducting several tests.
These include a blood sample analysis for blood sugar,
cholesterol and other chemicals, an X-ray of the chest
for ascertaining heart size, a resting electrocardiogram
and an exercise ECG. The last is of special importance
in diagnosing heart disease including coronary artery
disease.
An exercise ECG shows how the heart reacts to
exercise. In many persons with angina the resting
ECG may not show any change, but specific changes
become manifest in the exercise ECG. Analysis of
these changes and the degree of exercise in tolerance
is very useful in diagnosing and quantifying the
severity of coronary artery disease.
Radioisotope scanning of the heart shows how
much blood docs the heart pump with each heart
beat and also the size, shape and contraction of the
heart. It may show specific areas of decreased blood
flow due to coronary artery disease.
Cardiac catheterisation and coronary angiography
provide a precise indication of how well the heart is
functioning and pinpoint the arteries which are nar
rowed. the degree of such narrowing and the site of
the blocks. This test is always done before a surgical
procedure like bypass surgery is taken up.
Medical treatment of coronary disease
(0 Control risk factors
Control of risk factors is essential. The high blood
pressure must be controlled by drugs or without
drugs, as required. Changes in life style and dietary
changes are helpful, like cutting down on the salt
consumption in the diet and losing weight if the per
son is overweight. Cigarette smoking is specially
harmful. Not only it is an important coronary risk
factor, but also the smoking may precipitate or worsen
angina, cause irregular heart beats and reduce chan
ces of recovery after a heart attack. Stopping ciga
rette smoking can repair some of this damage. It is
never too late to give up smoking. It should also
be noted that no cigarette is safe.
(if) Dietary Control
Adequate dietary control should be exercised re
garding calories, the quantity and quality of fats and
salt intake. To avoid too much fat and cholesterol
it is necessary to eat lean-meat, fish and poultry,
reduce the amount of eggs and organs meats like
liver and limit use of butter, cream and other satu
rated fats. Fried food should be limited or avoided.
Extra salt on the table should not be used. Losing
weight is beneficial and can be achieved by control
ling diet and a judicious amount of exercise. Exercise
increases the capacity of doing physical work with
lesser degree of circulatory stress and strain; it in
creases physical stamina. The amount and type of
exercise required varies from one person to another
and is best prescribed by your doctor.
(z7z) Controlling Stress
Control and reduction of stress is necessary. Adopt
ing a simpler life style, taking a weekend off, regular
vacations, more time for fun and recreation, pursu
ing active hobbies, relaxation exercises. Yoga, trans
cendental meditation, etc., which help in physical and
mental relaxation, are extremely beneficial.
(zv) Drug treatment
Drugs are often required for treatment of CAD
condition. For short term and immediate benefit
nitrates like nitroglycerin are used under the prescrip
tion and advice of the doctor. For long term bene
fits, the drugs like beta blockers or calcium blocking
drugs are currently used. The need for these drugs
and the quantity required varies from patient to
patient, which can be best decided by your doctor.
It is important that you follow the prescribed regi
men—when and how much. It may also be necessary
to develop a schedule, if many drugs are used, so that
you are not confused and do not miss the drugs. O
“Be bold, and face The Truth !
Be one with it 1 Let visions cease,
Or, if you cannot, dream but truer dreams,
Which are Eternal Love and Service Free”.
Swami Vivekananda
JULY 1985
157
Tieatment for coronary artery disease aims at improving bleed supply to the
hcai l muscle. Usually these goals arc met through medications and changes in
life style. But if these do not help and angina continues to interfere with everyday
life, suigical treatment is to be considered, and the result may be quite satisfactory.
The possibility of surgery depends upon several factors including the overall
condition of the heart.
CORONARY ARTERY DISEASE
Coronary Artery Bypass Surgery
Prof. P. Venugopal
oronary artery bypass
grafting is the most effec
tive means of directly increasing the blood supply
to the ischaemic heart muscle. Since 1968 when the
procedure was first performed, over a million of such
operations have been performed all over the world
and currently this is the procedure of choice for the
management of this widely prevalent and often fatal
disease.
C
What is coronary bypass surgery?
The heart muscle gets its blood supply from the
aorta through three main coronary arteries. Two arc
on the left side which arc branches of the left corona
ry artery. The single artery on the right is known as
the right coronary artcry. Branches of these arteries
ramify throughout the heart and provide oxygen
rich blood to nourish the heart muscle. When any of
these main arteries gets blocked by coronary artery
disease then there is decreased blood supply to an
area of heart muscle and this produces angina.
Coronary bypass’ surgery (grafting) is a procedure by
which alternate blood channels are created surgically
which carry blood from the aorta to the coronary
artery bypassing the obstruction, thus restoring blood
supply to the heart muscle. The conduit used for
this bypass is usually the saphenous vein from the leg,
158
which because of its superficial location and length
is an ideal conduit for this procedure. Removal of
the saphenous vein from the leg does not cause any
significant disability as other veins in the leg quickly
take over its function.
Advantages of coronary bypass surgery over medical
therapy
The advantages of surgery arc manifold.
Briefly
they arc:
(a) Relief of angina with less or no medication.
(b) Improved quality of life.
(c) Increased longevity.
(d) Reduced risk of repeated heart- attacks.
(e) Correction of associated complications like
ventricular aneurysm (dilatation of the heart
muscle), mitral regurgitation (leaking of the
valve), ventricular septal defects (hole in the
heart membrane), etc., which cannot be cor
rected by medicine.
The most significant advantage of surgery is that
the constraints on physical activity are removed and
the patient can lead a normal life, and even engage
himself in activities which involve physical exertion.
SWASTH HIND
The fear of ‘heart attack’, which hangs like the
Sword of Damocles’ over the head of every coronary
patient, is completely eliminated by surgery.
is disconnected from the heart-lung machine as soon
as the heart starts beating effectively. The chest and
leg wounds are then closed systematically.
Indications for surgery
Preparation for surgery
Surgery is indicated in the following circumstances.
(1) Angina unrelieved by medication.
(2) Triple vessel disease.
(3) Left main
stem disease.
(4) Complications of myocardial infarction.
The indications for coronary artery surgery have
broadened over the years as the risk of the operation
has decreased considerably. Surgery is advisable in
all patients with symptomatic coronary artery disease.
In such cases surgery provides relief of symptoms.
However in certain situations like main stem disease
(also known as ‘widow-maker disease’) and in severe
triple-vessel disease the life expectancy on medical
treatment alone is quite low; hence surgery is litesaving in this case. The 10-year .survival with triple
vessel disease is only 20% without surgery whereas
with surgery the 10-year survival becomes 80%.
Likewise the risk of sudden death in patients with left
main stem disease is more than 50% in one year.
Surgery provides long term relief in these patients.
Complications like ventricular aneurysm and mitral
regurgitation can be corrected only by surgery.
The surgical procedure
The operation is carried out under general anaesthe
sia. The first step of the operation is to remove the
saphenous vein from the leg, tic off all the branches
and to test it for any leakage. Then the chest is
opened by cutting across the breast bone (Sternum)
and the heart is exposed. For performing the delicate
suturing between the coronary artery and the saphe
nous vein, a still, bloodless field is essential. Ihis is
achieved by connecting the patient to a heart-lung
machine by special tubes. This machine takes over
the function of the heart and lungs while the surgery
is being performed. The heart is stopped and cooled
with ice-cold saline. Portions of saphenous vein are
then sutured between the aorta and the coronary
arteries bypassing the block or the obstruction. (Each
of these is known as a graft. The number of grafts
required is determined by the number of main vessels
blocked, which is determined by coronary arterio
graphy). The heart beat is then restored and the patient
JULY 1985
Best results are obtained only if the patient is opti
mally prepared for surgery—both physically and men
tally. Patient and family counselling is part of the
preoperative preparation
to allay the fears of the
patient and his family members, and also to gain
the patinet’s confidence. The physiotherapist plays
an important role in preparing the patient for surgery.
He teaches the patient breathing exercises and leg
Coronary bypass surgery (grafting) is a
procedure by which alternate blood channels
are created surgically which carry blood from
the aorta to the coronary artery bypassing
the obstruction, thus restoring blood supply
to the heart muscle.
exercises which must be strictly performed in post
operative period. A thorough check is made (or any
associated illnesses like diabetes, hypertension, chest
infection, dental infection etc., which are fairly com
mon. These have to be controlled adequately before
surgery to prevent any complications. The patient is
usually admitted a few days prior to the scheduled
date for operation so that all the above preparations
can be made. In addition, the patient gets acclima
tized to the hospital atmosphere and also gains con
fidence and strength by seeing and talking to patients
who have already undergone surgery.
The postoperative course
The first 24—48 hours are spent in the intensive
care unit after which the patient is transferred to the
postoperative ward. The patient is able to eat a
light meal in the following morning after the surgery
and by evening he is made to walk about the ward.
It is during this period that the maximum coopera
tion of the patient is required. Breathing exercises
that have been taught must be performed religiously
159
and the patient must make every effort to be up and
about. The physiotherapist plays an invaluable role
during this period. Over the next few days the patient
is gradually able to perform routine activities and is
discharged after removal of all stitches on the tenth
day after operation. A certain feeling of physical
weakness is expected during the postoperative period.
However, a good diet and graded exercise can soon
overcome this problem. By six weeks the patient
should be able to return to his work.
Common problems during this period
(a) Chest pain: This results from the movement*of
the ununited cut-ends of sternum (breast bone). This
pain usually subsides within six to eight weeks by
which time the cut-ends of the bone unite. Analgesics
like Proxyvon or Analgin will relieve this pain.
(b) Swelling of the legs: This results from venous
congestion in the legs after removal of the saphenous
vein. To prevent this the patient must wear clastic
stockings or a crepe bandage whenever he is standing
or walking. When he is sitting he must keep his feet
elevated on a stool. Swelling usually subsides by
3-6 months.
(c) Breathlessness: The body usually takes a few
weeks-to recover from the effects of a major surgery.
Till then it is wise not to over exert and to take rest
at frequent intervals. This usually subsides in 6-8
weeks.
Do’s and dont’s after surgery
1. Do not smoke at all: It accelerates coronary
artery disease and may lead to blockage of the
grafts.
2. Drinking: Alcohol is best avoided, but if it
cannot be given up, restriction to two ounces
a day is desirable.
3. Heavy exertion like driving, lifting weights,
cycling, etc., should be avoided for at least
six weeks after surgery.
4. Sex: There is no restriction on sex as long as
the patient feels fit. Undue pressure on the
sternum, however, must be avoided in the
initial period after surgery.
160
Experience at the A.1.1.M.S.
Over the past three years more than 160 patients
have undergone coronary artery bypass surgery at the
All India Institute of Medical Sciences (A.I.I.M.S.).
The number is increasing rapidly and currently we are
performing four to five such operations every week
in addition to other types of open heart surgery. The
patients who have undergone surgery have mostly
been referred when they have been severely sympto
matic and have advanced disease. Thus more than
80% of these patients have had severe triple vessel
disease. 28 patients had obstruction of the left main
coronary artery disease which, as has been mentioned,
carries a very high risk. About 40 patients were under
45 years of age.
On an average every patient has received four
grafts. In addition some patients required other
procedures like endarterectomy in 32, valve repla
cement in 6, and removal of a left ventricular aneur
ysm in 9 patients.
Despite the severity of disease in these patients the
results have been very good. The overall mortality
is 3-4% which is comparable to reports from the ad
vanced centres in the west. If patients come in the
early stage of the disease the risk of the operation is
negligible.
On follow-up 90% of the patients are free of angina
and have returned to gainful occupation.
Repeat
coronary arteriography, done in a small group of
patients, shows that the grafts are patent in the
majority of the patients.
Coronary bypass surgery at the AllMS costs each
patient approximately Rs. 12,000. This is towards
the cost of the disposable items required during the
surgery. No charge is levied on account of opera
tion. This is a negligible amount compared to (he
cost of getting the same surgery done at USA which
is Rs. 3.3 to 3.5 lacs. We believe that coronary
bypass surgery is a safe, effective and reliable mode of
treatment for coronary artery disease, and we at the
Institute are capable of offering it safely an^ econo
mically to the public. A
SWASTH HIND
BLOODLESS OPERATION INSIDE
BLOOD VESSELS
Iosif Rabkin
new branch of medicine—X-ray endovascular
surgery—-has turned a traditional diagnostician,
X-ray expert, into a physician. The new method, which
is, in many cases proves as efficient as classical surgery,
is free of the latter’s undesirable consequences in ad
dition. Application of this method makes it possible
to revive what seems to be a doomed patient within
literally a few days’ time. Here are two examples of
that kind.
A
Short-circuiting of blood
About four years ago a patient with a connection
between the spinal artery and a vein which had ap
peared as a result of an injury was admitted in the
All-Union Centre of Surgery. The blood which had
already passed through the heart was short-circuited,
returning from the artery to the vein through this
connection and back to the heart, thus straining it
additionally. As part of this blood never reached the
lungs and, therefore, was not oxygenated, the patient
suffocated. However, the main danger was an arterio
venous aneurysm (A local broadening of a blood
vessel with extremely thin walls), which could result
in profuse bleeding any time. To save the patient that
vessel enclosed among vertebrae had to be closed.
The question was in what way we could reach it. Of
coursej- we might have hollowed the backbone to
reach the artery, but we were apprehensive of damag
ing the cerebrospinal nerves next to it. When dama
ged, they may cause paralysis. It also happens that
as soon as the surgeon reaches the aneurysm it will
burst... Surgeons and neurosurgeons refused to per
form the operation, so the patient was transferred to
our department.
First time in world
No one in the world had ever performed such a
surgery before. Under continuous X-ray control we
JULY 1985
introduced a conductor (a twisted metal string) into
the femoral artery. The conductor passed through
the common iliac artery, long thoracis aorta, left sub
clavian one and finally entered the left spinal aorta.
A catheter was put on the string and reached the aneu
rysm along it. The string was removed, and a con
trast agent was administered through the catheter to
make some X-ray photographs of the aneurysm and
the blood short-circuit in order to put a more precise
diagnosis. After that some minute steel spirals, each
5 mm long and 2 mm in diameter, were introduced
through the catheter in a stream of the same contrast
medium. Those spirals had woollen threads fixed to
their ends, like tails. The display showed the spirals
reaching the fistula and stopping it. The short-cir
cuit between the artery and the vein ceased to exist,
and the aneurysm shrank. The operation was over:
it lasted only 25 minutes. A day later the patient was
allowed to go for a walk, and a few more days after
the operation we discharged him from the clinic.
Difficult operation
Another operation, which was also performed at our
department for the first time in the world, dealt with
autoimmune haemolytic anaemia. The spleen of a
patient suffering from that disease starts “devouring”
the erythrocytes (red blood cells), thus causing leuka
emia with a lethal outcome. The usual treatment for
it would be an operation to close the blood vessel
supplying blood to the spleen. When the vessel is
blocked, the spleen stops functioning, shrinks to the
size of a wallnut and does no more harm to the orga
nism. The problem is that the spleen artery is situa
ted behind the pancreas or within it, which make
surgery much more complicated.
The woman who was admitted to our department
would hardly have survived such an operation. She
had been treated by hormones for two years, and the
161
course of the disease was complicated by the consump
tion of the adrenal glands* cortex. We performed
that operation jointly with our colleagues from the
Institute of Haematology and Blood Transfusion. A
catheter was inserted into the spleen artery through
which artificial thrombi reached the vessel and
embolised (stopped) it.
Pieces of teflon, or emboli, with the volume of 2
to 3 cubic millimetres, were sprayed into the catheter
together with the physiological solution by a hypoder
mic. The number of emboli was determined by
the length and the diametre of the vessel. As soon
as the emulsion was administered to the artery it
caused the formation of thrombi which stopped it
tightly—we could see it on the display of our X-ray
installation. Having made sure that there were no
blood stream in the artery, we removed the catheter
from it. The operation lasted for only half an hour.
Whereas a traditional surgery would have taken at
least two hours. The erythrocyte and blood cell ex
penditure in the patient’s body dropped by 50 per
cent, and the haemoglobin contents increased. Five
weeks later the number of erythrocytes in her blood
was back to normal.
Broadening narrowed) arteries
It is a tradition in classical surgery to examine the
patient thoroughly before the operation. As for X-ray
endovascular surgery, which is not surgery in a pro
per meaning of this word but rather a hybrid of
roentgenology and therapy, it combines diagnostication with treatment A catheter is used to administer
-■■i
a contrast medium and all the compounds necessary
for treatment, and often to perform an operation. Thus
we used a catheter with a tiny reservior filled with a
contrast medium to perform dozens of surgeries to
broaden stenotic (narrowed) arteries. Under the pres
sure of the medium reaching 5 to 8 atmospheres the
reservior blows up in the narrowed part of the vessel
thus pressing the cholesterol particles into its walls.
The opening broadens up and a normal blood stream
in it is restored.
Of course, far from all vascular disorders can be
treated by endovascular techniques. In many cases
cholesterol sediments are too old and hard. In such
cases the treatment is useless, but, unlike a surgical
interference, it does no harm to the patient.
It is actually impossible to enumerate all the disea
ses which can be cured by the new technique. It is
non-traumatic, sparing and works quickly. It can be
used to treat ischaemia, renovascular hypertension,
congenital embolism of the lung artery, alternating
lameness and profuse bleeding. It can also block
a sick kidney to stop its functioning.
Over 120 centres of endovascular surgery have
been set up in the USSR. Besides, recommendations
have been developed to make it possible to apply this
technique in cases of emergency actually at any hospi
tal. A
ANAEMIA AND HEART
Anaemia, if severe (haemoglobin in blood less than 5 gms. per 100 ml), and especially when of
acute onset, can produce symptoms and signs of heart disease. The patient may tire easily, suffer
from breathlessness on exertion, palpitations, oedema of feet, giddiness, heart pains (angina), enlargement
of the heart, heart murmurs, and even heart failure. Patient may also exhibit ECG changes suggestive of
a heart attack. But all these signs and symptoms disappear when the patient is given blood transfusion,
or when anaemia is controlled with medication, suggesting that these changes are reversible. When
patients of ischaemic heart disease, rheumatic heart disease, congenital heart disease (blue babies) etc*
have anaemia, all the signs and symptoms are aggravated. Hence, correction of anaemia, whenever
present, is an important step in treating these patients.
—Heart News
April 1985
162
SWASTH HIND
Stroke or cerebro-vascular accident is a disease of the brain resulting from the
abnormalities of blood vessels. Blood vessels constitute arteries, veins and capil
laries. Arteries carry the oxygenated blood from the heart to various organs of
the body, and veins bring back the used blood from different organs to the heart
and then to lung for oxygenation and removal of carbondioxide.
Dr m. C. Maheshwari
ccording to world statistics, Stroke is the third
commonest cause of death in the past middle age
group people. The other two causes are cancer and
heart attack. Strokes can occur at any age, but
essentially it is a disease of elderly people. Of all the
A
strokes in India, aj^out one-fifth occur, in the age
group under forty (which is called stroke in young).
Exact incidence of mortality and morbidity due to
stroke in India is not known, but a fair percentage
is made disabled every year. Western statistics do
indicate a reduction in the incidence
of stroke
in last two decades and this healthy trend is attribu
table to reduction of rheumatic heart disease and
improved control of hypertension.
Brain gets almost l/6th of the total blood, while it
weighs only l/6Oth of whole body weight. Brain
utilizes maximum amount of glucose and oxygen for
its proper functioning. Irreversible damage results if
no oxygen or glucose is available to brain for three
minutes. A person may become unconscious if there
is interruption even for ten seconds. Brain receives
this amount of blood via two carotid arteries in the
front and one vertibro-basilar artery system in the
back. One should appreciate that the vertebral arter
ies pass through the bone before entering the brain.
JULY 1985
These two systems have communications to help in
the adjustment of blood volume to both the halves
as well as various parts of the brain. Blood supply
to the brain is so vital that nature has given autore
gulating mechanism to adjust the blood distribution.
Ischaemia and haemorrhage
Arteries (blood vessels) are the delivering pipes.
Any disease process which may lead to occlusion or
rupture of these pipes will result in a stroke. The
disease process may either be in the lumen, in the wall
or outside the wall to cause occlusion. Occlusion of the
lumen wall lead to what is called Ischaemia and,
therefore, ischaemic stroke. Rupture of the vessel
will lead to haemorrhage and, therefore, haemorrhagic
stroke. There are many factors which will influence
and determine the extent of ischaemia and haemonhage. Understanding of these factors is of utmost
importance.
Blood pressure and stroke
At the critical point of occlusion if the blood pres
sure is low, greater degree of ischaemia will result.
On the other hand if blood pressure is high, at the
time of rupture, greater amount of bleeding will occur.
163
-This means a high degree of blood pressure is as bad
for a haemorrhagic stroke as low blood pressure for an
ischaemic stroke. This leaves no doubt on the need
of a reasonable adequate blood pressure. There are,
however, some factors which are not in our control.
Atherosclerosis
As mentioned earlier there are several causes of
ischaemic strokes.
Atherosclerosis is by far the
commonest cause in elderly patients. Atherosclerosis
is essentially an ageing process which leads to harden*
ing of the arteries. Hardened arteries lose resilience
and it leads to systolic hypertension. Hypertension,
diabetes, hyperlipidaemia (hypercholesterolaemia) ag
gravate atherosclerosis. A fair number of patients
before developing the stroke have several transient
ischaemic attacks (TIA) of focal neurological deficit.
The TIA lasts for a few minutes in majority of the
cases but never lasts more than 24 hours. These are
due to microemboli with arterial occlusion or haemo
dynamic with relative ischaemia or acute hypotension.
TIAs are warning signs before the occurrence of the
storke. This is the most important point to remember
as something can be done at the stage of TIA, but
nothing much can be done once a stroke has taken
place. Another important risk factor which aggra
vate cerebral ischaemia is smoking and, therefore, it
requires your consideration to stop smoking. For hae
morrhagic stroke there are several causes but hyper
tension is the most important cause. Adequate con
trol of hypertension has definitely reduced the inci
dence and severity of haemorrhagic stroke and benefitted ischaemic strokes as well.
Diagnosis
Diagnosis of TIA and ■ stroke is not difficult and
mostly depends upon a good description by the pa
tient or the relative. Symptoms (like paralysis, blind
ness, unconsciousness, etc.) are of sudden onset and
after a critical period there is always a history of
improvement if the person survives. Haemorrhagic
strokes are more common during exertion and activity
while ischaemic strokes take place during sleep and
inactivity. AU body parts and functional activities
are represented in the brain. From the impairment
of body functions a doctor clinches the site of lesion
in the brain. Medical technology has reaUy improved
the diagnostic capabilities in last 10-12 years. Com
puter assisted angiography, CT scan, Doppler blood
164
flow and NMR have contributed a lot not only by
providing non-invasive methods of diagnosis but also
the specificity and accuracy. However, one should
remember that these advanced technologies cannot re
place the medical history. Therefore, observe the illness in as much detail as possible and pass on aU
the information to the doctor for correct diagnosis.
Stroke in young
As for the stroke in young, we in India are more
concerned about the peripartum strokes, i.e., stroke
occurring in women either during pregnancy or soon
after birth. By and large women belonging to poor
socio-economic status are affected. Some study has
been done, but the exact cause remains still elusive.
This is the area where research activities should con
centrate.
Early treatment
As mentioned earlier one should not remain un
concerned till the stroke occurs. Treatment should
be instituted with the first occurrence of TIA. There
is medical as well as surgical treatment available and
your doctor should take the responsibility for advis
ing you. Prevention and management of the risk fac
tors are of utmost importance. Specialised medical
attention is of great importance in the first 48-72 hours
of occurrence of the stroke. One cannot do much for
the dead brain tissue. However, all attention should
be paid to revive the surrounding and partially da
maged tissues. This would determine the degree of
recovery as well as the rehabilitative potentials. The
partially damaged tissue requires adequate glucose and
oxygen. Some cases do require the management of
vasospasm and increased intracranial hypertension.
Once the critical period is over, the only therapy then
is physiotherapy. The role of physiotherapy and re
habilitation is to make the disabled person as much
independent as possible in the activities of the daily
living.
In conclusion, there should be awareness of the
problem in the forties. Hypertension should be ade
quately treated. Smoking should be stopped. Tran
sient ischaemic attacks (TIAs) should be recognised
by the doctors as well as the patients and specialist
consultation should be sought. Funding organiza
tions should be alert and liberal to promote research
in the areas relevant to us in India.
A
SWASTH HIND
CORONARY BYPASS SURGERY
Some Patients Require Re-operation Later
coronary artery
bypass surgery will require reoperation after
8-10 years, Dr G. Reul told the International Con
ference on Recent Advances in Cardiology and
Cardiac Surgery in Bombay, recently.
ome of the patients undergoing
S
Dr Reul, who is Associate Chief of Surgery at the
Texas Heart Institute, Houston, was delivering a key
note address on “Coronary artery surgery—15 years’
experience”.
a year for the first 5-8 years and a slightly greater
decrease (2-3%) thereafter. Confirming this trend,
other groups have reported that after 8-12 years about
50% of vein grafts develop either occlusion or stenotic
disease if they were patent at one to three years postoperatively.
“So there is a natural degeneration of vein grafts,
a natural degeneration of ventricular function and a
natural degeneration of the coronary arteries,” Dr
Reul observed.
Of the 35,000 patients who received coronary artery
grafts between 1969 and 1983 at the Texas Heart
Institute, nearly 1,000 were reoperated for a variety
of reasons, such as graft occlusion and progression of
the underlying (atherosclerotic) disease.
Again, at the end of 10 years, only 34.5% of the
survivors were completely free of angina. Like the
survival rate, the number of symptom-free patients
drop quite dramatically after 6-8 years.
“The patients you operate on for the first time may
be back for more surgery in 8-10 years, and they
may return even for the third or fourth time,” Dr
Reul stressed.
It is obvious, therefore, that coronary artery surgery
does not cure the patients, who must be followed up
very carefully and all attempts at modifying risk
factors should be made, Dr Reul said.
Reoperation carries a higher operative mortality,
of about 6%, compared to the first time operation,
which has a mortality rate of 1.2%. The additional
risk stems from the more advanced—usually end
stage—coronary disease in patients, needing repeat
surgery, sometimes cauused by the patients* failure to
modify their heart risk factors.
Reviewing the objectives of coronary artery sur
gery, Dr Reul said these were as valid today as in
1969 when he and Dr Denton Cooley performed
their first procedure, namely, (1) relief of angina
pectoris, (2) revascularisation of the myocardium
to improve myocardial function, (3) prevention of
myocardial infarction, especially in the preinfarction
anginal state, and (4) prolonging life, especially for
certain subsets of patients, such as those with left
main or multiple artery disease.
Long-term survival
A computer analysis of the survival rate among
25.000 patients showed a gradual decrease of 1-2%
JULY 1985
Age and arteries
Another finding over the years, he continued, is
that mortality correlates with age: “the older the
patients, the higher the mortality”.
Mortality also correlates with the number of arteries
bypassed, being highest in the group with double
and triple-vessel bypass and lowest in patients with
multiple grafts demonstrating the importance of com
plete revascularisation.
“The more arteries bypassed does not mean the
mortality is higher.
More bypasses actually end up
protecting the myocardium”, Dr Reul noted.
“We have also seen,” he added, “that the degree of
revascularisation is relatively proportional to the
success of the operation”. Their policy of complete
revascularisation, bypassing arteries with over 50%
blockage, had resulted in lower mortality and attrition
rates.
(Contd. on page 175)
165
Rheumatic fever licks the joints but bites the heart. Rheumatic fever is an
acute inflammatory disorder characterised by specific symptoms and signs,
initiated by infection of the throat by a group of bacteria called ‘group A
Betahemolytic streptococci’.
RHEUMATIC HEART DISEASE
Dr Rajen Tandon
heumatic fever is a world wide phenomenon.
It affects both sexes equally. The most common
age when the fever attack is between 5 to 15 years,
though it can occur at any age. Population surveys
in India indicate its prevalence to be around 2 per
thousand.
R
20 to 50 per cent of all cardiac hospital admissions
are for rheumatic fever induced heart disease. Survey
in children indicates its prevalence to be 5.3 per 1000
children between the age of 5 to 15 years in India.
Predisposing factors
1. Unhygienic living conditions,
6. There is no investigation which is diagnostic
for rheumatic fever.
7. The diagnosis is possible during the acute
phase. However, if the heart is not involved
the diagnosis in retrospect may not be possible.
8. Once the heart is damaged, medicines can
not cure this heart disease.
9. Operative treatment for rheumatic heart disease
is also not a “Cure”.
10. Once rheumatic fever has occurred, preven
tion of further attacks will have to be con
tinued life long (ideally).
2. Undemutrition & malnutrition,
3. Over-crowded living conditions.
Adverse features of rheumatic fever
1. It affects the heart in 60 to 70 per cent cases.
The resulting heart disease is in general per
manent.
2. The heart disease is acquired in childhood
and the suffering lasts for the rest of the
life.
3. Rheumatic fever has a tendency of recur
rence. If heart disease is present it will get
worse with each recurrence. If heart disease
is not present, it can occur with a recurrence.
4. Rheumatic fever can be prevented, but if it
has occurred in a child it cannot be cured.
5. The diagnosis depends
on clinical findings
which overlap with some other diseases.
166
Features indicating rheumatic fever
Ten to 15 days after the onset of the fever, strepto
coccal sore throat is followed. This fever is accom
panied with joint pains with or without swelling, heart
involvement, skin rash, nodules below the skin and
abnormal movements of the body indicating brain
disease.
(a) Joint disease : Occurs in 90 per cent cases.
Large joints like ankle, knees, elbows and wrists are
involved; uncommonly smaller joints of hands or feet
may be involved. Only subjective pain (arthralgia)
may be present or the joint may be swollen, hot, red
with limitations of movement (arthritis). The pain and
swelling come on quickly and subside spontaneously
within 5 to 7 days. Generally multiple joints are in
volved in an episode although only one joint may be
involved at one time. There is no residual damage
to the joint
SWASTH HIND
(b) Heart disease : Occurs in 60-70 per cent cases.
Starts early in the course of rheumatic fever. All layers
of the heart are involved—the covering called peri
cardium, the heart muscle called the myocardium
and the heart valves. The damaged valves result in
leaking of blood. Over a period of time the valves
may gel fused resulting in obstruction to flow of blood.
Damaged myocardium results in poor pumping func
tion of the heart. Heart damage is permanent.
weeks. Suppressive treatment reduces the inflammation
but does not cure it. The two drugs used for suppres
sive treatment are Aspirin and Corticosteroids. As
pirin has a weaker suppressive action than steroids,
but has less complications compared to steroids. We
prefer to use steroids in those patients who have heart
involvement, reserving aspirin for those who do not
have heart involvement.
(c) Nodules below the skin tend to appear 4 weeks
after the onset of rheumatic fever. They are not pain
ful.
They last for a variable period of time and
then disappear, leaving no residual damage.
The damaged heart
(d) Brain involvement manifests as abnormal jerky
purposeless movements of the arms, legs and the body.
They result in difficulty in walking, eating, writing or
any finer movements. This manifestation is more
common in female children. It lasts about 6 weeks
and gradually disappears leaving no residual damage.
(e) Skin :Various types of skin rash is known due
to rheumatic fever. Perhaps because of the darker
complexion, the rash is rarely identified in our coun
try.
It is thus obvious that except heart disease all other
manifestations of rheumatic fever do not
cause
permanent damage.
Investigations
The investigations for the diagnosis of rheumatic
fever are confied to two aspects: (i) To indicate the
presence of an active disease (non-specific); (ii) To
indicate the presence of streptococcal infection or re
cent streptococcal infection (non-diagnostic).
There
is no test which will conclusively prove that the
child has rheumatic fever.
Treatment
Once initiated rheumatic fever cannot be ‘‘cured”
by medicine. The treatment consists in: (i) bed rest,
(ii) nutritious diet, (iii) Penicillin therapy, (iv) sup
pressive drugs, (v) management of heart dsease, if
present, (vi) rehabitation of the patient if heart dis
ease is present.
Rheumatic fever runs a course of about 12 weeks in
80 per cent of the patients. In 20 per cent it can be
longer. Suppressive treatment is indicated for 12
July 1985
Two parts show specific persisting damage—the
heart valves and the myocardium (heart muscle).
There is no specific medical and/or surgical treatment
for the damaged myocardium.
If valves have become obstructive the obstruction
can be relieved by operation. If the valve is leaking
the valve may be repaired or it may have to be chang
ed. Rheumatic valve damage
is such that valve
change is more likely than repair, but the decision
is possible only at the time of operation.
The commonest valve damaged is the mitral valve.
This valve lies between the left side atrium and ven
tricle. The next commonest valve affected is the aor
tic valve, lying between the left ventricle and aorta.
Both are involved in about 25 per tent cases. Mitral
valve is involved in all those who have rheumatic
heart disease.
Indications for operation
The indication for operation is when the heart is
not able to cope with the requirements of the body
at rest or at work.
Milder damage of the valve is compatible with a
normal life span. As such every patient with heart
disease is not a candidate for operation. The patients
require to be followed up by the physician at six
monthly or yearly intervals. Electrocardiograms, Xrays and other investigations may be required from
time to time. Depending on the symptoms of the
patient and findings, the physician decides as to when
an operation
is necessary (Physicians believe that
God-made valves are better than man-made valves):
167
Prevention of rheumatic fever
It must be re-emphasized that rheumatic fever is
preventable, but once it has been initiated it cannot be
cured.
Most of the developed countries have been able to
control rheumatic fever and rheumatic heart disease.
The decline appeared even before penicillin became
available.
Non-medical means of controlling rheumatic fever
are related to improving living conditions and socio
economic status:
(1) Improve sanitation and hygiene.
(2) Improve nutrition.
(3) Prevent over-crowded living.
(4) Awareness regarding hazards of sore throat
and the specificity of preventing heart disease
by penicillin.
Specific prevention
Specific prevention is possible with the use
penicillin.
of
Ideally a sore throat should be swabbed and cul
tured. If streptococci are present the child should be
put on penicillin. Since facilities for throat culture
are not easily available, it is justified to treat a sore
throat with penicillin even without having the culture.
For this purpose one injection of penicillin containing
3.00,000 units of crystalline, 3,00,000 units of pro
caine and 6,00,000 units of benzathine penicillin is
enough (available as one injection).
Alternatively,
4.00,000 units of procaine penicillin may be given
twice daily for 10 days.
If a patient has had rheumatic fever, prevention of
further attacks is possible with injections of Benza
thine Penicillin given every 2 or 3 weeks. This will
have to continue (ideally) life long.
Less than ideal
would be to continue upto the age of 35 years. The
injections are painful, but the pain is less than life
long suffering due to heart disease.
Adverse reactions to penicillin are very rare in
children. Adverse reactions to Benzathine penicillin
are also very rare.
Prevention is better than cure.
Fortunately, rheumatic fever can be prevented but
unfortunately, it cannot be cured. Protect your child’s
heart.
1. Do not neglect sore throats.
2. If a child complains of joint pains consult a
doctor immediately. The diagnosis may not
be possible in retrospect.
3. If one child has sore throat, all children
should be checked. Streptococcal infection is
contagious, but rheumatic fever is not.
4. Unexplained fever—even in the absence of
joint pain symptoms—can be rheumatic fever.
5. A fever associated with chest pain or follow
ed by palpitation or shortness of breath in
a child could be rheumatic fever.
6. If the child has had rheumatic fever it is the
responsibility of the parents to ensure conti
nuation of penicillin to prevent further attacks
of rheumatic fever and further damage to the
heart.
7. Penicillin injection given every 3 weeks may
cause pain only for 17 days in a year. (If
given every 2 weeks the pain is only for 26
days in a year).
This is certainly a much better proposition than
suffering every day for that whole life.
®
The articles on Coronary Artery Disease by Prof. M.L. Bhatia;
Coronary Artery Bypass Surgery by Prof. P. Venngopal; Stroke
by Dr M.C. Maheswari; and Rheumatic Heart Disease by
Dr Rajen Tandon in this issue are based on Public Lectures at
the All India Institute of Medical Sciences, New Delhi.
“Thou brave one. be proud, take courage, be proud that thou art an
Indan and proudly claim I am an Indian, every Indian is my brother”
“The soil of India is my h’ghest heaven the good of India is my good”
Swami Vivekananda
168
SWASTH HIND
IN POINT OF FACT..........
Rheumatic Fever and Rheumatic Heart Disease
rheumatic heart disease are
problems of major importance in many parts
of the world. In developing countries, rheumatic heart
disease is the commonest form of heart disease in
young people and the main cardiovascular cause of
death among children and young adults.
R
heumatic fever and
* Rheumatic fever is typically a disease of childhood
and adolescence (5 to 15 years). It is triggered by
a streptococcal sore throat or tonsillitis.
* Most cases of tonsillitis can be easily treated and
cured. However, a few patients, two to three weeks
after streptococcal sore throat infections, develop hot,
painful and swollen joints accompanied by fever, hence
the name rheumatic fever given to the disease.
* Sometimes the joint symptoms and fever can be
so mild as to pass unrecognized. If severe, they can
be brought under control with aspirin and the joints
recover completely.
* Unfortunately, whether mild or sever and even
when it passes unnoticed, rheumatic fever can cause
permanent damage to the heart, particularly the heart
valves, leading to a serious chronic condition, known
as rheumatic heart disease. The consequences of chro
nic rheumatic heart disease include: continuing dam
age to the heart; increasing disability; repeated hospi
talization, and premature death usually by the age of
35 years or even earlier.
The prevalence rates of rheumatic fever and rheu
matic heart disease in school-age children usually
reported from various countries range from 5 to 20
per 1000, although figures as high as 33 per 1000
have been observed. In many developing countries
rheumatic heart disease accounts for over 30% of car
diac cases admitted to hospital.
* Available mortality statistics in developing countries
show that rheumatic heart disease ranks high among
causes of death in the age group 15 to 24 years. In
many areas it is second only to accidents as a cause
of death in this age group.
* In some ways, rheumatic fever can be regarded as
a “social” disease: linked to poverty, overcrowding,
poor housing conditions and inadequate health ser
vices. It declines sharply when the standard of liv
ing is improved, but even in the most affluent coun
tries, there are areas where the disease still exists.
* Of all serious, chronic conditions, rheumatic heart
disease is one of the most readily preventable. Two
july
1985
prevention approaches are possible. Primary preven
tion consists in preventing rheumatic fever before it
occurs, by identifying all patients with streptococcal
throat infection and treating them with penicillin.
However, this approach entails serious practical, logis
tic and technical difficulties, particularly in some de
veloping countries. Furthermore, some cases of rheu
matic fever occur without a clinically recognizable
sore throat that can be effectively identified and treat
ed.
* Secondary prevention which is a more practicable
approach, especially in developing countries, consists
in identifying those who have had rheumatic fever
and giving them one injection of penicillin every 3-4
weeks. This prevents streptococcal sore throats and
therefore recurrence of rheumatic fever and rheuma
tic heart disease. The cost of secondary prevention
is estimated at 15 L’S dollars per patient per year.
* The World Health Organization (WHO) has carri
ed out an international cooperative study in seven
developing countries. This study demonstrates the
feasibility and cost-effectiveness of secondary preven
tion.
* WHO, in collaboration with the International So
ciety And Federation of Cardiology (1SFC) is promot
ing a strategy to develop national programmes for
the pievention of rheumatic fever and rheumatic heart
disease based on this secondary prevention approach
and implemented through primary health care systems.
* As a medium-term objective, the WHO Cardiovas
cular Disease Unit plans to collaborate with 15 deve
loping countries, so that by 1989, they will be able
to prevent recurrences of rheumatic fever in 70 to 80
per cent of known and identified patients, by means
of regular administration of penicillin. The treat
ment has to be continued for at least five years after
the last attack of rheumatic fever or up to the age
of 18 years whichever is longer.
* To be effective, a rheumatic fever/rheumatic heart
disease/prevention programme must benefit from go
vernment and community support. Furthermore, ex
perience has shown that such a prevention programme
does not survive in isolation. It is doomed to failure
if it cannot be incorporated into the general health
services of the community. It is therefore impor
tant to involve the general public and to provide ap
propriate health education in order to improve case
detection and patient compliance with the
treat
ment.
A
—W.H.O.
1.69
In order to combat the diseases effectively, the USSR set up cardio-rheumatological
service in 1958. It played an important role not only in reducing the primary disease
rate but also made the relapses much less on the patients. As a result, the life expec
tancy of patients suffering from rheumatic valvular diseases has considerably gone
up, which has now reached almost at the national average life expectancy level.
COMBATING RHEUMATIC DISEASES
EFFECTIVELY
K. R. Swadeshi
eople have been suffering from arthritis (poly
arthritis) since the Stone Age, and it still re
mains an acute problem. According to an estimate,
nearly one per cent of the global population is afflict
ed by this disease. The rapidly progressing grave
and irreversible changes in various structures mak
ing up the joint can lead to disability and sometimes
finish the professional career of the patient for good.
About ten per cent invalids are rendered disabled by
joint diseases alone. Usually such kinds of arthrites
affect people between the age of 30-40 and make
them completely disabled for the rest of their life
within three to four years. About one-tenth of them
even cannot look after themselves.
P
In order to combat the diseases effectively, the
USSR set up cardio-rheumatological service in 1958.
It played not only an important role in reducing the
primary disease rate but also made the relapses much
less on the patients. As a result, the life expectancy
of patients suffering from rheumatic valvular
diseases has considerably gone up, which has now
reached almost at the national average life expect
ancy level. Besides, it created an opportunity to
170
concentrate on the treatment of chronic disorders of
the sustenacular and motion apparatus and on syste
mic disorders of the connective tissue.
Soviet pathophysiologist Alexander Bogomolets
created a theory of the connective tissue as a physio
logical system protecting the organism from the da
maging impact of the environment. The skin—one
of the forms of the connective tissue—forms a reliable
barrier protecting the internal organs from infections.
The spot of infectious agents’ penetration into the or
ganism is infiammed, and later this inflammation turns
into fibrosis—scar.
Rheumatic diseases affect all the structure of the
connective tissue. Macrophages and fibroblasts, or the
main cell form capable of responding to damage, are
the first to be affected. Macrophages are known as
cells which devour infectious agents. Since their
discovery by a Russian scientist Ilya Mechnikov, ma
crophages have been known as cells devouring infec
tious agents. Quite recently, it was established that
macrophages, of all other factors, transfer information
SWASTH HIND
on an “enemy’s” intrusion to lymphocytes, or the main
“hero” of the immunity system. It enables the or
ganism to resist the infection.
Today, the problem of fibrosis formation, i.e., the
replacement of the soft connective tissue by scarred,
is especially topical. Majority of the rheumatic dis
eases is characterised by rapid development of fibro
sis. In fact, all the inner and outlying joint tissues of
connective tissue in all the organs are damaged ac
counts for various irreversible changes in the organism,
i.e., inflammation of various joints, valvular diseases
resulting from fibrosis, particularly sclerosis of the
heart valves, as well as kidney and lung diseases.
Systemic scleroderma—a kind of natural model of
sclerotic processes—is one of the most curious rheu
matic disorders. This disease affects cells and fibro
blasts producing collagen, especially those in the skin
which is rich in them and in the connective tissues
of various internal organs. They are involved in the
process in cases of systemic scleroderma for which pro
gressive fibrosis in those structures is very typical. The
specialists of the institute of Rheumatology of the
USSR Academy of Medical Sciences are studying the
processes involved in collagen formation in the skin
of systemic scleroderma patients. They have succeed
ed in finding out that the biosynthesis of collagen pro
tein is very rapid even at the initial stages of the dis
ease. As a result, fibroblasts produce a multitude of
collagen fibres of different size and shape, which has
been established through electron microscopy.
These changes are caused by the faulty synthesis
and maturing of collagen proteins which lead to the
appearance of great quantities of immature collagen.
Remarkably, the ability of fibroblasts found in sclero
derma patients to enhanced collagen synthesis turned
out to be a stable symptom. Moreover, it also results
in the generally increased activity of the cells produc
ing various types of collagen and even an accumula
tion of proteins in tissues. At this stage, it is of para
mount importance to find out the reasons for excessive
collagen synthesis.
The research scholars have also studied the effect
of catecholamines on fibroblasts in the tissue culture
taken from systemic scleroderma patients. They have
established that the contents of cyclic adenosine mono
phosphate (cAMP), one of the major biochemical re
gulators participating in molecular mechanisms of
JULY 1985
hormone activity, is considerably lower in fibroblasts
remarkable for their very high ability to synthesise
collagen, and that the impact of their catecholamines
on nucleotide synthesis in cells is much weaker. As
cAMP inhibits collagen synthesis, its lower contents
in the fibroblasts of systemic scleroderma patients leads
to a more rapid collagen synthesis.
This means that the lower contents of cAMP and
lower sensitivity to, say, catecholamines, are among
the factors leading to excessive collagen production
and development of fibrosis. Further research in
this field will provide definite practical results, for
they are to determine the damage that can be re
paired by drug therapy.
According to Valentina
Nasonova, Director of the Institute, the development
of fibrosis is typical of the entire group of inflam
matory rheumatic diseases, but not to such a great
extent as in cases of systemic scleroderma.
The development of the genetic foundations of rheu
matic diseases have made it possible for the researchers
to come close to understand the nature of its here
ditary predisposition, to establish the risk factors and
provide a theoretical description of those groups of
population which are threatened with inflammatory and
degenerative diseases. The scientists used an over
all approach comprising of various genetic technique
—from clinical and genealogical ones to mathematical
models.
The Polygene models, helped them establish the
quotient of hereditary predisposition to rheumatism,
which amounted to 60 to 80 per cent, or to 55-56 per
cent in cases of rheumatoid arthritis. The first on
the scale of hereditary predisposition to rheumatism
are patients suffering from rheumatic mitral stenosis,
followed by cases of combined mitral and aortic ste
noses and those of mitral incompetence. The next
category is of patients who have had rheumatic fever
not accompanied by a valvular disease.
The above mentioned studies cover only some of the
fundamental problems arising in rheumatic cases. How
ever, the study of genetic factors is important for
two reasons: First, it makes possible for physicians
to identify people likely to contract the disease and
find means of protecting them. Secondly, this re
search will enable the scientists to prevent grave, ir
reversible changes in cases where the disease is con
tracted.
A
171
The need for some salt for human beings has been established but the necessary
quantity is in doubt. In any case it is quite obvious that the body gets all the
salt it needs from natural foods, otherwise many isolated cultures all over the
world who know nothing of the existence of salt could not have survived.
LET’S TALK ABOUT SALT
Smt. Aruna Palta
an’s love for salt is due to habit and a long tra
dition. Human beings have been consuming
salt since five to ten thousand years, so the habit
has been pretty well ingrained. Historical records
also reveal that salt was always of great importance
as wars have been fought over it’s sources and for
centuries it’s trade was more important than that
of any other material, even more than precious je
wels and metals. Men were often paid in the form
of salt for the work they performed in early times.
M
Since the beginning of Medical Practice, man’s
need for salt has been a subject of dispute. Dr
Desnoo reminds us that civilized man has been using
salt for centuries, because food tastes better with
salt, rather than because his body needs it. As man
became aware of the physiology of human body, it
was suspected that effect of salt on body was dis
astrous.
Since then researches have been carried
out to see the effect of salt on body.
Normal intake
The chemical name for the common salt is sodium
chloride. The normal intake of sodium chloride by
people may range from 2 to 20 gms daily depending
upon individual taste. There is some natural salt
in just every food we eat, which is enough to meet
the needs of the normal body. Dr Lehmann found
that most animals in freedom and in captivity do very
well on natural foods without the addition of any
salt. R. Ackerly states that the body requires only
2-3 gms of salt a day. German scientist G. Von
Bunge made the guess that extra salt is necessary to
those civilizations which depend upon agricultural
products for much of their diet. Dr Dahl suggests a
maximum salt intake of about 5 gm. per day for an
adult without a family history of high Blood-Pres
sure. In the presence of existing blood pressue the
amount of salt should be reduced below 1 to 2 gms.
172
Common salt or sodium chloride contains 39% of
sodium. Sodium element never occurs in free form
in nature. It is found in associated form with many
minerals especially in plentiful amounts with chlorine.
Sodium chloride when dissolved in water yields sodium
and chlorine ions. Both are important for chemical
processes in our body. Practically all the sodium
in the body is found in the extracellular fluids. So
dium ions make up 93% of the basic ions in the blood.
Sodium plays an important role in the regulation of
the acid-base balance in the body fluids including
blood, lymph, cerebrospinal fluid, urine, tears and gas
trointestinal secretions. It also determines to a large
degree the osmotic pressure of the extracellular fluids.
It also takes part in the maintenance of muscular con
traction and normal nerve irritability. Chloride is
very closely associated with sodium in the extra-cellu
lar fluids. It is taken in the body largely as sodium
chloride and it’s excretion in urine, sweat and gastro
intestinal tract usually follows the excretion of sodium.
In addition chloride is found
in the gastric
juice as a component of the hydrochloric acid molecule
and in salivary amylase the chloride ion activates the
starch splitting enzyme of saliva.
Both excess and deficiency of salt may produce bad
effects on human body. This has been experienced
in different pathological conditions.
Salt Excess
The sodium in the salt has been condemned many
times as a contributing factor in cardiovascular and
renal diseases as well as for other physical problems:
(i) Excess salt causes hyperacidity as the chloride
part of salt takes part in the formulation of hy
drochloric acid. Hyperacidity is further res
ponsible for the production of ulcers.
SWASTH HIND
(ii) Dr Allen Frederick conducted experiments and
found that when animals were fed a high salt
diet, blood-pressure increased. Salt intake is
usually restricted in hypertension as it causes
greater retention of fluid in blood stream con
tributing to higher total blood volume. Some
of the fluid may seep out in the tissues caus
ing swelling.
(iii) In congestive heart diseases when a low salt
diet was given it produced beneficial effect.
Some people with damaged hearts have diffi
culty in eliminating the excess fluid from their
bodies. Swelling occurs in different parts of
the body which is one of the signs of a failing
heart. The excess fluid adds as extra burden
to the heart which is already weakened.
(iv) Salt irritates the soft and delicate membranes
of our body. Dr Henry C. Sherman have stat
ed that “through over stimulating the digestive
tract salt may interfere with the absorption and
utilisation of the food”.
(v) In later stage of pregnancy salt free diets show
good results. Swelling and blood pressue due
to pregnancy is reduced and also the length
of labour and severity of pain is diminished.
(vi) In natural food items sodium chloride is pre
sent in small quantities. So the function of the
kidney is to reabsorb the sodium chloride which
is present in the glomerular filterate. Excess
salt interferes with the body’s power of excre
tion. The kidneys have to work harder to ex
crete the excessive amount of salt.. In 24 hours
about 180 litres of glomerular filterate is ob
tained which contains 552 gms. of sodium. This
is about 8 times of the total body sodium con
tent and 250 times of the average daily intake.
In order to maintain the balance about 99.5 per
cent of the filtered sodium and .chloride is re
absorbed. In kidney diseases either due to
reduced glomerular filtration rate or dimini
shed tubular reabsorption or due to therapeu
tic doses of cortisone or other adrenal cortical
harmones, sodium excretion is reduced and
oedema may result.
(vii) An excess accumulation of fluid in the abdo
minal cavity is known as ascites. It is some
times referred to as abdominal dropsy or hydro
july
1985
peritoneum. It is often found with the cirrho
sis of liver. Restriction of dietary sodium has
a salutary effect on the generalized oedema
and on the accumulation of ascitic fluid. Low
sodium diet also serves as a prophylaxis against
future resumption of fluid collection.
Thus salt has been found to be a causative and
aggravating factor in many pathological conditions.
Sodium restricted diets not only help in the manage
ment of cardiovascular disorders but also serve in.
the management of Renal diseases with oedema, cirr
hosis of the liver with ascites toxaemias of pregn
ancy and when treatment with adrenocorticotropic
harmone, cortisone or other similar steroid harmone
is done.
Low sodium diet
Joi life and Tisdal have stated that good health
can be maintained on as little as one gm. of salt
per day. Some people lake as much as 20 gms per
day. It is just as if a doctor had prescribed a drug
and people lake about 20 limes of it.
Salt restriction is beneficial in the all above des
cribed conditions. The American Heart Association
has published 3 booklets describing exchange lists
for different levels of sodium restriction.
(1) Your Mild Sodium Restricted Diet (2 to 3 gm
Sodium) :
Light sailing of food such as is done in canning
is permitted. Brined foods and those prepared with
mono-sodium glutamate is omitted. The patient ad
justs quite readily because the food is palatable.
(2) Your Moderate Sodium Restricted Diet (1
Sodium diet):
gm.
The quantity of milk, meat and bakery products
is restricted. Some vegetables are omitted. No table
salt is added during cooking.
(3) Your Strict Sodium Restricted Diet (500 M'digram
Sodium diet):
Many foods are too high in natural sodium to be
allowed on this diet. It often is not well accepted
by the patient. The strict sodium restriction is used
for congestive heart failure and occasionally in scle
rosis with ascites or renal disease with oedema. Low
173
sodium dialyzed milk is used. All convenience and
canned foods have had sodium added. Foods con
taining sodium-bicarbonate, mono sodium glutamate,
baking powder, sodium, benzoate, sodium citrate or
sodium acetate should be restricted.
The Institute of Human Nutrition Columbia Uni
versity had prepared a list of foods which contain insignilicanl amount of sodium and which are permitt
ed for all diets.
FOODS WITH INSIGNIFICANT AMOUNTS OF
SODIUM*
Grains
—•
Wheat, Oat,
products
Fruits
—•
All fresh & canned fruits and theiir
juices
Rice, Barley & their
Vegetables — AU except Artichokes, Beet, Carrot,
Celery, Mustard-leaves, Turnip and
spinach. Canned or frozen salt free
vegetables permitted.
AH fresh, frozen or canned without salt,
beef, lamb, pork, veal, poultry fish,
shell-fish and game meats.
Meats
- -
Eggs
— All fresh.
Fats
All vegetable oils and shortening, lard
and unsalted butter and margarine.
Condiments —
Vinegar, all spices, mustard, flavourings
that do not contain salt.
Sweeteners
Sugar, honey, syrup, jellies, molasses.
Beverages -— Alcoholic beverages,
drinks.
coffee, tea, soft
♦Permitted for all diets.
From Institute of Human Nutrition. Columbia University,
Nutrition & Health, 1:3, 1979.
Some people find it difficult to adjust with a salt
free or low sodium diet. For them cooking foods
with unusual herbs and spices may creat new fla
vour and will make the person forget that he ever
used salt.
Such spices and herbs are: all spice,
caraway, chillipowder, coconut, ginger, lemon juice,
saffron, peppermint, mustard seeds, dried mango pow
der, etc. Besides, unrefined sea salt can be used in
stead of common salt as it contains less sodium ch
loride. ft is also rich in other trace elements such
as iron, iodine, copper, cobalt, calcium which we are
not likely to get from common salt. Increasing the
potassium content of the diet may help in neutraliz
174
ing the bad effect of sodium to some extent in body.
Foods high in potassium are fruits, vegetables, nuts
and sea foods. “Salt substitutes should not be used
without the physicians permission because some of
them contain sodium which are harmful if there is
the complication of kidney insufficiency. Some of the
substitutes contain ammonium which is harmful to
I he patient with liver disease.
Salt Depletion
In tropics where people sweat excessively, they
may sometimes suffer from salt depletion. Salt de
pletion may also follow sometimes after extensive
blood loss, recurrent vomiting, protracted diarrhoea,
burns, adrenal cortical insufficiency chronic
renal
disease and after prolonged use of diuretics. Sodium
depletion symptoms include weakness, lethargy, head
ache, anorexia, muscular weakness, abdominal cramps
and in severe cases may result in mental confusion.
Normal individuals have no danger of salt deple
tion because more than enough salt is provided by
the usual diet even without added cooking or table
salt. Sodium is also present in softened drinking
water, in a number of condiments and spices and fla
vour enhancers.
Sometimes athletes and outdoor
workers may sweat profusely in hot weather resulting
into sodium depletion. Salt tablets can be given to
maintain salt balance in their systems. In sodium de
ficiency states the adaptation of body is maximum as
all the sodium reaching the glomerular filtrate is re
absorbed and no sodium chloride can be detected
in urine. A very simple test of adding silver nitrate
to urine can be performed for detecting the primary
salt deficiency. If sodium is present in urine a white
precipitate of sodium nitrate is obtained. Absence of
precipitate indicates sodium deficiency.
Conclusion
Purley vegetarian diet contains less salt than non
vegetarian foods as fruits and vegetables do not con
tain as much natural sodium as the animal products.
So people consuming non-vegetarian foods do not
require salting their foods with cither cooking or table
salt. This can be done gradually by using less and
less salt in cooking. It would be wrong to say that the
body does not use any salt taken along with foods.
The need for some salt for human has been established
but the necessary quantity is in doubt. In any case
it is quite obvious that the body gets ail the salt it
needs from natural foods, otherwise many isolated
cultures all over the world who know nothing of the
existence of salt could not have survived.
If added salt is avoided from foods we eat, we
would be surprised to see that how different and how
better the food tastes without added salt. We would
also realize that we have never really tasted food be
fore, because what we had been tasting was the salt
of food. With a diet having no added salt will result
into an increased health and good flavour of natural
foods which will be our reward.
A
SWASTH HIND
exercise and cardiovascular fitness
OUR heart, like any other muscle in your body, gets ston-* ger with ecgular exercise. 1 lie right kind of exercise
increases cardiovascular fitness by improving blood circu
lation throughout your body and allows you to exercise
vigorously for long periods of time without tiring-
Exercise that promotes cardiovascular
fitness improves
your body’s-circulation so that your heart. lungs and other
organs work together more efficiently- Cardiovascular fit
ness also may give a person the ability to meet physical
and emotional demands more readily.
It may help reduce the risk of heart disease. A strong
heart does not have to work as hard to circulate the
blood through the body because it can pump more efficiently
with each beat. It is impossible to prove you will live longer
or never have a heart attack if you are in good physical con
dition, but cardiovascular fitness helps you feel better and
can improve the quality of your lifeWhat type of exercise is good for your heart?
Dynamic (also
called aerobic) exercises challenge
the
heart and circulatory system to meet extra oxygen needs.
They are endurance or high energy activities that require
large muscle groups to work in rhythmic motion. Exam
ples of dynamic exercises include jogging, swimming, bicy
cling, jumping rope, and even fast walking- You can tell
if these activities are increasing your body’s demands for
oxygen by taking your pulse before and after the exercise.
Static exercise like weight lifting does little to promote
cardiovascular fitness.
It may help build muscle strength.
but not help improve your cardiovascular system, supple
ment it with dynamic exercise.
How to choose an exercise programme?
Once you have made the decision to exercise regularly
there arc a few factors to consider when choosing an ex
ercise programme. Your health and physical capability arc
some of the most important considerations when deciding
on an exercise programme. Choose a sport in which you have
some skill and ability. Also, choose an exercise activity
you really enjoy. Bv concentrating on one activity, you
will improve votir skill and endurance more rapidly, and
it will be easier for you to chart your progress.
Choose an exercise activity that is convenient for you.
Your exercise programme will not continue long if it is
difficult to accomplish. Individual sports such as jogg
ing and swimming are obviously more convenient activi
ties than sports that require other players, or special courts
or facilities.
One of the most important factors in beginning an ex
ercise programme is to determine the most convenient time
for you to exercise. If is also important to follow a re
gular schedule so that exercise becomes a habit.
A few sports such as tennis, squash, basketball, football
and hockey can be considered dynamic exercises if they
arc played vigorously ai least three times a week.
(contd. from page 165)
Disease in vein grafts
With increasing reoperations it was becoming ap
parent that while some vein grafts remain patent for
several years, others develop atherosclerosis and
blockage. In other words, “you can see all the changes
in a vein graft that yon see in atherosclerotic disease”.
Therefore the grafts themselves often pose a pro
blem, requiring reoperalion.
Tn the Houston series, rcoperation was necessitated
mainly by graft: occlusion, by the natural progression
of the disease in the bypassed arteries and less often
by technical errors and incomplete revascularisation.
Although a second operation prolongs life, because
of the development of end stage coronary disease in
some, it does not do so dramatically. Dr Reul added.
Balloon angioplasty
Percutaneous transluminal coronary angioplasty
(PTCA) or balloon angioplasty is being carried out with
increasing frequency for the treatment of single and
even multiple-vessel disease. Despite its pronounced
value, PTCA, with an initial failure rate of 30%, has
improved to be 92% successful. However, it pro
vides only temporary relief until a bypass can be per
formed, Dr Reul stated.
JULY 1985
— Heart News
March 1985
PTCA also requires a surgical team on stand by,
to carry out emergency bypass in high risk patients.
especially those with ongoing myocardial infarction.
Dr Reul also referred to laser technology as an ex
citing future method of treating coronary artery
disease, by “blasting away” atherosclerotic plaques
cither through direct vision or an angioscope intraopcratively. Laboratory testing had reached a pro
mising stage.
Summing up. Dr Reul described the status of coro
nary artery surgery 1984 as:
— Operative mortality—1 %
—Use of post-operative intra-aortic balloon pump—
1%
—- Peri-operativc infarction—2%
— Later rcoperation—-2-6% •
— Attrition rate—1-2% a year
Myocardial infarction—1% a year.
“This is really quite a change from 15 years ago
when we first started and to-day there is no question
that coronary bypass improves both quality and length
of life”, he declared.
Courtesy :
Sandoz Medical Times
December 198
175
A YEAR FOR THE YOUTH
the longest moment in life, is the time to
dream. But, as things arc, few among the youth
can afford to drcam, for so overwhelming are the
harsh realities and hostile environs they face. If to
day’s world is yesterday's dream, let them get a chance
to drcam for the future of mankind.
Y
outh,
The year 1985 Has been dedicated to discussions,
debates and indepth studies on the problems of youth
so that in the years to come, they may fare better and
may even drcam.
Visible and “invisible” at-the same time, "youth
permeate developing nation’s economies. In house
holds, farms, factories and elsewhere, work is one of
the responsibilities of youth and they arc taking an
176
increasing share of the work. Young people through
out the world, in the developing world particularly,
constitute an important part of the labour force.
Where labour-intensive production characterises all
economic sectors, teenagers and young adults are a
major source of labour. They are working now; they
will be working more in future.
Yet, youth in the developing world faces high un
employment. low standards of living and wide dis
parities in wealth and opportunities, because the cco-%
nomic contributions of youth tend to be ‘invisible*
and hence uncounted, unvalued, unplanned and un
acknowledged. It makes effective and efficient inte
gration of their effort into economic development diffi
SWASTH HIND
cult. Development programmes and policies integrat
ed with the specific needs and conditions of the youth
are few indeed.
resources. Only a sustained, systematic and organis
ed effort can make them a really visible force in the
development process.
Who arc (he Young ?
Womn and Children
- Women and children account for upto 80 per
cent of the developing world’s population. As wo
men are, so are the children. If women arc educated
they have fewer children. If women are healthy, they
produce healthy children. If women value female
children as much as they value male children, there
will be more equity. As far as the problems faced
by women and youth in being integrated into the deve
lopment process, they too are the same. Their work
on the farm or off-farm, seasonal or full time needs
to be duly taken into account by development plan
ners. Better data and clearer definition of the roles
of both are also required. It must not be forgotten
that women often work with their children in the
factory in home production and on the market. Child
ren are economic assets, in some cases as early as
at the age of three and hence the case for large families
in most developing countries. A development frame
work that embraces women and youth in farm family
and in the labour market is urgently called for.
In the developing world, some 70 crore people
(20 per cent) are between the ages of J 5. and 24 and
some 140 crores arc under 15. Against this in deve
loped countries, the percentage of under 15 is very
low and it is shrinking fast. Accepted international
definition of ‘youth' is persons aged 15-24: in practice
it is anywhere between 10-30. Some are forced out
of the family umbrella at the age of 10, while some
continue to be totally dependent on their families even
at the age of 30.-
Development process neglects youth mostly because
they have no proper knowledge of what they are do
ing, of their capabilities and of the impact of deve
lopment on them. Moreover, as younger children are
born, the older ones usually arc ignored.
The kind of work youth is engaged in is conducive
to its neglect in the development process, because
they are. most often found in unskilled or low paid
jobs and they are easily replaceable. Their work is
intermittent in casual or secondary labour markets
and at unstructured worksites. Only when there is
gross abuse and exploitation, child protection issues
arise.
Even though it is assumed that those under 15 arc
at school, the reality is quite different. And as it is taken
for granted that they arc all at school, their labour
is not looked upon as an economic resource. In spite
of the spread of basic education, not all rural child
ren, particularly girls, attend school at primary or se
condary level. “Complete” school is far lesser. Im
provement in education and training is a must for
increase in productivity and quality of the workforce.
Efforts arc afoot to coordinate school schedules with
work schedules, to initiate appropriate curriculae, to
bring fees and uniforms within universal reach and
to make training relevant to the existing labour mar
kets. Linking health and nutrition with education
and training is also receiving world-wide attention.
Since young persons appear to be an abundant re
source, they may be perceived to be without economic
value. But when they arc unemployed under-employ
ed or uneducated, it leads to substantial loss of human
july
1985
Suggestions for the Year
Incorporation of the concerns of women and youth
into development efforts calls for the formulation of a
new corps of committed scholars and practitioners.
Another requirement is an accurate and expanding in
formation base which includes their economic roles
differentiated by their sex, age, area, family status,
income, education, etc. Development impact cn youth
and women such as happens when young persons
free their parents to go to the market to sell pro
duce and the result of obtained education on youth
in relation to present and future productivity have to
be extensively studied. Projects and policies which
deal directly with the productive potential of wo
men and youth have to be formulated urgently. Tra
ining of techniques dovetailed to the available re
source mix, emphasising human oriented technologies
instead of mere labour-saving devices should be made
available to the managers. Teaching should incor
porate youth and women and “Youth in Develop
ment” could become a part of the sub-discipline “Wo
men in Development”.
The year 1985, as the International Year of the
Youth and the end of the UN Decade for Women,
is an appropriate time to merge the overwhelming
common interests of women and youth.
177
New Hospitals for Heart Diseases
The following hospitals in the country have facilities for advanced cardio-thoracic
surgery for treating certain complicated heart diseases :
(i) Southern Railways Hospital, perambur, Madias.
(ii) Christian
Vellore.
Medical
College
and Hospital,
(iii) K.E.M. Hospital, Bombay.
(iv) All India Institute of Medical Sciences, New
Delhi.
(v) Bombay Hospital, Bombay.
(vi) G.B. Pant Hospital, Delhi.
(vii) Sree Chitra Tirunal Institute of Medical Sci
ences and Technology. Trivandrum.
(viii) Post Graduate Institute, Chandigarh.
(ix) S.S.KM. Hospital, Calcutta.
(x) Samaritan Hospital, Alwaye (Kerala).
(xi) Kasturba Hospital, Bhopal (BHEL).
(xii) N.M. Wardia Institute of Cardiology.
and
Pune;
(xiiii) Apollo Hospital, Madras.
(information given in Rajya Sabha by Shri Yogendra
Makwana. Minister of State for Health and Family
Welfare,, on 274March, 1985.)
Suit. Mohsina Kidwai, Union Minister of Health and Family Welfare, inaugurated a two-day Conference
on c Strengthening of State Health Education Bureaux' in New Delhi on 4 March, 1985. The conference
was organised by the Central Health Education Bureau. Sitting on the dais from left to right are :
Dr M. D. Saiga], Add!. Director General oj Health Services', Shri P.K. Umashankar, Addl. Secretary,
Health', Smt. Mohsina Kidwai, Union Minister of Health and Family Welfare', Smt. Serla Grewal,
Secretary Health and Family Welfare', Shri R.P, Kapoor, Addl. Secretary and Commissioner, Family
Welfare-, Dr Mahendra Dutta, Deputy Director General (p); Dr H.C. Agarwal, Director, CHEB; and
Dr Imam S. Mochny, Health Education Specialist {Family Welfare), W.H.O. {For report please see
S was th Hind June 1985 issue).
178
SWASTH HIND
Observance of World Health Day—1985
orld Health Day, 1985, was observed by the
Central Health Education Bureau at the School
of Social Sciences Auditorium. J.N. University. New
Delhi, on 10 April, 1985. Prof. P.N. Srivastava.
Vice-Chancellor of J.N. University was the Chief
Guest.
W
Addressing the meeting. Prof. Srivastava said that
if Health for All was to be achieved by 2000 A.D..
drinking water and sanitation had to be taken care
of on priority basis. Both the community and the
individual had to share great responsibility for look
ing after their health. Elaborating about the pro
blem of safe water supply and sanitation be dealt
with the role of National and International Organi
zations. Emphasizing the role of Radio/T.V. for the
achievement of the goal of health for all, prop. Sri
vastava said that programmes on health could be
incorporated in the programmes
directed towards
rural audience such as “Krishi Darshan” etc. He
said that the educated youth should do whatever they
could in spreading the message of healthful living
which would supplement Government efforts.
The keynote address was delivered by Dr Mahen
dra Dutta, Deputy Director General of Health Ser
vices. He mentioned about the comprehensive plan
JULY 1985
drawn out by the Government of India to mobilize
the youth power for the national development and
promote activities involving the youth in the coun
try. He added that involvement of youth in health
and welfare activities was essential if we were to
make any headway towards a better and bright fu
ture and also for achieving the goal of health for all
by the year 2000 A.D.
The meeting was also addressed by Dr H.S. Has
san. Regional Advisor (Health Education). SEARO.
W.H.O. and the President of the Students’ Union.
J.N. University. New Delhi.
Earlier welcoming the Chief Guest, Dr H.C. Agar
wal. Director, CHEB. mentioned about the relevance
of the theme of the World Health Day at this junc
ture when India is entering into a new era of pro
gress and change. He also mentioned that the the
me is an integral part of the International Youth
Year with its emphasis on participation, development
arid peace.
Prof. P.N. Srivastava, Vice-Chancellor of J.N. Uni
versity also inaugurated the exhibition on the theme
“Healthy Youth-Our Best Resource” organized and
set up by the Central Health Education Bureau on
the occasion.
179
Major Advance in Thyroid Research
John Newell
at the Welsh National School of Medi
cine in Cardiff, the capital of Wales, have achiev
ed dramatically successful results with a new. so far
experimental, approach to the treatment of thyroid
disease.
octors
D
The technique, developed by Alan McGregor and
his team, may prove valuable in the future treatment
of the muscle wasting disease myasthenia gravis, the
kidney disease Goodpastures syndrome, and the in
herited blood disorder haemophilia.
Auto-immune thyroid disease is common in most
parts of the world, especially in women aged over
40. of whom up to one in 20 may be affected at some
time in their lives. The particular form of the con
dition Dr McGregor and his colleagues are working
on is called Hashmimoto's thyroiditis.
It is caused by white cells. B-lymphocytes. which
normally defend the body against disease by identify
ing and attacking foreign organisms, mistaking part
of their own body’s thyroid gland for foreign tissue
and attacking it. with harmful consequences.
Eliminating Cells
Only a small proportion of the B-lymphocytes in
the bloodsteam take part in this auto-immune reaction.
as it is called. If just these cells could be eliminated
from the bloodstream, the condition would be cured.
This is the approach followed by Dr McGregor’s
team. They first purified the particular component
of thyroid gland tissue, an antigen, to which the auto
immune reaction is directed. This antigen was ex
tracted from thyroid tissue removed surgically from
patients.
Molecules of it were then joined chemically to those
of a deadly toxin, ricin, one molecule of which is
sufficient to kill any cell it enters. This conjugate was
then mixed with blood samples from sufferers of
Hashimoto’s thyroiditis.
Dr McGregor found that the B-lymphocytes in the
blood sample responsible for the harmful auto-im
Please don't forget to intimate the change of address.
mune response reacted with the conjugated antigen.
mistaking it for thyroid gland tissue. As the B cells
engulfed the antigen, they were killed by the ricin.
Trials in rats
No other white cells were affected because the ricin
used had been treated chemically to make it deadly
only at very short range, when actually absorbed by
living cells.
Following good results in human blood samples,
trials of the technique in rats are now going on at
Cardiff. Dr McGregor is using animals’in which a
condition imitating human auto-immune thyroid dis
ease has been induced.
One major problem to be overcome before the
technique can be used in human is that of finding
a way to ensure the conjugate of antigen and ricin
slays in the bloodstream for long enough to do its
job of eliminating all the harmful clone of B-lymphocytcs.
Techniques for delaying the natural process in which
foreign matter, including the conjugates, would nor
mally be cleared out of the bloodstream are being
developed at Cardiff. * And extensive safety tests would
also be needed before a toxin as potent as ricin could
be passed for use against a non-life threatening con
dition such as auto-immune thyroid disease.
Treatment for other ailments
Dr McGregor sees the work on thyroid disease as
important largely as a model for treating more seri
ous, life threatening conditions such as myasthenia
gravis. Tn that, the antigen targeted for the harm
ful auto-immune reaction is known, and could easily
be obtained in quantity to be conjugated to ricin and
used in treatment.
If all goes well, what has been nickamcd the “poi
soned bail" technique may become a reality in per
haps ten or 15 years for dealing with some of the
body’s highly dangerous auto-immune reactions affect
ing the blood and kidneys.
A
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BOOKS
Authors of the Month
Prof. M. L. Bhatia
Head, Department of Cardiology
and
Treatment' and prevention of acute diarrhoea: Guidelines
for the trainers of health workers, Geneva, World Health
Organization, 1984. ISBN 92 4 154200 4. v + 35 pagesPrice: Sw. fr. 8-.
Arabic,
French and Spanish editions
in preparation- Available from the South East Asia Re
gional Office, W.H.O-, World Health House, I-P. Estate,
New Delhi-110002-
Prof P. Venugopal
Head, Department of Cardiothcracic and Vascular
Surgery
Dr M. C. Maheshwari
Professor and Head,
Department of Neurology
and appropriate treatment of diarrhoea,
particularly in infants and children, can prevent
undernutrition and save life. In the early stages of
the disease, the most appropriate treatment is adminis
tration of oral rehydration solution, which is a simple
and effective means of restoring the water and salts
lost from the body in diarrhoea Community health
workers should be made aware of this method of
treatment and encouraged to use it.
P
rompt
Dr Rajcn Tandon
Iosif Rabkin
Head of a Department of the All-Union Centre of
Surgery, USSR Academy of Medical Sciences,
Shri K R Swadeshi
John Newell
Editor Science, Industry and Exports,
BBC, London.
ment—including lifestyle, marital status, family sup
availability of health services—and went on to conavailability o fhealth services—and went on to con
sider the possibility or measuring degrees of health.
autonomy, and disability. Such
indicators would
have to be clearly defined, readily assessed, univer
sally applicable, and of practical use in recognizing
groups at risk and in planning for and evaluating
the efficacy and effectiveness of services. The actual
problems of making assessments of health status in
elderly populations are discussed in a separate chap
ter and guidelines for surveys are given in a useful
annex.
The Scientific Group made a number of propo
sals for research and concerning ways of developing
the application of epidemiology to the wellbeing of
the elderly. These concerned specifically the need
for an information clearing-house, studies of the epi
demiological transition, the definition and measure
ment of autonomy, applications of health systems
research, the study of patterns of aging of popula
tions, and ways- of increasing public awareness of the
consequences of the aging of populations and of the
possibilities of coping with the problems that arise.
time immemorial, some people have lived
to a ripe old age, but they have formed only a
very small proportion of the population. During the past
few decades, however, the decline in birth rates and
in infant mortality, the control of communicable dis
eases, and improvements in nutrition and living stan
dards have resulted in an increased life expectancy.
ince
In this report the WHO Scientific Group reviews
the information available concerning the age structure
of populations in countries at different stages of the
“epidemiological transition”, and discusses the impli
cations for health services of the changing patterns
of morbidity and disability among those over 65 years
of age. The Scientific Group recognized that the health
and autonomy of this age group are affected by many
interwoven aspects of the social and physical environISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU,
DELHI-110 002
AND
PRINTED
BY
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and
C/o Editor Soviet Features, USSR Information
Department, 25. Barakhamba Road,
New Delhi-110001
Smt Aruna Palta
Lecturer, Department of Home-Science,
Govt. Girls P. G. College,
Raipur-492001 (M.P.)
The uses of epidemiology in the study of the elderlyReport of a WHO Scientific Group on the Epidemiology
of Aging. World Health Organization Technical Report
Series, No- 706, 1984- ISBN 92 4 120706 X. 84 pages.
Price: Sw. fr- 8—. Arabic, French and Spanish editions
in preparation. Available from the South East Asia Re
gional Office, W.H.O., World Health House, i.P- Estate,
New Delhi-110002.
NEW
and
Professor of Cardiology,
All India Institute of Medical Sciences (AllMS),
Ansari Nagar,
New Delhi-110029
This book is intended primarily for the trainers
of such middle-level health workers, to help them
present the topic in training courses. It gives guide
lines on both the treatment and prevention of diarr
hoea, with particular emphasis on the use of oral re
hydration in children. It describes, in simple terms,
the importance of preventing dehydration in a child
with diarrhoea, and gives instructions for making re
hydration solution, using either packets of oral rehy
dration salts or locally available materials. Easy-tofollow charts summarize the management of diarrhoea
and indicate the signs and symptoms that the health
worker should look for in assessing the patient and
determining treatment. The importance of good do
mestic hygiene and appropriate child-care practices in
preventing diarrhoea is stressed, and the role of the
health worker in educating the community is given
particular attention.
zl
S
and
The number of old people in the world is expect
ed to increase by more than 100 million before the
year 2000 and nearly three-quarters of these will
live in developing countries.
This report will un
doubtedly be of interest to all of those who should
now be making plans to cater for their needs.
(DIRECTORATE GENERAL OF HEALTH SERVICES), KOTLA MARG,
MANAGER,
GOVERNMENT OF INDIA
PRESS,
COIMBATORE-641 019-
Regd. No. D-(C) 359
Regd. No. R: N. 4504/57
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