CURRENT AWARNESS BUILETIN ON HEALTH ULY-SEPTEMBER 1998.pdf
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J U LY-S E PTE M B E R 1998
CURRENT AWARENESS BULLETIN ON HEALTH
Drug Therapy in
—•
Page 3
• Diabetes h/teitus
Page 5
The Hazards of
Smoking
• Hepatitis-B
Page 15
Page 7
Letter from
Dr Barry Smith
HAPPEN
EDITORIAL
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Volumel, Number 1
July-September 1998
http://www.hapworld.org
C R SOMAN
V RAMANKUTTY
CONTENTS
current trends
Drug Therapy in Asthma
3
Features the latest consensus on the treatment of Asthma
laboratory diagnosis
Daibetes Mellitus
5
Highlights WHO and ADA recommendations on diagnosis of diabetes
health alert Hepatitis B
Facts about this emerging epidemic
lifestyle The Hazards of Smoking
Tips to adopt a healthier life style
2 •
HAPPEN
July-September 1998
7
15
Editorial
2
Medicine Today
8
HAP News
10
Letters
12
PSBH Roundup
14
ASTHMA is perhaps the most common
affliction which a general practitioner is
called upon to treat. Western estimates
put the prevalence of asthma at around
15% of the population, i.e., about one
in seven persons is affected. It is further
estimated that two-thirds of these
patients suffer from mild asthma, which
does not lead to major functional
disability. Nevertheless, it is important
Drug Therapy in
The key points of the recommendations
are:
1.
Early use of inhaled corticosteroids
to gain control and prevent inflam
matory damage to the airways. This
is recommended in children under
five years also, as an alternative to
cromolyn sodium (sodium cromo
glycate) .
2.
Prompt control of symptoms,
according to severity of symptoms.
Thus,starting with high dose of
inhaled or oral steroids and tapering
down, once control is achieved is
recommended instead of starting
with low doses and raising the dose
if found inadequate.
3.
Long acting beta agonists
(Salmeterol)can be added to low/
medium- dose steroid inhalation for
control of symptoms.
4.
Patient involvement in manage
ment plans, especially the use of
peak flow meters by patients to
measure their own peak expiratory
flow rate (PEFR)on a regular basis
is encouraged.
Asthma
CURRENT TRENDS
that proper scientific principles are
followed in long term management.
Guidelines for therapy in asthma from
United States National Asthma
Education and Prevention Program
(NAEPP) and the British Thoracic
Society emphasize the need for
aggressive approach to establish proper
control at the onset of asthma. Both
these guidelines were published in 1997.
Therapeutic Strategies In Asthma
LONG TERM CONTROL OF SYMPTOMS
Need
What to use
Drug names
Prevent long term symptoms
Inhaled corticosteroids
Beclomethasone,
Triamcinolone
Prompt control of inadequately
treated symptoms
Oral corticosteroids
Methylprednisolone,
prednisolone, prednisone
Long term control of symptoms,
especially nocturnal symptoms
and exercise induced asthma
Long acting beta
agonists
Salmeterol (inhalation)
Salbutamol
Prophylaxis against known
allergens and for prevention
of long term symptoms
Mast cell stabilisers
Nedocromil, sodium
cromoglycate
Long term control of
nocturnal symptoms
Methylxanthines
Theophylline
July-September 1998 HAPPEN
3
RELIEF FROM ACUTE ATTACK
Need
What to use
Drug names
Fast relief from symptoms
Inhaled beta agonists
Salbutamol, Terbutaline
Relieve acute bronchospasm
Anticholinergics
Ipatropium bromide
Need
What to use
Drug names
Prevent progression of
exacerbations
Oral corticosteroids
Methylprednisolone,
Prednisolone, Prednisone
RELIEF FROM EXACERBATIONS
Step-wise approach to managing asthma in adults and
children aged >5 years according to the new US National Asthma
Education and Prevention Program (NAEPP) disease categories.
Disease
Symptoms
_
,
Exacerbation Nocturnal
Daily long term
medication
None
Frequency
Physical
activity
Mild
intermittent
(Step 1)
<2/week
activity
normal
between
episodes
Rare. PEFR
normal
when not in
exacerbation
2 episodes/
month
Mild
persistent
(Step 2)
>2/week
activity
likely to be
affected
sometimes
> 2 /month
Low-dose
inhaled
corticosteroid
OR mast cell
stabiliser OR
theophylline
OR leukotriene
antagonist
Moderate
persistent
(Step 3)
Daily
somewhat
limited
52/week
1 episode
/week
Medium dose
inhaled
corticosteroid
OR low/
medium dose
inhaled
corticosteroid
+ long acting
inhaled beta
agonist (with
as needed
medium/ high
dose inhaled
corticosteroid
+ long acting
bronchodilator)
Severe
persistent
(Step 4)
4 •
Continual
HAPPEN
limited
often
52
episodes
/week
July-September 1998
High dose
inhaled cortico
steroid + long
acting broncho
dilator + long
term oral
corticosteroid
The use of Inhaled
corticosteroids in mild asthma
Even though early use of inhaled
corticosteroids has been advocated even
in mild form of the disease, long term
complications of such use are not yet
clear. Hence it has been recommended
that mild forms of adult asthmawhen the
patient is largely symptom free and lung
function is near-normal, can be treated
with inhaled beta-agonists like
salbutamol alone, and steroid inhalants
added only when symptoms are not
controlled with these. Over two-thirds
of sufferers from asthma have mild form
of the disease, and hence the decision
of when to put the patient on long term
inhaled corticosteroids is one affecting
a large number of people.
Use of Inhaled beta-agonists
in asthma
1. In mild asthma, beta-agonist
inhalation should be used as needed;
there is no advantage in using them
on a regular basis.
2. In patients with asthma who have
regular symptoms, inhaled cortico
steroids have an advantage over the
use of long term beta-agonists.
3. Regular use of inhaled cortico
steroids in patients with moderate
symptoms reduces the frequency of
acute attacks, but regular use of
inhaled beta-agonists does not.
4- Beta-agonists are extremely useful in
providing rapid relief from acute
attacks, and in preventing allergen
or exercise induced asthma.
Sources:
Prompt Control of Asthma Essential: The Emphasis
from the blew US and UK Guidelines. Drugs
andTherapeutics Perspectives 1997:9 (8): 6-8.
Jeffrey M Dra;en Treating mild asthma- when are
inhaled steroids indicatedl Editorial, New
England Journal of Medicine 1997: 337,9.
Paul M O'Byme and Huih A M Kerstjens
Editorial, New England Journal of Medicine
1996:334.8.
Diabetes mcllitus is a disorder of multiple
etiology, characterised by hyper
glycemia, glycosuria and a wide spectrum
of clinical and pathological mani
festations. Diagnosis of this metabolic
disorder is simple and straightforward
when patients present with typical
symptoms such as thirst, polyuria and
weight loss. Glycosuria is invariably
heavy, often associated with ketonuria
Diabetes Mellitus
refined and reset at considerably higher
values than in the past and a category of
impaired glucose tolerance (IGT) has
been interposed between normal and
diabetic levels. The recommendations of
the expert committee of the World
Health Organization (1980,1985) have
been widely accepted. Recently, the
American Diabetic Association have
suggested further simplification of the
diagnostic criterion. They suggest fasting
venous plasma glucose level as the sole
criterion for diagnosing diabetes.
Oral Glucose Tolerance Test
(OGTT)
LABORATORY DIAGNOSIS
In over 80% of subjects presenting with
clinical symptoms, diagnosis of diabetes
and blood glucose concentration is so is established by a single bkxid glucose
grossly elevated that a single measure estimation. At present, diabetes is dia
gnosed if the random venous plasma
ment confirms the diagnosis.
glucose level is above 200 mg/dl
Problems in diagnosis arise where
(1 l.lmmol/lt) or if fasting values are
routine testing of either asymptomatic
above 140mg/dl (7.8mmol/1t). However,
subjects or patients with unrelated or
efforts towards early chemical diagnosis,
non-specific symptoms reveals lesser
in the hope of preventing long term
degree of glycosuria and random blood
complications, stimulated research into
glucose levels that are not grossly
more sensitive techniques for detecting
elevated. Diagnosis then depends on the
hyperglycemia, even in the absence of
level of blood glucose measured under
symptoms and signs. The use of two-hour
specific conditions and related to
OGTT has now been accepted as a
diagnostic criteria, which mark the cutoff
standard procedure for the detection of
points between normal and abnormal.
diabetes mellitus. The current consensus
Over the last three decades, the glycemic on OG1 1, recom-mended by WHO is
criteria defining diabetes have been furnished below:
Diagnostic criteria for diabetes using fasting and two-hour post glucose,
blood sugar (venous plasma glucose)
Fasting
2-hr. after glucose
Remarks
S 140 mg/dl
> 200 mg/dl
Diabetes
2 140 mg/dl
< 200 mg/dl
Diabetes
< 140 mg/dl
2 200 mg/dl
Diabetes
< 140 mg/dl
< 200 mg/dl
S 140 mg/dl
Impaired tolerance
July-September 1998 HAPPEN
5
A fasting blood glucose level of 140 mg/
dl or more and a two hour value of 200
mg/dl or more establishes diabetes
unequivocally even in the absence of
symptoms, provided the abnormality is
confirmed by one more testing. A twohour level between 140 mg/dl and 200
mg/dl, even when the fasting level is
below 140 mg/dl, is termed impaired
glucose tolerance (IGT). Inorder to
achieve feasible international compari
sons, WHO recommends a standard
procedure for oral glucose tolerance
test.
Glycosuria of pregnancy is also an
indication for an OGTT. WHO recom
mends the same criteria for diagnosing
pregnancy diabetes as for non-pregnant
adults.
Recommendations of the
American Diabetic Association
An international expert committee
constituted by the American Diabetic
Association has recommended further
modifications of the WHO criteria.
They have suggested still lower fasting
venous plasma glucose levels for a
Procedure for OGTT
Glucose load
:
Adults
75g in 250-300ml of chilled water
Children: 1,75g/kg body weight
Drink within 5 minutes
Preceding diet and activity
:
Unrestricted carbohydrate (> 150g daily) and
physical activity for at least 3 days before test.
Note: The expert committee considers
FPG as the preferred test and recom
mends a move towards its universal use
for testing and diagnosis based on ease
of administration, convenience, accepta
bility to patients and lower cost. The
expert committee also has introduced a
new category named impaired fasting
glucose, which includes values al 10
mg/dl but < 126 mg/dl.
DIABETES FACTS
© Indians are believed to have
a higher prevalence of
NIDDM than Caucasians.
o
Expatriate Indians have a
higher prevalence of
diabetes than Indians at
home.
o
Fasting period
:
10-16 hr on the night before test.
Pure water allowed in the morning of the test.
Prevalence of diabetes
among urban Indians
exceeds 10% in many parts.
Timing of samples
:
Before and 2hr after oral glucose
(also 30, 60 and 90 minutes if required )*
Remain seated and no smoking through test.
o Rural people have much less
prevalence than their urban
counterparts.
Types of samples
:
Venous or capillary; whole blood or plasma**
o
Precautions
:
Note any drugs (e.g. Thiazide diuretics,
corticosteroids) which may influence OGTT
responses.
Malnutrition-related
diabetes mellitus (Pancreatic
diabetes) that was once
common in Kerala is not a
common disease now.
o
Diet and Exercise form the
cornerstone in the manage
ment of early diabetes. Oral
drugs shall be taken only
under medical advice.
Note departures from desirable OGTT
conditions.
* Under special circumstances.
**Venous plasma recommended for uniformity.
Gestational Diabetes
Quite often, glucose intolerance is noted
during pregnancy, particularly in the last
trimester. This requires attention since
severe glucose intolerance is often
associated with increase fetal and
perinatal mortality and morbidity.
Previous history of obstetric problems
such as still births, large babies and
respiratory problems or hypoglycemia of
newborn should alert the physician.
6 •
HAPPEN
confirmatory diagnosis. The summary
recommendations arc:
• An FPG of > 126 mg/dl (at least 8hrs
of fasting) or
• A casual plasma glucose > 200 mg/dl
(taken at any time of the day without
regard to the time of last meal) in
combination with classic symptoms
of diabetes like increased urination,
increased thirst or un-explained
weight loss.
July-September 1998
• Most of the much
advertised herbal cures for
diabetes have no scientific
basis.
• The best biochemical index
of control of diabetes is the
level of glycated
haemoglobin determined
once in three months.
HBV infection can be spread by:
HEPATITIS B is a serious disease
of the liver caused by hepatitis B
virus, or HBV. All people, no matter
how old they are or where they live,
may be at risk for hepatitis B.
• an infected mother to her baby
during birth;
• sharing needles for injecting drugs;
• having sex with an infected person.
HBV attacks and destroys the liver,
which is such an important organ
that you cannot live without it.
You are at increased risk for hepatitis if
• you live in the same household with
someone who has lifelong HBV
infection;
• you have a job that exposes you to
human blood.
Hepatitis B
If you feel healthy, can you still
have hepatitis B?
Some people who have hepatitis B
have no symptoms and may not know
they are infected. Others who are
infected with HBV never fully recover
and carry the virus in their blood for
the rest of their lives. These people are
known as carriers, and they can infect
other household and sexual contacts
throughout their lives.
Hepatitis B may cause:
• Scarring (cirrhosis) of the liver
• Liver cancer
® Lifelong (chronic) HBV infection
• Liver failure
• Death
How do you find out if you
have hepatitis B?
Why is hepatitis B a problem
for pregnant women and their
babies?
Pregnant women may have HBV in
their blood without knowing it and can
pass it on to their babies at birth. Many
of these babies develop lifelong HBV
infection and can pass the virus on to
others throughout their lives. At first,
babies may not look or feel sick, but as
they grow up, they may have liver
damage. About 25% of babies who
develop lifelong HBV infection die of
liver disease or liver cancer.
How does one get infected
with hepatitis B?
HBV is spread from person to person
by direct contact with infected blood
or body fluids. Even small amounts of
infected blood can cause infection.
Get a blood test under doctor’s recom
mendation in a dependable laboratory.
If the test is positive, the doctor will
tell you how to take care of yourself and
how to prevent infecting your baby and
others.
How do you protect your baby
if your hepatitis B blood test is
positive?
A safe vaccine has been used since 1982
to prevent hepatitis B. The vaccine is
given in a series of three shots. If you
have HBV infection, your baby should
get the first shot within 12 hours of
birth, along with another shot, hepatitis
B immune globulin. The next two
injections of hepatitis B vaccine will
be given along with other immuniCont'd on page 10
July-September 1998 HAPPEN
7
Communicable diseases
should receive high priority
Non-surgical abortion:
an emerging option
As a result of the ‘health transition’
which saw death rates falling across the
world and the important causes of
morbidity shifting slowly away from
infections and deficiency diseases to
chronic degenerative diseases, there is
an argument that research and inter
vention priorities should also move more
Attempting to induce early first tnmester
abortion by prescribing orally admini
stered drugs is not new. Many agents
have claims to this property including
hormonal preparations. However, none
have been generally available which had
the universal approval of the medical
profession.
Medicine Today
NEWS & VIEWS
in favour of chronic degenerative diseases.
However, though non-communicable
diseases are becoming important health
problems even in poorer parts of the
world, in terms of total burden of disease,
communicable diseases still claim first
priority. Moreover, communi-cable
diseases as agents of death and disability
are more important in the poorer regions
of the world and among the world’s poor,
when compared to affluent areas. Noncommunicable diseases caused 34% of
deaths among the poorest 20% of the
world’s population and 85% among the
richest 20%. This clearly shows that a
shift of emphasis in funding and attention
away from communicable diseases would
be to the disadvantage of the poor and
underdeveloped commu-nities in the
world. Enormous health gains have
accrued to all the nations in the world in
the last fifty years; however, the extent to
which the world's poor have shared in
these gains is questionable. The health
problems of the poor are thus even at the
present age, distinct from those of the
rich.
Davidson R Gwatkin, Patrick Haeuveline.
British Medical Journal 1997; 15,7107
8 • HAPPEN
July-September 1998
Surgery continues to be the method of
choice for abortion wherever it has been
legalised, including India. There is some
indication that the future may hold
something different. Two drugs have
been found to have abortifacient
properties: methotrexate and mife
pristone. Mifepristone was developed in
France as RU486 and has been available
to women in Europe since 1986. It has
been estimated that approximately
250,000 women all over the world, in
countries such as France, Sweden, China
and Great Britain have used it. It is a
derivative of a synthetic progestin,
norethindrone. It is a competitive
blocker of progesterone and cortisol, and
thus prevents establishment of preg
nancy, for which progesterone is essential.
Methotrexate is a folic acid analogue
which inhibits production of folates which
are essential for nucleic acid synthesis,
thus preventing cell division. It is also
cytotoxic to neoplastic and nonneoplastic trophoblastic tissue. Either of
these drugs, for inducing abortion, is
administered together with another
drug, Misoprostol which is a synthetic
prostaglandin that induces uterine
contractions.
Surgical termination of first trimester
abortion is 99% efficacious and has a
complication rate less than 1%.
Compared with this, oral abortifacients
have an efficacy rate of only from 9098% at less than 6 weeks’ gestation and
80-90% at 6-8 weeks’ gestation. However,
the non-invasive nature of the new
approach, and the preservation of
privacy, are features which may attract
more women.
With further research, many of the
problems associated with these drugs
may be overcome. Oral abortifacients
may emerge as the choice for the future.
Eric A Schaff, Steven H Eisinger, Lisa S
Stadahus. Weighing the options in medical
abortion. Medscape: Women's Health
Genetic engineering to
control disease
Insect borne diseases take a major toll
of life and cause a lot of suffering all over
the world. Malaria, filariasis, Chagas'
disease, sleeping sickness, cholera,
encephalitis and yellow fever are all
scourges which are borne by insect
vectors. Despite various approaches such
as extensive use of chemical insecticides,
biological control, and use of other
techniques like radiation to control the
insect population, the arthropods seem
to have the last laugh in this battle with
man. Large scale killing of insects has
also been shown to have adverse
ecological consequences. Recently, basic
researchers have reported a novel
approach which may ultimately hold
great promise in the future: instead of
trying to destroy insect populations, alter
them so that they can no longer
effectively act as carriers of disease.
Trypanosoma cruzi, the agent of Chagas’
disease, is carried by Rhodnius prolixus,
commonly called the reduviid bug.
Researchers have tried to alter the
genetic composition of a bacterium
normally present in the bug’s gut, so that
it produces peptides that kill T cruzi.
Thus without killing the bug, its
capability as a vector is neutralised.
Though this approach is still in the
experimental stage, it could hold great
promise for human disease prevention
by other means also. Think of a lacto
bacillus (a normal occupant of the human
gut), that can produce antibodies against
diarrhoea producing organisms. This may
be the ultimate vaccine.
John E Conte Jr.
A novel approach to preventing insect home
diseases. New England Journal of Medicine
1997;337:785-786
Should professional
organisations officially endorse
products?
In the US, the decision of the American
Medical Association to enter into an
agreement with a company, the
Sunbeam corporation, which makes
home use products such as scales, air
cleaners, massagers, thermometers,
vaporisers, and humidifiers to officially
endorse their products ( and receive a
royalty from the sales of such products
) has come in for sharp criticism.
Though the royalty goes to the
organisation and not to individuals,
critics feel that the knowledge that the
organisation stands to gain from the
transaction would seriously undermine
its credibility. Though the AMA has
declared that this money would be used
only for research and education, it is
easy to see how this could readily be
changed once the money starts
accumulating. The question whether
the AMA does indeed have the
expertise to examine the quality of such
products has also been raised.
Contrast this debate with the tame
acceptance of the receipt of financial
cut backs by doctors from laboratories
and hospitals in our country. All over
the world, the credibility of the
profession is at a low ebb. Medicine, like
politics, is a profession which demands
adherence to the highest moral
principles from its practitioners.
Deviation from these standards taints
not only the individual, but the whole
community practising the profession, as
we are finding out in India too.
Jerome P Kassirer and Marcia Angell. New
England Journal of Medicine 1997:337,700
Is alcohol good for the heart?
It has been held by many in the medical
profession that drinking in moderation
may be good for health. Recent evidence
on consumption of alcohol and the risk
of coronary heart disease seems to point
to a beneficial effect for alcohol on the
heart, in quantities which do not exceed
one or two drinks a day. Sir Richard Doll,
one of the pioneering epidemiologists to
probe the relationship between mortality
and the use of tobacco, reviews the
evidence on alcohol and the heart in the
December 20/27 issue of British Medical
Journal. His major conclusion is that
there seems to be a U-shaped relation
ship between consumption of alcohol
and mortality risk, with risk decreasing
with the quantity consumed up to a
point, and then increasing with
increasing consumption. So there is an
optimal level for alcohol consumption,
which seems to be around 8 gms of
ethanol /day. The decreasing limb of the
U, from all evidence, seems to be attri
butable to the protective effect of alcohol
on vascular episodes including coronary
events, and the rising limb of the U due
to its effects in larger quantities on the
liver and other systems, greater risk for
violent deaths and accidents, and greater
risk for cancer. The optimal quantity may
also depend on age and gender. Contrary
to popular belief, however, the type of
drink seems to make no difference to the
effect. Consumption of small and mod
erate amounts of alcohol is estimated to
decrease risk of death by about a third,
but in any individual, the degree of
protection will be decided by the com
peting risks for other causes of death.
July-September 1998 HAPPEN
9
What are the public policy implications?
Does this mean that the public should be
encouraged to take up drinking on a
regular basis? Hardly. Among regular
users of alcohol, a considerable proportion
may be imbibing a quantity much larger
than the desirable maximum. Arrack,
the common form of alcohol used by
Indians, is dispensed in a minimum
pack of 100ml, providing 40ml of ethyl
alcohol; 5 times the prescribed optimal
amount.The useful part of the finding
to be emphasised would be that any
consumption greater than moderate is
harmful. As for the rest who have not yet
taken up drinking, is it not better to leave
them like that rather than introduce them
to the potential dangers of drinking too
much alcohol?
Doll R. One for the heart.
British Medical Journal 1997;315
Gene Therapy
for Sickle Cell Anemia
Gene therapy may offer the first oppor
tunity to correct the cell defect that causes
sickle cell anemia, say Duke University
researchers in a report released recently.
After adding the ribozymes to red blood
cells taken from several patients with
sickle anemia, senior author Dr. Bruce
Sullenger and others found that the ribo
zymes correctly repaired the hemoglobin
defect in each case, by correcting the
genetic defect at the messenger RNA
levels of defective hemoglobin.
His team will next try to use the new
technology to correct the sickle cell
defect in mice with the disease. If these
experiments work, the researchers hope
to test the gene therapy in human
patients with sickle cell anemia within
the next two to three years.
Science 1998;280:1593-1596
Fertility drugs not linked to
ovarian cancer
Ovulation inducing fertility drugs do not
10 •
HAPPEN
appear to increase a woman’s risk of
developing ovarian or breast cancer,
according to a study published in the
current issue of the American Journal of
Epidemiology.
Researchers at the Chaim Sheba Medical
Center in Tel Hashomer, Israel and else
where, found that women who were given
ovulation inducing drugs were not more
likely to develop breast or ovarian cancer
than those who were not treated with the
drugs. Whether the drugs boost the risk
of endometrial cancer is still unclear,
concluded the authors of the study.
American Journal of Epidemiology
1998;147:1038-1042
Cont'd from page 7 Hepatitis B
zations. All other members of your
household should get a blood test for
hepatitis B. Ideally, if the blood test is
negative, hepatitis B Vaccine should be
given to the other household members.
Do you need to protect your
baby if the hepatitis B blood
test is negative?
In the West, Hepatitis B vaccination
is recommended for all infants to
protect them from becoming infected
with HBV. The baby may get the first
injection either before leaving the
hospital or with the first injection at the
doctor’s office or clinic. The doctor will
advise you on the injection schedule.
Paediatricians in our country advise
their clients to protect their children
with HBV vaccine.
Should not HBV administration
be included in routine children's
immunisation package?
Many people think that cost considera
tions make it difficult for government to
recommend HBV vaccination as part of
the immunisation package. While cost is
an important factor (it may cost between
July-September 1998
Rs 600-1200 for each child, depending
on the make of vaccine), we also need
more information on the prevalence of
the infection in our population and
efficacy of the vaccine under Indian
conditions, before such a policy is
considered for adoption.
Reprint
of Articles
HAP provides reprint of articles
compiled from various important
medical journals for the academic
community.
The reprints are available on request
against payment at Rs 3 per page.
The current list of full text articles
available on Asthma:
Descriptive epidemiology of asthma.
Lancet 1997; 350 ( suppl 11): 1-4
The cellular and mediator basis of
asthma in relation to natural history;
Lancet 1997; 350 (suppl 11): 5-9
Environmental factors. Lancet 1997;
350 (suppl 11): 10-13
Towards prevention. Lancet 1997; 350
(suppl 11): 14-17
Treatment of acute asthma. Lancet
1997; 350 (suppl 11): 18-23
Limitations of current treatment Lancet
1997; 350 (suppl 11): 24-27
Prompt control of asthma essential:
The emphasis from the new US and UK
guidelines; Drugs & Ther. Perspect.
9(8): 6-8,1997
Ragweed immunotherapy in adult
asthma; NEJM vol. 334(8) Feb 22,1996
Inhaleed(beta) 2 agonists in the
treatment of asthma; NEJM.vol.335
(12) Sep 19, 1996
Is immunotherapy for Asthma worth
while? NEJM- vol. 334(8) Feb 22, 1996
Treating mild asthma- when are
inhaled steroids indicated? NEJMVol.331(11) Sep 15, 1994
Medline Searches at HAP
HAP has been offering Medline services
for more than three years. This is the
most popular service that HAP offers the
medical profession and is enjoyed by a
wide spectrum of students, residents,
young professionals and researchers from
all over Kerala.
What's happening at
HAP
NEWS AT HAP
________
The recent availability of free Medline
through Internet has not diminished
the popularity of the CD-ROM search
at HAP This may be due to a variety of
reasons. Most importantly, though
there are at least two other government
institutions in Trivandrum which offer
Medline search facility, Medline at
HAP continues to be as popular as ever!
This is a tribute to the high degree of
professionalism with which our staff
handle the requests.
FAQs on Medline
Here are some FAQs (Frequently Asked
Questions) on Medline for your easy
reference:
What should I do to ensure a
thorough literature search?
You need to clearly identify:
(a) the search terms, which are key
words that one uses to narrow down
your search
(b) the period of the search, i.e., the
years you would like to scan for
articles /documents of your interest
(c) any special requests.
It would help us greatly if you state your
research question, if any, or the specific
purpose of your search, very clearly.
Which are the most popular
databases?
There are several health related data
bases which can be accessed through
HAP The most frequently accessed ones
are: Medline, AIDS line, Toxline, Health
Star, Cancerlit, PDQ and Embase.
Which search option shall I
choose?
If you are only interested in medical
literature, it saves you a lot of rime and
money to confine your search to Medline.
Ifyou are interested in a broader scientific
question, you have to request for a search
of science databases also. You may also
order a search of AIDSline, Toxline,
Health Star, and Cancerlit. A detailed list
of over 250 databases can be had from
HAP
Medline Search: For a Medline search,
you can hand over your search request
personally at HAP or mail it to us. We
will make a professional search for you
and have the results ready within 24
hours for collection or despatch by mail.
You can also sit with our search profes
sional and browse the CD for articles of
interest to you. If you are planning for a
broader search, CD browsing would be
the right option.
Online Database Search: Owing to the
inability to establish internet connection
during business hours, online access to
HAPPEN
OCTOBER - DECEMBER
1998
Urinary Tract Infections
Acute Renal Failure
Hepatitis-C
Laboratory Diagnosis of
Thyroid Disorders
July-September 1998 HAPPEN
11
databases are not practical. You can place
your search request using the ‘Request
for Search’ forms available at HAR
Searches will be made by us against your
requests and made ready for collection
or despatch normally in 24 hours. How
ever, if there is a delay in establishing
internet connection, results will also be
delayed.
How much will it cost me
to make a search?
Database searches involve utilisation of
resources such as computer rime, skilled
personnel, lease charges for the
telephone lines, charges for access to
certain databases, and other overheads.
As such, they are generally expensive.
However, h@pnet's linkages with
international organisations and our
professional search strategies help us
keep down costs to the minimum. We
assure you that our searches will be
competitively priced, and that you are
guaranteed the best available service in
terms of approachability, thoroughness,
and speed of delivery. You may do well
to remember that generally the browse
option works out to be more expensive
than conventional search, and online
searching much more so than CDROM search.
LETTER
Dr. Barry H. Smith md, Ph.D
Director, Dreyfus Health Foundation
Dear colleagues.
I am honored to have the opportunity to write a few introductory words for the
first issue of HAPPEN. This is especially so because HAPPEN is directed toward
the primary care physicians of Kerala. I can't imagine a more important group of
colleagues to address because it is you who play such a critical part in healing
and improving the health of the people of Kerala.
HAPPEN is a product of Health Action by People, an outstanding group of Keralite
physicians, scientists, and concerned, caring human beings with whom we of
the Dreyfus Health Foundation have had the privilege of working for over five
years. HAPPEN is dedicated to achieving better health for more people in the
State of Kerala through the enhancement of the communication of experience
and ideas among all front-line physicians. This is an incredibly important effort
because all of you have good ideas that can be used to achieve better health
and those ideas, as well as the ideas of other colleagues in India and around the
world need to be communicated and shared with us all if they are to achieve all
they can.
You will Likely see the initial issues of HAPPEN in print, but, as we all know, the
information technology available today enables us all to communicate over vast
distances without any real limitation. The information that you find in, and
contribute to, HAPPEN will be distributed widely throughout the world through
the Health Action by People website and the Dreyfus Health Foundation's
communications for better Health/ Problem Solving for Better Health electronic
network. We are excited about this because your ideas and experience can be of
Some of the specific online-science
databases charge rather heavily for
downloading (taking articles or other
materials from their server into our
computer). You should order online
searches only after having exhausted
other options, and ascertain beforehand,
the rates charged for such searches.
help to health professionals everywhere. We hope that you share our excitement.
There is no greater goal, I believe, than the achievement of "Health for AU" as
set by the World Health Organization. We all know the enormous problems
associated with attempting to achieve it, but we can do it if we all work together.
HAPPEN is an important contribution to that end both in and of itself and as a
model for all of us outside Kerala to emulate. Congratulations on its publication
and on the great work that all of you are doing for the people of the great State
of Kerala.
On an average, a routine search costs
about Rs 50 to Rs 100, and the browse
option costs around Rs 200. The online
searches of priced databases work out
to be much more expensive. We shall
provide you a rough estimate of the cost
before we initiate the search.
12
HAPPEN
July-September 1998
Warmly - and with the greatest respect for your commitment and the work that
you do.
(Barry H. Smith )
Problem Solving for Better Health is a
global network supported by the Dreyfus
Health Foundation, New York, and
operated in 20 countries through
universities, voluntary agencies and
professional bodies. Health Action by
People are proud partners in the move
ment and co-ordinate PSBH activities
in India.
As a follow-up of the PSBH workshop in
Madurai in December 1997, a committee
has been formed with Dr. Lakshmi
Rehimatullah as chairperson to co
ordinate the progress of the projects.
Lenin Gross from the DHF and
Dr. Raman Kutty from HAP met
Dr. Rehimatullah in Madurai in April
to finalise the arrangements.
PSBH Project Summary
PSBH
PSBH in Kerala and India is about five
years old. During this periixl, we have had
several unique projects which rook shape
in our workshops, and were completed
successfully, thanks to the efforts of the
participants and support from many
institutions. Most important of these is
the Dreyfus Health Foundation, which
have initiated this process in India.
PROBLEM SOLVING FOR BETTER HEALTH
In 1998, the first PSBH workshop
exclusively for nurses in India was
conducted in Trivandrum on April 1315, at the College of Nursing. 16 MSc
HAPPEN proposes to profile one project
Nursing students from the host college
in every issue. Naturally, we may not be
as well as 8 from Calicut, along with a
able to cover every project, but we consider
number of faculty, participated in the
all of them equally important. The selected
workshop. It was co-sponsored by Action
ones are included as encouragement to our
in International Medicine, a UK based
new participants to get on with their work.
NGO. Dame Sheila Quinn, renowned
nursing expert, educationist and chair In this issue, we include an unique project
man of AIM, participated as a resource which came out of the medical students’
person along with Jan Sabotka from the workshop at Medical College, Calicut. It
Polish Academy of Hygiene and Lenin demonstrates what collective student
Gross from the DHF, New York. HAP effort can do in focusing on health
hopes that nurses’ PSBH in India grows problems of the community, the first step
into a nationwide movement.
towards intervention.
Survey of morbidity in a population affected by
pollution from a Rayons factory and a
control population
Aparna Govindan, Biju Simon, Sajid Jamal, Shamsuddeen M, K P Aravindan
BACKGROUND
The study is an attempt to gain insights
into a local environmental problem. It
was conducted by a group of medical
students in the Medical College,
Calicut, Kerala, India.
“Gwalior Rayons” factory near Calicut
is the largest private sector industrial
concern in Kerala, employing about
5000 people. The factory manufactures
pulp and staple fibre from bamboo and
wood. Chemicals like sulphuric acid
July-September 1998 HAPPEN
13
needed for pulp and fibre production are
also manufactured. Smoke from the
factory flows south and south east
towards Vazakkad, which, incidentally,
is at a higher altitude. The emissions
contain sulfur dioxide, hydrogen sulfide,
carbon disulfide, carbon monoxide etc,
which, when inhaled in quantities above
permissible limits can cause respiratory
disease. The industrial effluent, after
anaerobic and aerobic processing, is
taken by pipe to Chungapalli, seven
kilometers to the west and discharged
into the Chaliyar river. For about two
decades, people affected by pollution
from the factory have been complaining
of ill health. Previous studies directed
towards resolving this issue have not
been conclusive.
The questionnaire touched on demo
graphic details, economic indicators of
the household, drinking water and
sanitation, and morbidity (sickness) in
the past two weeks.
SUBJECTS AND METHODS
One area each was selected for household
health survey to study the effects of air
pollution (A) and water pollution (W).
A third area, approximately the same
distance away from the factory but not
subjected to water or air pollution because of the direction of flow of the
wind and water- was chosen as control
(C). In areas A and C, 10 clusters of ten
houses each were chosen by systematic
random sampling. For area W, 300 houses
on either side of the river bank were listed,
and five clusters of ten houses on each
bank were selected by systematic random
sampling.
The survey was conducted by 3 groups
of students in the three areas on a single
day. The teams received prior training.
14 • HAPPEN
9.
About eight out of ten heart attacks
in men under 45 are associated with
smoking.
10.
Arterial disease is associated with
smoking and kills more people than
cancers.
11.
Nine out of ten people with
circulation problems are smokers.
12.
Smoke is an irritant and within hours
can cause eye irritation, sore throats,
nasal symptoms, dizziness, nausea
and headaches in those who share
closed spaces with smokers.
13.
Children exposed to a parent's
smoke are more likely to suffer from
asthma and more likely to be
admitted to hospital with bronchitis
and pneumonia.
14.
Glue ear in children is more common
when exposed to parent’s smoke.
15.
Babies born to smoking mothers
tend to be smaller at birth.
16.
Parental smoking is associated with
cot death.
17.
Smoking ages the skin prematurely.
18.
Teeth get stained brown with
nicotine.
19.
Smokers suffer from more gum
disease than non-smokers.
20.
At the rate of 20 cigarettes/day,
a smoker will pay around Rs. 10,950
per year to support the habit. Even
if the price were to remain steady
for the next 30 years (we all know it
will never happen) a smoker has to
spend Rs. 3,285,00 - enough money
to educate two children through
medical or engineering colleges.
RESULTS
Morbidity' rate, i.e., proportion of people
who reported sick in the two study
weeks, expressed as number of persons /
1000 population, were 122.3 in the
control area C, 134.4 in the air pollution
area A, and 217.3 in the water pollution
area W. Clearly, the area affected by
water pollution shows a considerable
increase in sickness compared to the
other two areas. Further break-up of the
data according to type of sickness is
shown in the table below:
QUESTION
Do populations living in areas affected
by water and air pollution from
"Gwalior Rayons" factory suffer more
morbidity than unaffected populations?
Continued from page 15 Smoking...
Relative risk of specific morbidities
in air and water pollution areas.
Relative risk
when compared to
control area C
P value
Diarrhoea
in area W
6.99
0.032
Asthma
in area A
3.38
0.044
Skin disease
in area W
2.91
0.086
Category of
Sickness
Variables such as socio-economic
conditions, quality of drinking water and
proportion of households with access to
sanitary facilities were similar in the three
areas, and therefore unlikely to have
influenced the results.
CONCLUSION
The areas suffering air and water
pollution reveal excess morbidities. The
most likely cause is industrial pollution
caused by “Gwalior Rayons" factory.
July-September 1998
If after reading this piece, you still
want to smoke, it is time for an IQ
check!
Each year, tobacco is responsible for the
death of more than three million
people, one death every ten seconds.
These numbers are increasing, and
unless current trends are reversed, by
the 2020s or early 2030s, tobacco will
kill 10 million people each year, with
The Hazards of
Sm©kmg
LIFESTYLE
70% of these deaths occuring in develop
ing countries. Since the early 1950s,
scientific evidence has been accumulating
to the point where more than 25 diseases
are known or strongly suspected to be
causally related to smoking. However, the
costs of smoking extend well beyond the
tragic health consequences, encom
passing large economic and social costs
as well.
Reflecting the concern of the inter
national community, the World Health
Assembly has adopted a number of
resolutions on tobacco control, including
a call for the implementation of compre
hensive tobacco control strategies.These
measures are urgently needed in countries
with an already burgeoning tobacco
epidemic, yet are just as important in
countries where there is still potential to
prevent what is a wholly avoidable
tobacco epidemic.
Absence of reliable information on
tobacco related deaths and morbidity acts
as a major impediment to making
governments take stern regulatory
measures on tobacco promotion and sales.
The serious health consequences of
tobacco use begin to appear only two to
four decades after tobacco use becomes
widespread. Disease registries have been
identified as a very promising source of
data on tobacco-related illness and death.
Detailed methods for estimating the
number of deaths attributed to tobacco
are described by international agencies.
However, these methods should only be
used when all the criteria for their use
are met.
As useful as additional information on
tobacco use and related health effects
will be, it is already known that tobacco
is the most important preventable cause
of premature death in many countries,
and that half of persistent smokers who
start smoking in adolescence will die
from their use of tobacco. The need for
effective global action against the
tobacco epidemic is urgent.
20 good reasons to stop
smoking
1.
Tobacco smoke contains at least
50 known toxic or cancer forming
substances.
2.
Smoking is linked to cancer of the
lung, mouth, larynx and esophagus.
3.
Nine out of ten lung cancer deaths
are due to smoking.
4.
Lung cancer deaths exceed death
from any other type of cancer.
5.
Smoking helps promote cancers of the
bladder, pancreas, kidney, stomach,
and cervix.
6.
Nine out of ten deaths from bronchitis
and emphysema are due to smoking.
7.
Women who smoke have greater risk
of infertility, miscarriage, premature
labor, still birth, early neonatal
deaths, earlier menopause and
osteoporosis.
8.
Smoking, while using oral contra
ceptives, increases the risk of heart
disease and stroke by at least 10 times.
Cant'd on |>uge 14
July-September 1998 HAPPEN
15
Some people
think it is
■
.
style to smoke.
Last year 3,000,000 such people
died in style.
•
■
QUIT SMOKING TODAY!
AND LIVE IN STYLE TOMORROW!!
, Health^^.
Action* People
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