Wednesday, August 25, 1999

The basics of child-care and our future
By Dr Praveen Kumar
Children below 15 years of age constitute 40 per cent of our country's population. Nearly 50 per cent of the deaths in the developing countries occur in the first five years of life. So, children constitute not only the largest population group but also the most vulnerable one.

Antibiotics and diarrhoea
By Dr Chetana Vaishnavi
During World War II penicillin came on the horizon as a potentially important breakthrough in the management of battle wounds or injuries. However, it was soon realised that it, as prepared for clinical use, was toxic in the guinea-pigs.Subsequent work indicated that several other antibiotics like clindamycin and lincomycin were frequently and sometimes fatally associated with pseudomembranous colitis (PMC) and its milder variants like antibiotic-associated colitis and diarrhoea. In the 1950s, PMC became a relatively common complication of antibiotic usage.

Cutting edge of medicine Arsenic hell
Now it is known that more than 250,000 Bangladeshis have developed inflamed skins, lesions and skin growths that are among the symptoms of arsenic poisoning. In West Bengal, arsenicosis is believed to have killed at least 1,000 people.

Sphere of transplantation
By Dr J. D. Wig

Careful glucose control is of utmost importance in the prevention, stabilisation and reversal of chronic lesions of diabetes. The shorter life expectancy and the worsened quality of life in patients with late diabetic complications necessitates efforts to prevent the pathogenetic process. Published data indicate that persons with diabetes experience significantly greater cardiovascular morbidity and mortality. Diabetic patients with concomitant chronic renal failure experience an additional cardiovascular burden that leads to greater mortality. There is a significantly greater risk of heart failure as a result of diabetic cardiomyopathy.

Strict glycaemic control by exogenous insulin administration is known to influence the development of secondary diabetic complications. Metabolic control is more easily normalised by pancreas transplantation than any other form of diabetic therapy. Pancreatic transplantation ameliorates, improves and prevents some of the secondary complications of long-standing diabetes mellitus. This is especially true with peripheral neuropathy secondary to diabetes.

Pancreatic transplantation is feasible and is a widely accepted therapy for diabetic nephropathy with 85 per cent to 90 per cent of grafts surviving at one year. In the United States of America, about 1000 pancreas transplants are performed each year. In December, 1996, there were 101 pancreas transplant centres in the USA. Twenty to 25 per cent of cadaveric donors are used for pancreas transplantation in the USA. Over 1200 pancreas transplants are performed worldwide each year (International Pancreas Transplant Registry). Simultaneous pancreas-kidney transplantation continues to be a safe option for patients with type I diabetes mellitus and end-stage renal failure. The main goals of this surgical procedure are recovery of the renal function and the control of blood sugar without insulin supplementation.

The optimal surgical technique remains to be defined. Various techniques are whole pancreas grafts, segmental grafts; and islet cell transplantation.

The most-often used technique of pancreas transplantation today is the transplantation of the whole gland with a duodenal segment and pancreatic juice draining into the urinary bladder or the bowel. Bladder drainage has become the most common method with the lowest technical failure and the highest graft survival rates. Bowel drainage represents the most physiologic drainage but is potentially associated with intra-abdominal complications. Total pancreas transplantation is expected to prevent better metabolic control than segmental grafts.

Segmental pancreas transplantation is technically simpler, but poor metabolic control is achieved, possibly due to the smaller amount of endocrine tissue transplanted.

Technical problems continue to be the leading cause of graft failure and include pancreatitis, graft thrombosis, infection and anastomotic looks. Rejection occurs in up to 40 per cent of patients.

Graft losses from rejection and technical failures have significantly decreased over a period of time. The use of new immunosuppressants appears to further improve the outcome. There is no evidence that the side-effects of chronic immunosuppression exceed those of diabetes, and it is logical to choose a pancreas transplant versus insulin treatment in motivated patients.

The complexity of the pancreas transplant and the potential for post-operative surgical complications makes the decision of choosing an acceptable donor a formidable endeavour. Pancreas grafts from donors older than 45 years are associated with an increased risk of developing poor glycaemic control and premature loss of pancreatic function.

Those patients who are not eligible for whole pancreas transplantation may benefit from pancreatic cell transplantation. Transplantation of isolated islet cells is an alternative approach. Islet cells are isolated with a standard digestion — the filtration method using a highly purified collagenase enzyme blend. Liver and spleen can be used as a site for human islet transplantation. Islet transplantation can be either by direct injection, or arterial or venous infusion. The liver would seem to be the most physiologic site as insulin is metabolised in the liver. It is a simpler and safer method than whole organ transplantation. Clinical trials have been reported in a few specialised centres worldwide. Beneficial effects are obtained quickly with better glycaemic regulation. Stable normoglycaemia and the continuous endogenous supply to islet cell peptides may both reduce the pathogenetic process, leading to diabetic organ damage.

The serious shortage of the availability of human pancreatic tissue motivated a search for alternative donor strategies. Because of the actual shortage of human donor islet tissue, it will be necessary in future to fulfil the demand by the employment of non-human tissue as a resource for donor islets. The pig appears to be a suitable donor of pancreas for humans. Improved storage techniques would facilitate transplantation effort by reducing the inevitable islet loss that occurs in any preservation method.

Long-term metabolic control in patients after successful pancreatic grafting, the protection from recurrent diabetic retinopathy (eye ailment), the suggested favourable influence on the secondary complications of diabetes (the heart, the kidney and the nervous system), and the better quality of life due to freedom from exogenous insulin and dietary restrictions make solitary pancreas transplantation and combined kidney-pancreas transplantation the treatment of choice in young diabetic patients.

The development of newer immunosuppressive agents and surgical techniques has improved significantly pancreatic transplantation to such an extent that graft survivals of 77 per cent and 62 per cent at one year and five years, respectively, have been reported. The progress has resulted in its broad acceptance as a treatment procedure in the diabetics.

The basics of child-care and our future
By Dr Praveen Kumar

Children below 15 years of age constitute 40 per cent of our country's population. Nearly 50 per cent of the deaths in the developing countries occur in the first five years of life. So, children constitute not only the largest population group but also the most vulnerable one.

The care of the child is inseparable from that of the mother. Mother and child must be considered as one unit. This is because, during pregnancy, the foetus is part of the mother deriving all its nutrition and oxygen from her blood. Also, the health of the mother— both during pregnancy and previously — is closely related to the healthy outcome of a newborn.

After birth, the child is completely dependent on the mother for feeding as well as mental and social development. Therefore, the health of the child cannot be improved without improving the health of the mother. It is well proven now that a malnourished mother produces a malnourished baby who becomes a malnourished adult. The cycle goes on. So, the improvement in child health will be effected only by an overall improvement in the health of women.

Special requirements of the child: Children are entirely different from adults in both their physiology and needs. They should not be considered as miniature adults. Children are undergoing continuous growth and development but they are dependent for their needs on adults, thus placing them at the risk of malnutrition, mental impairment and even survival. They are also vulnerable to injuries, accidents and harm.

The infant mortality rate (IMR) is considered to be one of the most sensitive indicators of the health of society. Although the IMR in the country has been decreasing steadily since Independence and has reached 71 per 1000, it is still 10 times higher than that in developed countries. Also, there is a lot of disparity between various states. Though Kerala has an IMR below 15, Bihar, MP and Orissa have the IMR of more than 100. More than two thirds of the infant deaths in our country currently occur in the neonatal period.

The causes of death in neonatal period are different from those in later infancy. The central and some of the state governments have realised this fact and are now modifying their approach by focusing attention on essential newborn-care to effect a further decrease in the IMR.

The care of the child begins in utero. The foundations of a healthy adult are laid in the antenatal and neonatal periods. The kind of care required keeps on changing with the age and stage of development. The following are the broad principles of child-care:

(i) Good antenatal care, particularly with respect to nutrition, immunisation and anaemia prophylaxis.

Prevention of complications at birth and ensuring a smooth labour, delivery and establishment of respiration in the baby.

(iii) Nutrition and growth: Because of the rapidly increasing body size (the weight of a baby triples in the first year of life), the child needs extra nutrition. The growth of the baby has to be periodically monitored by weighing and taking measurements of the head and the length or the height.

(iv) Development: The mental and social development of the child depends not only on adequate nutrition and lack of diseases but also on the stimulation provided by the environment at home, in school and in society. Healthy attitudes have to be taught by example by adults.

(v) Vaccination and prevention of infections: Infections have been the major killer of children over the past several years. Though they have been controlled in the West, they continue to be the most important cause of illness and death in the developing countries. Today, effective and cheap vaccines are available against several diseases and many newer vaccines are under development.

(vi) Education: Children have to be provided appropriate education with appropriate curricula to mould them into responsible adults and citizens.

(vii) Prevention of injury, accidents and harm: The child has an inquisitive and exploratory nature. On the other hand, he or she has not gained adequate control over the body function especially in the first few years. Hence, the child needs to be protected from injury and harm. The young girl child in our society needs special protection against harm from others.

(viii) Needs of adolescence: At puberty and adolescence, when the child is in transition to adulthood, a whole range of physical and mental changes take place rapidly. They place undue stress on the child. At this stage, the child needs reassurance and emotional support. The child also needs to be guided about the physiological changes and at the same time, his or her growing independence needs to be supported.

Who is responsible for child care? Although the parents are the immediate care-takers in the home environment and the teachers provide education at school, it is society at large which determines the outcome of a child. "Children are the future". To build a strong future for the nation, child-care has to receive top priority.

Dr Kumar is an Assistant Professor in the Department of Paediatrics, PGI, Chandigarh.

Antibiotics and diarrhoea
By Dr Chetana Vaishnavi

During World War II penicillin came on the horizon as a potentially important breakthrough in the management of battle wounds or injuries. However, it was soon realised that it, as prepared for clinical use, was toxic in the guinea-pigs.Subsequent work indicated that several other antibiotics like clindamycin and lincomycin were frequently and sometimes fatally associated with pseudomembranous colitis (PMC) and its milder variants like antibiotic-associated colitis and diarrhoea. In the 1950s, PMC became a relatively common complication of antibiotic usage.

Antibiotic induced diarrhoea usually occurs during the first week of the commencement of antibiotic therapy. However, at times, the onset may be delayed for as long as six weeks after the final dose, or the disease may also develop after a single dose.

Oral dosing is four-fold more responsible in producing the disease than parenteral injections or topical therapy. The usual offenders are clindamycin, lincomycin, ampicillin and cephalosporins due to their broad antibacterial activity. It should, however, be remembered that almost all antibiotics as well as anti-cancer agents like methotrexate have been implicated at one time or the other.

Causative agent: The causative role of the bacteria Clostridium difficile, in antibiotic-induced diarrhoea and other complications has been established without any doubt. Antibiotic therapy accounts for 98 per cent of all cases of C. difficile associated diarrhoea. The organism was originally identified as a component of normal intestinal flora of new-born infants. It is widespread in the environment and can be isolated from the stools of numerous animals as well as from the soil. C difficile is commonly present in the stools of 5 per cent of healthy human adults usually in low numbers and in 40 to 70 per cent of infants.

Clinical and pathological spectrum: The overgrowth of antibiotic resistant C. difficile after the suppression of competing gut flora by antibiotic therapy leads to antibiotic-induced diarrhoea. The frequency of the isolation of the organisms is directly correlated with the severity of the disease on the basis of both anatomical and clinical parameters. Like virtually all bacterial pathogens, C. difficile causes a spectrum of conditions ranging from asymptomatic carriage to full-blown clinical expression with PMC. Patients may have mild to severe diarrhoea accompanied by abdominal cramps, distention, fever, nausea and increased number of leucocytes in blood. At times the diarrhoea may last for several weeks or months after the discontinuation of the implicated drugs.

Two potent toxins are produced by C. difficile. The toxins attack the mucosa of the large intestine and the terminal small intestine, which becomes necrotic. Pseudomembrane, when formed, may be multiple, friable plaques of a few centimetres and attached to mucosal surfaces. At times they may coalesce. When left untreated, the C. difficile infection may either be mild and self-limiting or end up as a fatality.

There is substantial variation among strains in respect of the quantity of the lethal toxin produced. About 25 per cent of the isolates neither produce toxins nor cause any known disease. Both toxigenic and non-toxigenic strains may be present together in an individual suffering from antibiotic-induced diarrhoea.

Laboratory diagnosis: C. difficile can be usually cultured from stools on special bacteriological media. However, since both toxigenic and non-toxigenic strains would grow on culture, follow-up toxin testing is required.

Therapy and management: The withdrawal of the antibiotic in use most often results in the early resolution of the diarrhoeal symptoms even in some severe cases. Fluid-replacement and electrolyte-balance also need special attention. About 25 per cent of the patients respond to these simple measures within a few days. In non-responsive patients certain antibiotics, which are effective against C. difficile, are prescribed. Microbial interventions using Lactobacilli and Saccharomyces boulardi to replace the offending C. difficile flora are slowly catching up. Relapses also respond well to timely re-treatment since they are different from treatment failures.

Conclusion: As toxigenic C. difficile may be present in some healthy individuals in a carrier state without causing any harm, the final interpretation of a C. difficile aetiology ultimately rests with the physician based on the age of the patient, the clinical history and the antibiotic exposure. Recently, we have found out that monitoring the lactoferrin titers in the stool could help in distinguishing between inflammatory (bacterial) and non-inflammatory (viral) diarrhoeas and will aid in the clinical diagnosis.

Cutting edge of medicine Arsenic hell

Now it is known that more than 250,000 Bangladeshis have developed inflamed skins, lesions and skin growths that are among the symptoms of arsenic poisoning. In West Bengal, arsenicosis is believed to have killed at least 1,000 people.

"Arsenic in drinking water poses the highest cancer risk ever found," says Dr Alan Smith, a United States epidemiologist.

Many villagers call arsenic poisoning "the curse of God." In some cases, entire families are affected. Parents may try to conceal their daughters' affliction for fear that it will prevent them from marrying. Many poor families cannot afford treatment for debilitating arsenic-related disorders.

"Save us from arsenic," begs 35-year-old Kalimuddin, who has watched his neighbours in Miapur all fall ill from the scourge. "Let us live." (Concluded)

Today’s datun

After seven years of his centralised research on the important issue of oro-dental protection, the famous Ayurvedic scholar, Dr J.K.Goel, has come out with the fact that the role of the datun used in ancient times was not limited to mere cleaning. The datun, in fact, provided complete oral hygiene up to the throat. One also used to chew the datun as one rubbed it. That led to the extraction of its active natural ingredients into the saliva, thereby penetrating into our mucous membranes. He has made an experiment — Orohyl care. He has put together 21 herbs including neem, babool, bakul, ashoka, khadir, lavanga, chhoti ilaichi, etc. Modern technology based on the fundamental principles of ayurveda has been used. He calls it "today's datun" — Cynthia, K.

Poverty & asthma

NEW YORK, Aug 24 (DPA)— Children from poor urban districts are up to 21 times more likely to suffer from asthma than children living in wealthier areas, according to a study on the incidence of asthma in major US cities by the Mount Sinai School of Medicine in New York.

Scientists were surprised by the scale of their results. “We had suspected differences between rich and poor districts but we did not think the difference would be so stark,’’ said researcher Philip Landrigan.

The study counted the number of children admitted to hospital with asthma in different districts of New York in 1994.