HEALTH TRIBUNE Wednesday, March 15, 2000, Chandigarh, India
 

Breath control & comfort
By Dr Ashok K. Janmeja
Bronchial asthma has been known for centuries. It was described by the ancient Egyptians and has also featured in the ancient system of Indian medicine. It is a Greek word meaning "breathless" or to breathe with one's mouth wide open. Originally applied to the shortness of breath due to any cause, it came to be applied particularly to episodic breathlessness owing to airways disease.

Fever fits: what to do
By Dr Anil Thapar
Approximately 3 per cent of the children between six months and five years of age suffer from fits (convulsions) in fever, with a peak incidence between the age of 10 months and two years. Usually, the fit occurs when the fever is high. A common cause is the viral infection of the nose and the throat. A few cases, however, are caused by meningitis or encephalitis.

A look at lapses — II
Why have sick hospitals?
By J.C. Mehta
All models of new development are always first developed in universities. The following academic programmes were approved by the PGI Staff Council Building Committee/ Academic Committee/GB/IB.

Breakthrough in organ transplant—I
When the heart, liver or kidneys are given for transplantation, most patients do not really wonder about the donor, perhaps beyond offering a silent prayer of thanks. But when the donor has provided a pair of hands, it's different. Hands are visible, personal.

 
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Breath control & comfort
By Dr Ashok K. Janmeja

Bronchial asthma has been known for centuries. It was described by the ancient Egyptians and has also featured in the ancient system of Indian medicine. It is a Greek word meaning "breathless" or to breathe with one's mouth wide open. Originally applied to the shortness of breath due to any cause, it came to be applied particularly to episodic breathlessness owing to airways disease.

Asthma is more commonly prevalent in advanced countries as compared to underdeveloped or unwesternised societies. in the USA and other developed countries, 10% of the children and 6% of the adults suffer from asthma.

It is now a recognised fact that asthma is more common among the urban populace than in rural population.

The exact extent of the prevalence of asthma in our country is not known for want of authentic studies but certainly it is not as severe a case as we see in western countries. It is being realised all over the world that asthma prevalence, severity and deaths have increased during the past two decades. The explanation for this is not clear but urban living conditions, exposure to oxidants, pollutants, passive smoking and even current therapies are being implicated.

Asthma is a Reversible Obstructive Airway Disease (ROAD) in which bronchial hyper-reactivity plays a major role. Pathological changes in the wall of airways are in the form of chronic inflammation in which eosinophils play an important role. This inflammation results in airway hyper responsiveness. By that we mean an increased tendency of airways to go into spasm when they come in contact with triggers or stimuli.

Asthma can occur both in atopic and nonatopic people. Atopic are those individuals who show signs of allergy — rhinitis, dermatitis, urticaria, etc. — after coming in contact with external allergens. However, all atopics do not develop asthma. Many patients have asthma without exhibiting atopy to any identifiable external allergen. Basically, the genetic constitution of an individual decides the predisposition to asthma. The genetic factors, together with infection, allergy, occupational elements, etc, cause the inflammation of the airways. Inflamed airways are highly hyper-responsive to asthma-triggers such as cold air, smoke, pollution, stress, exercise, dust, pollen, nuts and food additives (ajinomoto, tartazine).

After coming in contact with any of these, a complex asthma cascade sets in and a large number of highly potent chemical mediators are released by the eosinophils and mastcells in the walls of the airways. These mediators cause contractions of airways throughout the lungs along with the exudation of thick viscid mucus. The dual changes reduce the lumen of the airways drastically which ultimately cause marked obstructions to the normal flow of air and other symptoms of an attack of asthma. The usual features of asthma are breathlessness with wheezing which is episodic initially and later continuously.

Sometimes, there may be unexplained cough with or without viscid sputum.

Asthma may present in a little less classical way too. Cough-variant asthma may come as persistent dry cough. Nocturnal asthma patients wake up at night with breathlessness. Such presentation also indicates poorly controlled disease. Gastric asthma patients develop or worsen their symptoms after meals. Aspirin-asthma patients develop symptoms with aspirin and other anti inflammatory pain-killer drugs. Exercise-induced asthma patients develop symptoms on physical exertion. Respiratory viral infection can also exacerbate asthma. Occupational asthma too is there. Certain occupations may cause asthma!

The diagnosis of asthma is very simple. In most of the cases it can be done just by taking careful history of the patient. Simple spirometric lung function tests, an X-ray chest and a blood count may be required occasionally. However, the peak flow meter is a valuable tool in the objective self-assessment of asthma.

The asthma management plan is effective and easy to deliver and highly rewarding in the majority of the cases. We can control asthma symptoms so much so that we can maintain normal activity including exercise. Lung functions can also be achieved to the normal or near-normal level. For achieving near-permanent control, one has to continue prolonged treatment and regular follow-up care under a specialist. This will also prevent irreversible airway obstructions and asthma-related death in the long run. The best results in the management of asthma are obtained when prevention and pharmacotherapy are practised seriously. It is popularly taught to the medical students that the best treatment of an asthma attack is to prevent it. For this, patient has to develop a partnership in the treatment for which he or she needs to be educated adequately.

An important part of prevention is the avoidance of identified culprit allergens of provoking factors, and the maintaining of a dust free atmosphere at home or at workplace. This can be done by keeping as little furniture as possible, avoiding carpets and using wet mopping or vacuum cleaning. However, laborious skin-testing or avoidance of multiple food items without a documented increase in symptoms is not necessary. Tinned and fried food should be avoided.

The pharmacotherapy of asthma consists of two basic classes of medications— quick relief and long-term preventive medication. It is important to use these two classes of medications appropriately. Quick-relief medications (e.g salbutamol, terbutaline, ipratropium, aminophylline) are those that give immediate relief. Their effect lasts for four to six hours. Long-term preventive medications do not provide immediate relief but, when given regularly these prevent further attacks. Corticosteroids are considered the most powerful and effective medication currently available for the treatment of the disease.

Worldwide, among the various routes of drug delivery (inhaled, oral, injection), the inhaled route stands out as "ideal" for drug delivery for asthma medication because of its associated significant and well-known advantages. However, the selection of an appropriate inhalation device for an individual patient should be carefully made considering age, cost, acceptability and the status of the disease.

In any case, every patient needs adequate training by the doctor for using the device efficiently.

In conclusion, one can say confidently that the modern-day management programme of asthma can easily control the disease with the regular and proper use of inhaled reliever plus preventer drugs, along with the adoption of an adequate preventive life-style.

Dr Janmeja is the Professor and Head of the Department of Chest Diseases and Tuberculosis at the Government Medical College Hospital, Sector 32, Chandigarh.

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Fever fits: what to do
By Dr Anil Thapar

Approximately 3 per cent of the children between six months and five years of age suffer from fits (convulsions) in fever, with a peak incidence between the age of 10 months and two years. Usually, the fit occurs when the fever is high. A common cause is the viral infection of the nose and the throat. A few cases, however, are caused by meningitis or encephalitis.

The fit: The child who has high fever becomes unconscious and all the limbs start violent movements because of alternate contraction and relaxation of muscles of the limbs (clonic convulsions). The fit usually lasts a few minutes and then complete recovery ensues.

In some cases, however, the fit may be prolonged, and if it lasts more than 30 minutes, it can cause brain damage such as epilepsy or cerebral palsy.

Any fever which is high can cause convulsions. A sudden rise in the body temperature provides the stimulus.

The fear of epilepsy: When the fit occurs for the first time, the fear of epilepsy grips the mind of the young parents. Actually, a simple febrile convulsion is usually harmless. Generally, a single episode occurs which is brief (lasting a few minutes), followed by recovery which is usually complete. Only one in 40 children who are otherwise normal develop epilepsy subsequently. It is the complex fit which has a one in six chance of developing epilepsy.

A complex fit is described as one which is long, lasting more than 15 minutes or repeated in the same episode, or is focal, i.e, only a single part of the body, such as a cheek or a thumb is involved in the abnormal movements. (All the limbs are not involved.) A child who has a family history or epilepsy is more likely to throw fits in fever. One who has a prior brain damage or disorder, or had delayed development, is more likely to develop epilepsy.

Management: When febrile convulsions occur for the first time, you may not be prepared for the occurrence. don't panic. Take the following action:

Since a prolonged fit carries a risk, call your paediatrician immediately.

In the mean time, remove the child's clothing.

Put him in the prone position or on one side.

Keep him cool; put on the fan, cooler or air-conditioner.

Start tepid sponging to lower the body temperature. Unlike in adults, do not use ice-cold water; it can cause the condition of shock. Check the temperature every 5-10 minutes. Suspend the sponging when the temperature drops to 102 F; restart when the temperature rises again to 104 F.

Give paracetamol (Crocin) to the child as soon as he is fully conscious and able to swallow.

Do not force any medicine, liquid or food into the child's mouth when he is unconscious or unable to swallow.

When the doctor arrives, he will take over the case and administer paraldehyde or an intravenous diazepam (Calmpose) injection to control the fit, if it has not already subsided.

In the first episode of convulsions, hospitalisation for 24 hours is advisable for observation and investigations, especially to rule out the possibility of meningitis. These investigations may include complete blood count, blood sugar and serum calcium estimation, and blood culture. Lumbar puncture may be necessary for the examination of CSF (brain fluid).

An electroencephalogram (EEG) may have to be done if the febrile convulsions are complex.

Management of subsequent fever and fits: Two-thirds of these children will not have a further febrile convulsion. Future attacks are likely if the first attack occurs below the age of 12 months. During any fever in future, keep the child cool with the help of a fan, a cooler or an air-conditioner; give him paracetamol if the fever is 100 F rather than at the usual 102 F. Tepid sponging (not ice-cold water) may be started if the fever rises to 104 F. A prophylactic dose of diazepam (Calmpose), as prescribed by the paediatrician (usually 0.3-0.5 mg per kg of body weight), may be given by mouth and repeated every 12 hours up to a maximum of four doses.

If in spite of the above prophylactic treatment, convulsions occur, emergency treatment with diazepam rectally will be required if the fit lasts more than five minutes. Learn from your paediatrician the method of administering diazepam rectally and give it to the child in the dose prescribed by him. If the convulsions last longer than 10 minutes, take the child to the nearest hospital.

Dr Anil Thapar is a consultant paediatrician and neonatologist of repute based in Ambala City.
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A look at lapses — II
Why have sick hospitals?
By J.C. Mehta

All models of new development are always first developed in universities. The following academic programmes were approved by the PGI Staff Council Building Committee/ Academic Committee/GB/IB.

1. A School of hospital engineers offering three to six months of post-ITI training in equipment repairs.

2. A post-diploma course in hospital engineering: a one-year full-time course after a three-year polytechnic diploma to train the middle manager.

3. A Master's degree in environmental health planning: a two year full-time integrated programme for doctors, engineers, architects, nurses, life-scientists (diversifying as MHA and MHE).

4. A centre for research in medical architecture slowly extending to a Master's degree in health facility planning and designing and a Ph.D programme. Dr Ramalingaswami, the former ICMR chief, gave the idea full support.

5. The Institute of Hospital Engineering (India): a professional body was founded in 1976 in the presence of 200 highly placed professionals with its headquarters at the PGI. Today, 100 countries have such associations.

6. The National Centre of Hospital Engineering: an autonomous centre — largely industry-funded and equipped. This was on the pattern of the National Centre in Falfield, London, which the author visited in 1972.

7. The Hospital Consultancy Services Corporation (India): a PSU was created following a written proposal from us by the Government of India.

Course structures were worked out by the TTTI, the AICTE and high-powered national committees appointed by the Ministry of Education. The total funding came from the Government of India and these programmes had a lot of potential to earn from candidates of other countries. Students came from Nepal and other countries. These were collaborative programmes between Panjab University, the PGI, the PEC, the COA, the TTTI, the Thapar Institute and industries. The Government of India wanted to start these programmes in all states to train manpower in emerging technical complexities of hospitals.

International networking: The Ministry of Health had appointed five review committees of experts and each one of them have recorded their appreciation for growth through conservation, dedication, dynamism, constant vigilance and the technical calibre of the staff. An expert from Hammersmith Medical School, London, was all praise for the workshop.

The WHO (Geneva) declared the PGI's hospital engineering department as a model for developing countries in 1981.

The author was invited to international congresses in Germany, Australia and to various famous British hospitals.

The City Beautiful is growing fast into a medical city. To avoid duplication, we started working on a model for shared hospital engineering services including laundry, repair workshops, CSSD, mobile units, etc, to cover the city's government and private hospitals. Our teams visited hospitals in Rohtak, Patiala and other places to repair their equipment.

Challenges ahead: The PGI and the city of Chandigarh have been listed in international publications as impressive models in this field.

There is an explosion of health sciences and technical universities in the region. The number of hospitals are bound to grow. Corporate health care delivery systems through insurance, etc, are the need of our times. A start has already been made through the Health Services Systems Corporation in Punjab and Karnataka. Haryana and Himachal are to follow. The government has to be a starter. Its action will have a multiplier impact.

The PGI, as the mother medical institute of the region, should revive the ideas of growth. The Director of the PGI and the Vice-Chancellor of Panjab University can help in a big way. The author will contribute his mite.

All states and Union Territories should have Directorates of Hospital Engineering.

The Cadre of hospital engineers should be separated from the PWD.

Each district-level or university hospital should have a central equipment workshop controlling towns and villages through mobile units, including service to private clinics. It should be self-supporting.

Organisations like the WHO and the ICMR should contribute to the building up of a National Centre of Hospital Engineering and support the training programmes.

The IHE (India) should be revived.

Nothing happens without personal suffering. My book "Habitat" says a great deal. My research continues. As an NRI technocrat since 1998, I have been writing to the PGI, the Chandigarh Administration and other bodies offering my honorary services. Our health systems are crumbling. They need vision and action. Ours is a century of knowledge, technology, competitive management and patient-care.

Concluded

The author, a Dubai-based consultant to hospitals and environmental organisations for 15 years, is a pioneer in the field of hospital engineering and planning in India. He worked at the PGI, Chandigarh, from 1969 to 1984.
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Breakthrough in organ transplant—I

When the heart, liver or kidneys are given for transplantation, most patients do not really wonder about the donor, perhaps beyond offering a silent prayer of thanks. But when the donor has provided a pair of hands, it's different. Hands are visible, personal. A constant reminder that someone now dead touched, are, lived and loved with them. And though few of us will ever have to look at someone else's hands and reflect on this — there have only been three hand transplants so far — the initial success of these operations suggests that many more will. Not just hands, either; other limbs, even faces. It is a startling thought, not encouraged by the surgeons behind this medical phenomenon. Speculation about the identity of donors in radical operations runs second to improving the lot of the living, even though reminders of those who died could be literally staring us in the face. (A detailed story will appear next week.)

But tiny, telling details emerge. The father of the donor involved in the world's first double hand transplant, performed last month in Lyons, France, was paralysed down one side of his body. He knew what it was like not to have the use of a limb, and that is why he said yes, when many other parents had said no. In effect he said yes, you can remove my braindead son's hands and sew them onto another man. It did not matter that another's blood would colour them pink again, that another's brain would make them move.

His son was 19 when he fell from a bridge at the beginning of last month. He lay connected to a life-support machine for several days. His family hoped for a recovery, but it didn't occur. Technically, the transplant surgeons did not need permission — in France you are presumed to have consented to organ donation on your death unless you state otherwise — but this was an exception they felt was necessary to make. The donation of internal organs was widely accepted, but hands? This was a medical leap that defied simple analysis.

The team had been waiting more than six months to perform the operation. It would be another world first; in September 1998 the same group, drawn from France, Britain, Australia and Italy, had succeeded in the first single hand transplant, on a man whose own had been cut off by an electric saw. But each time last year that a suitable donor match had been found for their double hand transplant patient — a man who had lost his in an explosion — no permission was granted.

To be continued


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