|HEALTH TRIBUNE||Wednesday, May 3, 2000, Chandigarh, India|
for your eye and sight
fitness: the goal
World Asthma Day today
Asthma is a disease characterised by recurrent attacks of breathlessness and wheezing which vary in severity and frequency from person to person. It attacks all age groups but often starts in childhood. This condition is caused by the inflammation (swelling) of the walls of the air passages in the lungs which makes the airways highly irritable. During the attack, the lining of the airways swells and the walls undergo constriction, causing the airways to narrow and reducing the flow of air in and out of the lungs.
Today, more than 150 million people in the world are suffering from asthma. In developed countries, approximately 10 per cent of the population has asthma. In India, overall 2 to 5 per cent of the population has this disease while the incidence is around 10 to 15 per cent in children. Our country alone has 15 to 20 million asthmatics.
The most unfortunate part of the story is that the incidence is increasing throughout the world. In Western Europe, asthma has doubled in the past 10 years. There is clear evidence that the disease is increasing among the Indian people. Though urbanisation has been blamed the increase in the incidence has been related to various factors.
The strong risk factors include exposure, especially during early childhood, to indoor allergens, e.g, domestic mites in beddings, carpets and stuffed furnitures, and pets and cockroaches. The family history of asthma or allergy, smoking and chemical irritants at workplaces are additional factors.
Other causatives include certain drugs (aspirin or other pain killers), respiratory infections and low birth weight. Cold air, extreme emotional expression and sometimes exercise can initiate an attack of asthma.
It is now amply evident that the asthma problem increases as we move from good old life-styles to modern ways of living. The incidence is very low in the countryside which modern life-style has not yet invaded. Although modernity cannot roll itself back to ancientness or primitivity to get freedom from a particular disease, people have to adopt certain do's and don'ts to alleviate asthma, if not in general, at least in asthmatic or vulnerable groups. Established trigger factors for the initiation and worsening of asthma in patients have to be taken care of along with drug treatment for the control and prevention of attacks. The important triggers, along with remedial measures, have been discussed below.
1. Housedust mite: This microorganism is the main cause of asthma which is aggravated by dust.
It is found in beds, furnitures, carpets, grains and books lying in humid places. Wearing dust masks, wiping things with wet cloth or vaccum cleaning help in preventing its effect.
2. Pollens: Seasonal asthma from (March to May and from September to November) is caused mostly by pollen grains found in the atmosphere. Keeping away from trees, weeds and plants in such seasons, using masks during work in farms and gardens and avoiding outdoor activities help.
3. Moulds: These microscopic fungi release spores in the air which, when inhaled, can lead to asthmatic attacks. During the rainy season patients should avoid going into damp basements and grain storage. Avoid dampness over the walls of bathrooms or rooms so as to check mould growth. Indoor humidity can be reduced by good ventilation, exhaust fans, air-conditioners and dehumidifiers.
4. Insects; Asthmatics allergic to cockroaches and those who are heavily exposed to insects at home are thrice more prone to severe attacks. So, keep a high degree of cleanliness in the house and in the surroundings. Check the breeding of insects (mosquitoes, flies, rainy insects, bees, etc.) by spraying insecticides regularly.
5. Drugs: Aspirin or painkillers, B-blocker hypertension drugs eye drops and ACE inhibitors can lead to the worsening of the symptoms. So, alternative drugs should be used.
6.Food: Five per cent of the asthmatics have food allergies because of the use of colouring agents and preservatives (monosodiumglutamate, tartrazine etc.) in junk and tinned foods like squashes, toffees, sauces and pickles. Reflux and heavy meals also aggravate asthma. In such cases the avoidance of contraindicated food improves asthma.
7. Exercise-induced asthma: When asthma is not controlled, patients should avoid doing exercise, playing vigorous games and performing hard physical work. About 15 minutes of slow warming and cooling down before and after the exercise alleviate asthma. Swimming, walking, tennis, table tennis and cricket are quite safe.
8. Vehicular pollution: The main constituents sulphur dioxide, nitrogen dioxide and suspended particles increase the severity of asthma. Therefore, keep roadside windows closed, wear a pollution-free mask and use a handkerchief, nasal filters, a full mask helmet and airconditioned vehicles.
9. Kitchen: Cooking has a lot to do with the triggering of asthma attacks. Chulha fumes and the smoke generated by frying pepper and other spices in oil or ghee are irritants for delicate nasal and airways lining. Proper chimneys, smokeless chulhas, good exhaust fans in kitchens fume-absorbing gadgets and the avoidance of frying things are helpful.
10. Mental stress: Emotional stress, family disputes, psychological illness, marital status, shock and excitement are all known to aggravate asthma. Look out for the factors constantly disturbing you and discuss these with your doctor. Yoga, relaxation and a judicious use of tranquillisers are also useful.
11. Cold-induced asthma: The temperature fluctuating in the lungs and the airways is important. So, avoid cold water bath , sitting in the direct stream of air (of the AC or the cooler), take cold edibles slowly, avoid drenching yourself in rain and bare-foot walking in winter and use full-mask helmets while driving in the cold weather.
12 . Sore throat: Asthmatic patients should increase preventive drug dosages during a few weeks after having a sore throat. They should treat sore throat promptly.
Besides the triggers mentioned above, there are many more a sudden climatic change, mosquito repellents, tobacco smoke, pets, firework and crackers, and agarbattis, for example. The environment of one's house is important. It affects the severity of asthma. Due care should be taken to construct a healthy house. The location, ventilation, furniture, decoration, curtains and paints require special attention.
Laser for your eye and sight
In recent times, lasers have become the standard of care in the treatment of many eye diseases. The word "Laser", is an acronym for "Light Amplification by Stimulated Emission of Radiation" and refers to a device that produces a powerful beam of highly coherent electromagnetic radiation". The era of lasers began in 1958 with the publication of the seminal theoretical paper of Schawlow and Townes which extended the principles of microwave masses to optical frequencies.
Since then, scientists and physicians have explored hundreds of potential medical applications for lasers. Today lasers are the tool of choice for sight-saving procedures in eye diseases and for the removal of various skin lesions as well as for the removal of specific tissue structures in neurosurgery, gynaecology, urology, gastroenterology, and orthopaedics. The eye, with its optical accessibility in the visible region, is especially receptive to laser treatment.
The physics of lasers:
Visible light, X-rays, ultraviolet rays, infrared radiation and radiowaves are forms of electromagnetic radiation. Laser light is a highly coherent form of electromagnetic radiation falling in the spectral range between the X-rays and the far infrared. A coherent light can be achieved by filtering ordinary light but the output beam has a very low intensity, rending it useless in most practical applications.
The usefulness of laser light in medicine stems from its unique combination of monochromaticity, directionality and brightness. In a laser system, a pumping sources (thermal or electric) excites the atoms in the laser beam. Of various lasers developed till date, the commonly employed ones in the treatment of eye diseases are Argon, Krypton, Excimer, Diode and Nd-Yog.
Selected application of lasers in eye diseases:
Lasers have exciting applications in the treatment of various eye diseases. The techniques are simple, painless, time-saving office procedures which have markedly improved the overall visual prognosis.
1. Diabetic retinopathy and other retinal diseases:
Diabetes is one of the leading causes of blindness. Roughly 30 per cent of the diabetic patients have eye involvement (diabetic retinopathy) at five years after the onset of diabetes. Visual loss occurs either due to the leakage of fluid from the blood vessels in the retina (macular oedema) or bleeding inside the eye (vitreous haemorrhage). The application of laser beams to the retinal tissues leads to a temperature rise and photo-coagulation of the tissues which helps in the closure of the leaking blood vessels and the regression of fragile blood vessels which are the source of bleeding inside the eye. Similarly, lasers are of immense use in the treatment of retinal vascular occlusions.
After cataract (jhilli):
Many treated patients of cataract complain of vision deterioration in the eye a few months after the surgery and intraocular lens implantation. This is generally due to the formation of an opacified membrane (commonly known as jhilli) behind the intraocular lens. T his membrane can be easily cut with a Nd:Yag laser, thus avoiding the need for an operative procedure. Marked visual recovery occurs in the next three or four days and is very gratifying to both the patient and the surgeon.
3. Laser treatment for the removal of glasses
Who doesn't want to get rid of the numbered glasses and look more smart? Now we have a solution to this. Excimer laser can be used to correct the refractive errors of the eye in this very promising technique, called photo-refractive keratectomy (PRK) or the recently introduced "Laser-Assisted In-situ Keratomileusis" (LASIK). Preliminary evidence indicates that this technique, which employs the reshaping of the cornea by laser beams, is safe and effective for reducing myopia up to six diopters. Though long-0term results are yet to come LASIK offers an alternative to glasses and contact lenses for millions of myopic individuals and could become the most widespread application of laser in the field of medicine.
4. Glaucoma treatment:
Lasers can avoid the need of surgery in certain forms of glaucoma.
5. Cataract surgery:
A common misconception is that stitchless cataract surgery is performed with a laser technique. In fact, the technique for stitchless cataract surgery is phaco-emulsification (popularly known as phaco) carried out with an ultrasound hand piece. The laser technique, for the removal of cataract, is still at the experimental stage.
Global fitness: the goal
In 1993, BASF India Limited (BIL) acquired 85 hectares of land, 20 kilometres north of Mangalore, initially for setting up two plants for the manufacture of dyes and dispersions and ultimately to be developed as an integrated site. Mangalore was chosen after taking into account its comparatively better developed industrial and social infrastructure, proximity to a petroleum refinery (MRPL), and its modern harbour. In the following article the author explains how the company is committed to preserving the environment and promoting social health.
In India, such greenfield sites nowadays face two main problems in the initial stages:
*Opposition from the local community apprehensive about environmental degradation due to industrial development, especially degradation caused by the chemical industry.
*Unexpected disruptions in construction, commissioning and production activities due to action by trade unions which do not have an industrial tradition.
BIL has dealt with both these problems in an appropriate manner. It succeeded in convincing the local community, particularly the fishermen/environmentalists, about the companys track record as a responsible member of the community in the different parts of the world in which it operates, and its commitment to conform to the best international standards for the disposal of effluents.
Even at the stage of site acquisition, BIL was conscious of creating a good rapport with the local populace and to improve their health. The relocation of the 16 families residing in the acquired property was one of the initial tasks to be tackled. The displaced families were resettled in a property specially purchased and developed with the necessary amenities by BIL. In addition, one suitable persons from each family was given employment in the BIL works.
During 1994, several firms announced their intention to set up large industries in and around Mangalore. This development made the local people, particularly the fishermen, very apprehensive about the adverse effects of large-scale industrialisation and consequent environmental degradation which caused various ailments. Within a very short time a movement to oppose the location of large industries in and around Mangalore gained ground. BIL was quick to recognise this emerging situation. BILs approach was to share with all stakeholders the correct information about its plan for environment management and to convince them that the new complex would not degrade the environment but rather would contribute to the economic development of the area instead. BIL disseminated the information widely through:
*several meetings with the fishermens spokesmen/environmentalists with the help of district authorities;
*talks given by the scientific personnel in the Fisheries Department and relevant higher educational institutions;
*a series of seminars for local opinion makers and concerned government authorities. Some of these seminars and meetings were repeated several times.
At the very outset, BIL commissioned an Impact Assessment Study of its proposed chemical complex by the National Environment Engineering and Research Institute, a trusted government body, whose conclusions were favourable.
The alignment of the effluent pipeline on and offshore was decided by the National Institute of Oceanography, a well-known and highly respected government institution.
A state-of-the-art effluent treatment system was set up. the capabilities and the performance of this plant were shared with everyone. In addition, an incinerator was built and commissioned to tackle the problem of solid waste disposal.
The company acquired ISO 14001 Certification International Standard on Environmental Management.
The site management took special care to befriend their neighbours. To create a stake for the local community in its works, BIL employed only locals in the bargainable category. It also undertook certain community development projects in the adjoining villages. Finally, every enquiry from the public was taken seriously and answered promptly.
Breast cancer in men continues to challenge investigators as an unusual disease entity. Male breast cancer constitutes one per cent of all breast cancers. A 14th century British physician, John of Arderne, reported the first case of such cancer in a priest of Colstone.
The natural history parallels that of female breast cancer. Male breast cancer is familial in a similar way to female breast cancer. There is a two-fold increased risk in the first-degree female relatives of male breast cancer patients and a six-fold increased risk in the first-degree male relatives. Male breast cancer has the same effect on breast cancer risks in first-degree female relatives as does female breast cancer.
The aetiology remains unknown and is a subject of intense debate. The majority of breast cancers are hormone receptor positive. Recent studies reveal the association of male breast cancer with a multitude of chromosomal and gene abnormalities. The best characterised of these mutations are in the BRCA2 gene.
The risk factors for this disease include previous chest wall irradiation, prolonged heat exposure, and conditions of relative hyper estrogeny (such as testicular abnormalities, disorders that cause gynaecomastia, exogenous oestrogens, obesity and genetic disorders).
The majority present as a painless breast lump. The lump is usually centrally located and often involves the nipple. Nipple discharge in more often bloody and a sign of malignancy. (The nipple discharge is females is usually non-bloody and associated with benign conditions). Nipple retraction and ulceration are common occurrences. Bilateral breast cancer is extremely uncommon. Bone pains and cough indicate the spread of the disease.
The diagnosis is confirmed by a fine-needle aspiration cytology from the lump or the cytology of the nipple discharge. Mammography is less useful than in women because of the small breast size. It should be done to evaluate the contralateral breast.
Surgery remains the mainstay of the treatment. Lumpectomy alone (removal of the lump) results in unacceptably high rates of local recurrence. The removal of the breast (mastectomy) is the primary treatment modality. The status of the lymph nodes in the axilla is the most important prognostic factor (even more than in female breast cancer). Axillary dissection is recommended as routine in all cases of operable male breast cancer.
Management options for advanced breast cancer (inoperable) include radiotherapy, hormones or chemotherapy. Orchidectomy (removal of the testis) was first described. But due to poor patient acceptance, tamoxifen (hormone-antioestrogen) has become the established treatment due to the high rate of oestrogen receptor positively, and the low toxicity profile of the drug. Tamoxifen has been effective in patients even without orchidectomy.
Chemotherapy (anti-cancer drugs) is reserved for those who do not respond to hormonal treatment and for hormone-receptor negative patients.
Poor survival in men has been a consistent finding. Concerted efforts are required to publicise and educate the population. A high index of suspicion, combined with a uniform approach to diagnosis may bring about some continued decrease in stage at presentation and attendant mortality.
Male breast cancer is not a biologically more aggressive disease than the same condition in females. All efforts need to be made for cure in the majority of the cases. Such treatment should include optimal local control, adjuvant tamoxifen for receptor positive tumours (the majority are receptor positive) and the consideration of adjuvant therapy (chemotherapy) in high-risk patients. Survival is similar to that in female breast cancer.
Professor Wig is
a reputed surgeon, teacher and clinician.