CURRENT MEDICAL JOURNAL

CONTINUING MEDICAL EDUCATION (CME) PROGRAMME
ISSN-NO - 0972-2203

MANAGEMENT OF BRONCHIAL ASTHMA

Dr. Anant Mohan,
Consultant, Deptt. of Medicine,
AIIMS, New Delhi.

Bronchial asthma is a chronic inflammatory disorder of the airways characterized by widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Diagnosis depends on a constellation of clinical features and the demonstration of reversible airway obstruction on spirometry.

Every effort must be made to classify asthma on a severity scale at the time of diagnosis for appropriate therapy and follow-up. In addition, it is imperative to assess and recognize a patient who is likely to develop near fatal or fatal asthma and are recognized by a combination of severe asthma with adverse behavioural or psychosocial features.

Inhalation therapy with steroids and ß2 agonists form the mainstay of treatment. In addition, proper patient education helps the patient to take care of one's disease. It is essential that patients be told that self-management is effective as well as easy. A simple asthma action plan gives patient-specific advice on signs of deteriorating asthma and appropriate actions to be taken in times of need.

BISMUTH SUBSALICYLATE IN ACUTE CHILDHOOD DIARRHEA -NON-ANTIBIOTIC SUBSTANCE
Dr. A.P. Gupta,
Consultant, Deptt. of Pediatrics,  
JLN Medical College & Hospital, Ajmer.

Eighty three male children with acute diarrhea aged 1 month to 3 years were assigned to receive Bismuth Subsalicylate (BSS) or Placebo in dose of 100mg/kg /day in 4 divided doses, alongwith oral or intravenous fluid therapy as per standard guidelines. Frequency, consistency and quantity of stool, IV fluid requirements etc. were monitored for next 4 days.

The 42 BSS treated children had 50-75% less IV fluid requirement on day 3/4; 50% less stool frequency and 50% less quantity of stools on day 4 of the treatment. BSS treated children with severe dehydration had 50% less IV fluid requirement on day 2 of the treatment.

BSS is being used as an adjunct alongwith rehydration therapy in acute childhood diarrhea and it provides a definite benefit in terms for early recovery by decreasing quantity of stool, water loss and IV fluid requirements. Thus, there was indirect saving in the cost of treatment.

ALUMINIUM PHOSPHIDE POISONING
Dr. Deepak Gupta,

Consultant, Deptt. of Medicine,
GMC & Hospital, Bhavnagar (Guj).

Poisoning is a very common mode of suicide in India and has been known since times immemorial. Various substances were used as poisons e.g. arsenic was a very common mode of poisoning in the past.

With the evolution of time, these substances have changed. Agricultural development had its own advantages but along with it came the use of chemical fertilizers and grain preservatives. These chemicals not only killed the pests but also human beings. People have taken grain preservatives for suicidal purposes on the spur of the moment not knowing their fatal effects and had even no time to regret their decision. Aluminium Phosphide (ALP) is one such preservative which has proved fatal in most of the cases.

Every family physician should be well conversant with the signs, symptoms and treatment of ALP poisoning, especially because that there has been a sudden upsurge in the cases of poisoning.

The main signs and symptoms of aluminium phosphide poisoning are referable to the cardio-respiratory and gastrointestinal systems.

As no specific antidote is available, the treatment is mainly supportive and mortality remains high. Preventive measures should form an integral part of the approach to this emergency condition.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
Prof. N. Khanna,
Deptt. of Pharmacology,
UCMS & Associated GTB Hospitals, Delhi.

The class of NSAID represents an important group of drugs indicated for treatment of inflammation. The drugs suppress inflammation through inhibiting prostaglandins synthesis. All the members of the class act by the same mechanism of action i.e. reduction of prostaglandin (PG) synthesis through inhibition of the enzyme cyclo-oxygenase (COX). All members of the class possess antipyretic and analgesic properties. However, only those with strong inhibitory effects on PG synthesis are useful as anti-inflammatory drugs.

Most members of the class predispose for the development of peptic ulcer disease. Hence, these are classfied as ulcerogenic agents. Gastric ulceration is attributed to the inhibitory effects of NSAIDs on prostaglandin synthesis and its subsequent inhibitory effects on mucin secretion.

Due to the inhibitory effects on thromboxane (TXA2) biosynthesis, prolonged use of most of the class members results in decreased blood clotting, which can lead to serious bleeding problems, if combined with the development of an ulcer.

NSAIDs, especially selective COX-2 inhibitors, represent a new class of cancer chemotherapeutic and chemopreventive agents. Several members of the class were found to be promising in the treatment and prevention of colon, breast and bladder cancer.

HIGH DENSITY LIPOPROTEIN (HDL) AND CARDIOVASCULAR RISK
Dr. Trinath Kumar Mishra,
Consultant, Deptt. of Cardiology,
MKCG Medical College & Hospital,
Berhampur (Orissa).

Low levels of High Density Lipoprotein (HDL) is an independent risk factor for coronary artery disease (CAD).

The risk of CAD rises sharply when HDL levels fall below 40 mg/dL. Prevalence of low HDL is rising because of increased incidence of obesity, diabetes mellitus and other met¬abolic disorders.

Raising HDL levels in blood can be challenging and frequently requires lifestyle modifications as well as multiple medications. Statins can raise the HDL level by 6%. Fibric acid derivatives are beneficial in patients with a combination of hypertriglyceridemia and low HDL. Niacin can increase serum HDL levels by 35%.

Lifestyle modifications (weight loss, smoking cessation, aerobic exercises etc.) are a part and parcel of therapy to increase HDL levels.

Moderate alcohol consumption though considered to raise HDL levels, but it is never recommended in practice, as alcohol addiction is known to increase many cardiovascular disorders.

URGE INCONTINENCE
Dr. Pradeep Mittal,
Consultant, Deptt. of Medicine,
SMS Medical College & Hospital, Jaipur.

Urinary urge incontinence is the most common type of incontinence. Office evaluation often allows for accurate diagnosis and treatment. The pathophysiology of urge incontinence is multifactorial and its etiology has many facets.

Reversible causes of urge incontinence are addressed before any medical or surgical therapies are considered. Medications are useful in those patients who do not want other forms of therapy. Modulators of the central nervous system have a realistic potential role in the treatment of urinary stress incontinence.

The precipitating events may be hearing running water, assuming a standing position from recumbent one, rapid changes in environment, drinking a small quantity of fluid etc.

Treatment mandates a search for all specific disease processes. When all medical options have exhausted, surgery may be considered. Urge incontinence is not a normal part of ageing and effective treatment is available for most individuals suffering from this condition.

DIAGNOSTIC DILEMMAS IN PEDIATRIC TUBERCULOSIS
Prof. Pushpa Chaturvedi,
Head, Deptt. of Pediatrics,
MGIMS, Sevagram, Wardha.

Tuberculosis is fast gaining prime importance due to the global HIV/AIDS pandemic and emergence of multi-drug resistant (MDR) strains.

The problem remains of utmost importance in the pediatric age group due to the high rate of tubercular infection in India and the impact of tuberculosis on the growth and development of the children, child mortality as well as morbidity.

In children, tuberculosis can very easily be missed, as the clinical features of tuberculosis can at times be extremely vague and non-specific. Also sputum, which is the best adulthood specimen for an adequate AFB yield, is hard to obtain in children. History of contact may not always be elicited due to the fear of stigmatization. Radiological features are extremely nonspecific and Tuberculin Skin Tests must be interpreted with a scientific understanding of the possibilities of false positive and false negative tests. Culture yield is positive in only about a third of the patients. Other newer modalities are costly, less easily available and require trained personnel.

Thus, absence of a single gold standard investigation necessitates a thorough understanding of the strengths and limitations of the available diagnostic modalities and a scientific as well as focussed approach.

URINARY TRACT INFECTIONS DURING PREGNANCY
Dr. Sunita Ghike,
Consultant, Deptt. of Obs & Gynae,
NKP Salve Institute of Medical Sciences, Nagpur.

Urinary tract infection (UTI) during pregnancy and renal involvement are common on account of certain anatomical and physiological changes during pregnancy and puerperium.

Asymptomatic bacteriuria occurs in 8-10% pregnant women and should be adequately treated. Otherwise 30-40% of patients will develop cystitis, pyelonephritis and symptomatic urinary tract infection.

The choice of antibiotic should be such that it should have no side-effects on the fetus. Acute pyelonephritis which may present around 16 wks of pregnancy should be vigorously treated to prevent further maternal, fetal and neonatal complications.

Pregnancy with Group B streptococcal bacteriuria should be treated with prophylactic antibiotics during labor. Urinary tract infection during pregnancy should always be treated and never neglected as it has got adverse effects on both mother as well as the fetus. The unsafe antibiotics in pregnancy are tetracyclines, chloramphenicol, quinolones, trimethoprim, sulphonamides etc.