Wednesday, December 23, 1998

Nuclear cardiology: a glimpse
By Dr Anish Bhattacharya
In the stressful and fast-paced life of today, combined with irregular food habits and a sedentary lifestyle, diseases of the heart have been registering an increasing trend, especially among the younger, competitive generation.

HIV: a seamless approach
By Jaya Shreedhar
A NONDESCRIPT building looms over a sleepy lane in Kodambakkam, the throbbing heart of Chennai (formerly Madras), the capital city of India’s southern state of Tamil Nadu.

Nuclear cardiology: a glimpse
By Dr Anish Bhattacharya

In the stressful and fast-paced life of today, combined with irregular food habits and a sedentary lifestyle, diseases of the heart have been registering an increasing trend, especially among the younger, competitive generation.

Medical science, in its perpetual effort to harness new technology in the continuing fight against disease, has not hesitated to utilise the power of the atom.

Thus nuclear cardiology is now emerging as a major diagnostic branch of the cardiovascular department, with the Stress Thallium test providing an extremely useful and popular adjunct to conventional tests like ECG, holter, doppler and angiography.

The stress examination with Thallium is a diagnostic nuclear medicine investigation used to determine if the heart muscle is getting the blood supply it needs, through its nutrient coronary arteries. The narrowing or blockage of coronary arteries by accumulation of fatty material is called atherosclerosis or, more commonly, coronary artery disease (CAD).

As CAD progresses, the heart muscle may not receive enough blood under stress conditions (eg, during physical exercise). This may result in chest pain, called angina pectoris. However, there may occasionally be no outward physical signs of the disease.

Preparation of the patient is important for an accurate Thallium study. The patient is asked not to eat or drink anything for three or four hours before the test. Some heart medications like beta-blockers and nitrates may interfere with the effectiveness of the investigation, and may also be temporarily discontinued before the test.

Immediately before the test, small electrodes are placed on the chest, and connected to an ECG monitor to observe continuously the heart rhythm during exercise, and an intravenous (I.V.) line fixed.

The patient is exercised by walking on a moving belt (treadmill) or by pedalling a stationary bicycle, under close monitoring of the pulse, blood pressure and ECG by a trained and experienced physician. The level of exercise is gradually increased, appropriate for the patient’s age and physical ability.

A small dose of the radioactive tracer Thallium-201 chloride is injected I.V. at peak exercise. This tracer is immediately carried to the heart by the blood. The exercise is halted gradually after a minute, and imaging is performed using a gamma camera. This sophisticated instrument, controlled by a computer, provides coloured images of the heart muscle in which the injected Thallium has perfused.

Images acquired under the gamma camera may be planar (i.e. flat) or tomographic (cross-sectional), as required. In either case, the study may take about half an hour. After three or four hours of rest, during which light-refreshment may be taken, a second set of images is again acquired. No exercise is performed this time, although a second injection of tracer is sometimes required.

Comparison of the two sets of images of the heart, i.e. one immediately after exercise and the second after four hours of rest, is performed using sophisticated computer software.

Deficiencies in blood flow into the heart muscle are seen as dark spots on the images, as compared to bright areas of normal perfusion. Reversibility, i.e. filling up of the dark areas after rest, may indicate the need for surgical intervention, in the form of angioplasty (ballooning) or bypass surgery, while fixed defects in blood flow show the sites of permanent scarring.

The Thallium stress test does not delineate individual blood vessels, nor can it quantify the percentage of blocks in any vessel. However, as a complementary investigation to coronary angiography, it highlights the amount of viable heart muscle and can differentiate between temporary, stress-induced deficiency of blood flow (causing anginal pain) and irreversibly) damaged heart muscle. In the latter case, needless surgery can be avoided, and alternative management implemented.

The investigation is completely non-invasive and requires only an I.V. injection of Thallium. The radiation to the patients body is comparable to that from a CT scan. The test is, therefore, not usually performed in female patients with known or suspected pregnancy. Allergic reactions are extremely rare, making this test safe as compared to investigations using iodinated contrast materials. Most of the Thalluim 201 injected is rapidly cleared from the body by natural processes.

It is, however, important to note that the stress Thallium test should only be performed under expert medical supervision, with cardiac resuscitation facilities available. The interpretation of the images, though aided by computer software, is accurate only in the hands of an experienced nuclear physician, in correlation with other supportive clinical and investigation data.

When properly used, the stress Thallium test has proved a boon in decision-making in the management of patients with coronary artery disease. The expensive equipment and imported Thallium necessary for the investigation make it a little expensive, at about Rs 6000-7000. However, when considered in the context of a life saving decision, it seems a small price to pay.

Dr Anish Bhattacharya, DRM, DNB, MNAMS, is a consultant in nuclear medicine at Body Visions, S.A.S. Nagar (Mohali), near Chandigarh.

HIV: a seamless approach
By Jaya Shreedhar

A NONDESCRIPT building looms over a sleepy lane in Kodambakkam, the throbbing heart of Chennai (formerly Madras), the capital city of India’s southern state of Tamil Nadu. Inside, muted light from a curtained window spills over a group of children, aged 2 to 9 years, sleeping peacefully together on straw mats spread on the floor. In a room nearby, an HIV/AIDS education session is in progress, with people speaking in hushed tones so as not to awaken the children. Downstairs, a nurse gently feeds an HIV-positive woman who is too weak to feed herself. And so begins another day at the hospital that houses the Community Health Education Society (CHES), a nongovernmental AIDS service organisation.

The brainchild of Dr Manorama Pinagapany, a paediatric gastroenterologist, CHES came into being five years ago at a time when the HIV/AIDS epidemic was largely invisible in Tamil Nadu.

“I was working at the Institute of Child Health when two children from a local orphanage were brought to us with severe jaundice,” relates Dr Pinagapany Krishnaveni, the girl was 5 years old and Ravi, the little boy, was barely 3. The children had been tested for HIV by the orphanage and found antibody positive. “Over a period of time they became the darlings of the ward. Unfortunately, the orphanage did not want them back after they recovered. They had no place to go to, and I, who had come to grow very fond of them, simply decided to take them home.”

The entry of the two AIDS orphans into Dr Pinagapany’s life led to CHES’s initial project, the Ashram (hermitage), a full-fledged shelter for people living with HIV/AIDS. CHES’s primary aim was to provide care for AIDS orphans, regardless of their HIV status. To learn how to do this better, Dr Pinagapany received informal training at the state-run Government General Hospital in Chennai.

Over time, the doctors at the General Hospital began referring destitute children and HIV-positive women to CHES. Many of the women had been abused, and some had been sold into the sex trade.

“The women required more than food and shelter,” Dr Pinagapany said. “They needed an emotional outlet of some kind. As the orphan children at CHES needed love and physical attention, it seemed only natural to connect these two groups to fulfil each other’s needs.”

The Ashram also serves as a temporary shelter for women and their children who have become destitute because of their HIV-positive status. It has had 69 admissions to date, from Mumbai (formerly Bombay), Calcutta and other parts of Tamil Nadu as well as Chennai. The care Ashram residents receive includes spiritual counselling and educational support. Older members who are illiterate are taught to read and write.

Up every morning at 7, the Ashram children meet the day with an energetic two-lap jog around the hospital compound, enthusiastically jostling each other in a bid to finish first. Twice a week Valavan, a student volunteer, patiently teaches the children yoga, which they have come to love. Following a simple breakfast of idlis (steamed cakes of rice flour), they settle down to learn to read and write the English, Tamil and Hindi alphabets till lunch time. Vijaya, a CHES worker, also teaches them smple mathematics, craftwork and singing.

“They are very endearing and this never fails to evoke a response from us workers or visitors,” says Geetha, a sex worker who left the sex trade to work with CHES full time. “Early in the project, a friend of mine who had looked after the children for a long time suddenly decided she would leave us, and the effect on the children was devastating. They had grown to love her so, and it took them days to recover their sense of security.

“What I earn here is not comparable to what I could earn in the sex trade,” Geetha added. “But I feel wanted and respected and feel I am part of a family. I cannot buy that with money, can I?”

Funding dilemma: By September 1995 CHES had eight women and four orphaned children under its wring, most of whom were HIV-positive. The space to house the inmates was provided free of charge by Raasi Hospital, a private hospital owned and run by Dr Pinagapany. Institutional and outpatient care and counselling services were also wholly funded by the hospital, while relatives and well wishers donated food and clothing.

Gradually, the NGO realised that it could no longer sustain its work through gifts and donations. However, obtaining the requisite funding to run a shelter for AIDS orphans and HIV-positive women proved next to impossible. “Funding shelters, hospices or institutional care for people living with HIV hardly figured on the list of the donors’ priorities,” Dr Pinagapany said. “We were advised to submit proposals for HIV prevention projects instead.”

In September 1995, CHES received a one-year grant from the Tamil Nadu State AIDS Control Society for an interaction with female sex workers. Weeks of painstaking work with a few friendly brokers and sex workers helped the CHES staff understand the structure of the sex circuits in the coastal areas of South Chennai that were chosen for the project, named Thozhi (companion).

Interestingly, Thozhi did not start with HIV education. Again, care was offered first. Brokers and women in the sex cricuits began to invite their contacts to the hospital for free medical help. There was no mention of venereal disease or AIDS. Once the women underwent a checkup and relaxed to a point where they could share their health concerns, the subject of HIV and other sexually transmitted infections (STIs) automatically came up.

Companions: As the women began attending the hospital regularly to obtain treatment for various problems, mostly STIs, they learned how to use condoms. Those who were interested were trained as peer educators and condom suppliers.

But they learned their most valuable lessons wile nursing some of the Ashram’s residents who were dying of HIV-related illnesses. AIDS was no longer an abstract intangible, but a friend, a colleague or a relative.

(To be concluded)

Why hate garlic?

Garlic is the most commonly studied herb and used for its unique flavour and taste in many Indian homes. A large majority of our people are not aware of the medicinal properties of this beneficial plant. A small fraction of our population dislikes the unsociable flavour of garlic and the invasive action deprives many of healthful benefits of this useful condiment.

Several researches have revealed that the presence of hundreds of sulphur compounds in this amazing plant makes it very effective in the prevention and treatment of degenerative diseases. Garlic contains allicin which makes it an antioxidant, antiviral, antibacterial and antibiotic. It is also known for lowering blood pressure and blood sugar, and boosting the immune system.

The most attractive characteristic of this neglected plant is its ability to fight the deleterious effects of cholesterol, thus preventing clotting. Cholesterol is considered as the main culprit for causing cardiovascular diseases. But this innocent molecular compound is harmful only when oxidised by the free radicals. So, as long as the diet is providing sufficient agents to neutralise the ill effects of these radicals, cholesterol does not cause heart disorders.

Garlic (due to its sulphur compounds and other trace minerals) acts as an antioxidant and protects cholesterol from becoming the causative factor. It also reduces the absorption of damaged fats and triglycerides into the arteries.

Although, the presence of many chemical compounds makes garlic a very useful plant, its unique odour and strong flavour make it unacceptable to many people. To help these people with a sensitive nose aged garlic extract can be used which is more useful because the sulphur compounds more easily assimilable than fresh garlic.

— Monica Seth (Nutrition specialist)

Whose sacrifice, whose survival? — II

The faults which occur at every stage are discussed below:

1. Against the mandatory procedure, that only physically fit women are operated upon, the clinical check-up is casual and quick. The menstrual history of the woman is taken at face value, such that it is not uncommon for sterilisation to be carried out on a patient already pregnant. Rarely is the subject given a careful examination, let alone a full clinical check-up. Almost never is she examined for heart and lung diseases, or even a pelvic infection that may well flare up because of the operation.

2. No care is taken for the comfort and privacy of the woman. Vaginal examinations are conducted even when others are present inside the room or tent. A thin flap separates the woman from the milling crowd outside awaiting their turn and the screams from the patient are freely heard. All this adds to the apprehension and fear of not just the woman on the table, but those outside as well.

3. More shocking is the absence of proper equipment. A properly carried out laparoscopic sterilisation requires a sterile laparoscope, carbon dioxide to create a pneumoperitoneum (gas inside the abdominal cavity to make the procedure easier and safe), and various surgical instruments and sutures which should be properly sterilised. What we normally encounter is a laparoscope cleaned only with water or a spirit swab and placed in a cabinet of formaldehyde vapour for ten minutes or less which does not ensure sterilisation. In place of carbon dioxide, what is used is air, and that too in some camps through a bicycle pump, without a thought-for the blindness, brain damage or death that can result from the air entering the blood vessels in the form of bubbles.

4. Instead of proper anaesthesia, what is given is a half-hearted and perfunctory local anaesthetic infiltration combined with a sedative, which was making a patient drowsy, does little to mitigate pain. The five to 10 minutes that a local anaesthetic takes to achieve its effect is too valuable for the camp organisers to waste!

5. The surgical procedures may well be crudely and inexpertly performed. Tasks which demand skill, such as passing a metal rod into the uterine cavity through the vagina to enable tubal ligation, are left to non-medical personnel, often with disastrous consequences. The doctors who are sent to these camps are usually too young and inexperienced, and given the pressure of numbers and destabilising environment end up converting a “minor procedure” into a full-blown operation with all its attendant complications.

6. Finally, what is shocking is the near complete absence of after-care and review. Since the patient is seen only as a statistic, there is no institutional procedure and pressure for follow-up, or for listening to and attending to complaints. The net result is an appalling frequency of intractable pelvic infections requiring removal of the uterus. Deaths due to resultant hysterectomy occur in one out of every 5,000 women targeted for sterilisation. Rarely is it realised that tubal ligation fails in one per cent of the women, who become pregnant in spite of the operation. Fifteen to 20 per cent of failed ligations thus result in ectopic (outside the uterus) pregnancies, which carry a 30 per cent fatality rate.

What is all the more shocking is that all this is neither unknown nor unexpected. Why, even reputed journals such as the Journal of Obstetrics and Gynaecology reports cases of a single doctor performing 60,000 operations in one year, or another 2,800 in three months. Figures of mortality varying from 7 to 150 per 1,00,000 reported from different camps should thus cause us no surprise. The talk about the “population problem”, a proliferation of incentive-based schemes for both doctors and patients to lure women into sterilisation, and the pressure to handle all this on a war-footing — the stage seems well set for an orgy of sacrifice on the alter of patriotism.

There is, as always, in such “horror tales” a lesson and a moral to be drawn. The regulation of family size is undoubtedly a worthwhile objective, both for society and the concerned individuals. But to be stunned into inactivity by a spectre of ‘the teeming millions’ overcrowding an already burdened globe, and to leave the initiative to a techno-managerially inclined bureaucracy and medical establishment, is only to invite disaster. One only wonders why our socially conscious investigative journalists, the dozens of very active women’s groups, or even sensitive medical personnel, what to speak of our esteemed representatives in the State Assemblies and the Parliament have so far not created a furore. It cannot be that they are all struck with a myopia caused by incidents that seen scattered and involve small numbers. Do we always have to wait for a Bhopal to act?

— Source: “State of India’s Health”(Concluded)