refers to a plant which completes its life cycle in one year.
Ben: Kesutthe, Kesraj;
Mal: Kannunni, Kayyonni, Kayyunnni;Tam: Kayyantakara, Kaikeri;Kan: Kadiggagaraga;Tel: Guntagalijeran; Arab: Kadim-el-bintImportance: Eclipta is one of the ten auspicious herbs that constitute the group dasapuspam which is considered to destroy the causative factors of all unhealthy and unpleasant features and bestow good health and prosperity. The members of this group cure wounds and ulcers as well as fever caused by the derangement of the tridosas - vata, pitta and kapha. It is used in hepatitis, spleen enlargements, chronic skin diseases, tetanus and elephantiasis. The leaf promotes hair growth and use as an antidote in scorpion sting. The root is used as an emetic, in scalding of urine, conjuctivitis and as an antiseptic to ulcers and wound in cattle. It is used to prevent abortion and miscarriage and also in cases of uterine pains after the delivery. The juice of the plant with honey is given to infants for expulsion of worms. For the relief in piles, fumigation with Eclipta is considered beneficial. A decoction of the leaves is used in uterine haemorrhage. The paste prepared by mincing fresh plants has got an antiinflammatory effect and may be applied on insect bites, stings, swellings and other skin diseases. In Ayurveda, it is mainly used in hair oil, while in Unani system, the juice is used in “Hab Miskeen Nawaz” along with aconite, triphala, Croton tiglium, Piper nigium, Piper longum, Zingiber officinale and minerals like mercury, sulphur, arsenic, borax, etc. for various types of pains in the body. It is also a constituent of “Roghan Amla Khas” for applying on the hair and of “Majun Murrawah-ul-arwah”.Distribution: This plant is widely distributed in the warm humid tropics with plenty of rainfall. It grows commonly in moist places as a weed all over plains of India.Botany: Eclipta prostrata (Linn) Linn. syn. E. alba Hassk. is an annual, erect or postrate herb, often rooting at nodes. Leaves are sessile, 2.5-7.5cm long with white appressed hairs. Floral heads are 6-8 mm in diameter, solitary and white. Fruit is an achene, compressed and narrowly winged. Sometimes, Wedelia calendulacea, which resembles Eclipta prostrata is used for the same purpose.Properties and activity: The leaves contain stigmasterol, -terthienylmethanol, wedelolactone, dismethylwedelolactone and dismethylwedelolactone-7-glucoside. The roots give hentriacontanol and heptacosanol. The roots contain polyacetylene substituted thiophenes. The aerial part is reported to contain a phytosterol, -amyrin in the n-hexane extract and luteolin-7-glucoside, -glucoside of phytosterol, a glucoside of a triterpenic acid and wedelolactone in polar solvent extract. The polypeptides isolated from the plant yield cystine, glutamic acid, phenyl alanine, tyrosine and methionine on hydrolysis. Nicotine and nicotinic acid are reported to occur in this plant.The plant is anticatarrhal, febrifuge, antidontalgic, absorbent, antihepatic, CVS active, nematicidal, ovicidal and spasmolytic in activity. The alcoholic extract of entire plant has been reported to have antiviral activity against Ranikhet disease virus. Aqueous extract of the plant showed subjective improvement of vision in the case of refractive errors. The herbal drug Trefoli, containing extracts of the plant in combination with others, when administered to the patients of viral hepatitis, produced excellent results.... ecliptaCauses The disease is directly contagious from another person already suffering from it – usually by sexual intercourse, but occasionally conveyed by the discharge on sponges, towels or clothing as well as by actual contact. The gonococcus is found in the discharge expressed from the urethra, which may be spread as a ?lm on a glass slide, suitably stained, and examined under the microscope; or a culture from the discharge may be made on certain bacteriological media and ?lms from this, similarly examined under the microscope. Since discharges resembling that of gonorrhoea accompany other forms of in?ammation, the identi?cation of the organism is of great importance. A gram-stained smear of urethral discharge enables rapid identi?cation of the gonococcus in around 90 per cent of men.
Symptoms These di?er considerably, according to whether the disease is in an acute or a chronic stage.
MEN After an incubation period of 2–10 days, irritation in the urethra, scalding pain on passing water, and a viscid yellowish-white discharge appear; the glands in the groin often enlarge and may suppurate. The urine when passed is hazy and is often found to contain yellowish threads of pus visible to the eye. After some weeks, if the condition has become chronic, the discharge is clear and viscid, there may be irritation in passing urine, and various forms of in?ammation in neighbouring organs may appear – the TESTICLE, PROSTATE GLAND and URINARY BLADDER becoming affected. At a still later stage the in?ammation of the urethra is apt to lead to gradual formation of ?brous tissue around this channel. This contracts and produces narrowing, so that urination becomes di?cult or may be stopped for a time altogether (the condition known as stricture). In?ammation of some of the joints is a common complication in the early stage – the knee, ankle, wrist, and elbow being the joints most frequently affected – and this form of ‘rheumatism’ is very intractable and liable to lead to permanent sti?ness. The ?brous tissues elsewhere may also develop in?ammatory changes, causing pain in the back, foot, etc. In occasional cases, during the acute stage, SEPTICAEMIA may develop, with in?ammation of the heart-valves (ENDOCARDITIS) and abscesses in various parts of the body. The infective matter occasionally is inoculated accidentally into the eye, producing a very severe form of conjunctivitis: in the newly born child this is known as ophthalmia neonatorum and, although now rare in the UK. has in the past been a major cause of blindness (see EYE, DISORDERS OF). WOMEN The course and complications of the disease are somewhat di?erent in women. It begins with a yellow vaginal discharge, pain on urination, and very often in?ammation or abscess of the Bartholin’s glands, situated close to the vulva or opening of the vagina. The chief seriousness, however, of the disease is due to the spread of in?ammation to neighbouring organs, the UTERUS, FALLOPIAN TUBES, and OVARIES, causing permanent destructive changes in these, and leading occasionally to PERITONITIS through the Fallopian tube with a fatal result. Many cases of prolonged ill-health and sterility or recurring miscarriages are due to these changes.
Treatment The chances of cure are better the earlier treatment is instituted. PENICILLIN is the antibiotic of choice but unfortunately the gonococcus is liable to become resistant to this. In patients who are infected with penicillin-resistant organisms, one of the other antibiotics (e.g. cefotaxime, cipro?oxacin or spectinomycin) is used. In all cases it is essential that bacteriological investigation should be carried out at weekly intervals for three or four weeks, to make sure that the patient is cured. Patients attending with gonorrhoea are asked if they will agree to tests for other sexually transmitted infections, such as HIV (see AIDS/HIV) and for assistance in contact tracing.... gonorrhoea
Ben: Kalmegh
Mal: Nilaveppu, Kiriyattu Tam: Nilavempu Kan: KreataImportance: Kalmegh, the Great or Green Chiretta is a branched annual herb. It is useful in hyperdipsia, burning sensation, wounds, ulcers, chronic fever, malarial and intermittent fevers, inflammations, cough, bronchitis, skin diseases, leprosy, pruritis, intestinal worms, dyspepsia, flatulence, colic, diarrhoea, dysentery, haemorrhoids and vitiated conditions of pitta (Warrier et al, 1993). It is used to overcome sannipata type of fever, difficulty in breathing, hemopathy due to the morbidity of kapha and pitta, burning sensation, cough, oedema, thirst, skin diseases, fever, ulcer and worms. It is also useful in acidity and liver complaints (Aiyer and Kolammal, 1962). The important preparations using the drug are Tiktakagheta, Gorocandi gulika, Candanasava, Panchatiktam kasaya, etc. (Sivarajan et al, 1994). A preparation called “Alui” is prepared by mixing powdered cumin (Cuminium cyminum) and large cardamom (Amomum subulatum) in the juice of this plant and administered for the treatment of malaria (Thakur et al, 1989). It is also a rich source of minerals.Distribution: The plant is distributed throughout the tropics. It is found in the plains of India from U.P to Assam, M.P., A.P, Tamil Nadu and Kerala, also cultivated in gardens.Botany: Andrographis paniculata (Burm.f.) Wall ex.Nees belongs to the family Acanthaceae. It is an erect branched annual herb, 0.3-0.9m in height with quadrangular branches. Leaves are simple, lanceolate, acute at both ends, glabrous, with 4-6 pairs of main nerves. Flowers are small, pale but blotched and spotted with brown and purple distant in lax spreading axillary and terminal racemes or panicles. Calyx-lobes are glandular pubescent with anthers bearded at the base. Fruits are linear capsules and acute at both ends. Seeds are numerous, yellowish brown and sub-quadrate (Warrier et al,1993).Another species of Andrographis is A. echioides (Linn.) Nees. It is found in the warmer parts of India. The plant is a febrifuge and diuretic. It contains flavone-echiodinin and its glucoside-echioidin (Husain et al, 1992).Agrotechnology: The best season of planting Andrographis is May-June. The field is to be ploughed well, mixed with compost or dried cowdung and seedbeds of length 3m, breadth 1/2m and 15cm height are to be taken at a distance of 3m. The plant is seed propagated. Seeds are to be soaked in water for 6 hours before sowing. Sowing is to be done at a spacing of 20cm. Seeds may germinate within 15-20 days. Two weedings, first at one month after planting and the second at 2 month after planting are to be carried out. Irrigation during summer months is beneficial. The plant is not attacked by any serious pests or diseases. Flowering commences from third month onwards. At this stage, plant are to be collected, tied into small bundles and sun-dried for 4-5 days. Whole plant is the economic part and the yield is about 1.25t dried plants/ha (Prasad et al, 1997).Properties and activity: Leaves contain two bitter substances lactone “andrographolid” and “kalmeghin”. The ash contains sodium chloride and potassium salts. Plant is very rich in chlorophyte. Kalmeghin is the active principle that contains 0.6% alkaloid of the crude plant. The plant contains diterpenoids, andrographolide, 14-deoxy-11-oxo-andrographolide, 14-deoxy-11,12-dihydroandrographolide, 14-deoxy andrographolide and neoandrographolide (Allison et al, 1968). The roots give flavones-apigenin-7,4-dio-O-methyl ether, 5-hydroxy-7,8,2’,3’- tetramethoxyflavone, andrographin and panicolin and -sitosterol (Ali et al, 1972; Govindachari et al, 1969). Leaves contain homoandrographolide, andrographosterol and andrographone.The plant is vulnerary, antipyretic, antiperiodic, anti-inflammatory, expectorant, depurative, sudorific, anthelmintic, digestive, stomachic, tonic, febrifuge and cholagogue. The plant is antifungal, antityphoid, hepatoprotective, antidiabetic and cholinergic. Shoot is antibacterial and leaf is hypotensive(Garcia et al, 1980). This is used for the inflammation of the respiratory tract. In China, researchers have isolated the andrographolide from which soluble derivative such as 14-deoxy-11, 12-dehydro-andrographolide which forms the subject of current pharmacological and clinical studies. Apigenin 7,4’-O-dimethyl ether isolated from A. paniculata exhibits dose dependent, antiulcer activity in shay rat, histamine induced ulcer in guinea pigs and aspirin induced ulcers in rats. A crude substance isolated from methanolic extract of leaves has shown hypotensive activity. Pre-treatment of rats with leaf (500mg/kg) or andrographolide (5mg/kg) orally prevented the carbon tetrachloride induced increase of blood serum levels of glutamate-oxaloacetate transaminase in liver and prevented hepatocellular membrane.... green chirettastrains: type A has been the cause of pandemics in the last century.
Types A and B produce classic flu symptoms; type C causes a mild illness that is indistinguishable from a common cold. The illness usually clears up completely within 7–10 days. Rarely, flu takes a severe form, causing acute pneumonia that may be fatal within a day or 2 even in healthy young adults. Type B infections in children sometimes mimic appendicitis, and they have been implicated in Reye’s syndrome. In the elderly and those with lung or heart disease, influenza may be followed by a bacterial infection such as bronchitis or pneumonia. Analgesic drugs (painkillers) help to relieve aches and pains and reduce fever. The antiviral drug amantadine may be given if the person is elderly or has another lung condition. Antibiotic drugs may be used to combat secondary bacterial infection.
Flu vaccines, containing killed strains of the types A and B virus currently in circulation, are available, but have only a 60–70 per cent success rate.
Immunity is short-lived, and vaccination (recommended for older people and anyone suffering from respiratory or circulatory disease) must be repeated annually.... influenza
Both HIV-1 and HIV-2 are predominantly sexually transmitted and both are associated with secondary opportunistic infections. However, HIV-2 seems to result in slower damage to the immune system. HIV-1 is known to mutate rapidly and has given rise to other subtypes.
HIV is thought to have occurred in humans in the 1950s, but whether or not it infected humans from another primate species is uncertain. It became widespread in the 1970s but its latency in causing symptoms meant that the epidemic was not noticed until the following decade. Although it is a sexually transmitted disease, it can also be transmitted by intravenous drug use (through sharing an infected needle), blood transfusions with infected blood (hence the importance of e?ective national blood-screening programmes), organ donation, and occupationally (see health-care workers, below). Babies born of HIV-positive mothers can be infected before or during birth, or through breast feeding.
Although HIV is most likely to occur in blood, semen or vaginal ?uid, it has been found in saliva and tears (but not sweat); however, there is no evidence that the virus can be transmitted from these two body ?uids. There is also no evidence that HIV can be transmitted by biting insects (such as mosquitoes). HIV does not survive well in the environment and is rapidly destroyed through drying.
Prevalence At the end of 2003 an estimated 42 million people globally were infected with HIV – up from 40 million two years earlier. About one-third of those with HIV/AIDS are aged 15–24 and most are unaware that they are carrying the virus. During 2003 it is estimated that 5 million adults and children worldwide were newly infected with HIV, and that 3 million adults and children died. In Africa in 2003,
3.4 million people were newly infected and 2.3 million died, with more than 28 million carrying the virus. HIV/AIDS was the leading cause of death in sub-Saharan Africa where over half of the infections were in women and 90 per cent of cases resulted from heterosexual sex. In some southern African countries, one in three pregnant women had HIV.
In Asia and the Paci?c there were 1.2 million new infections and 435,000 deaths. The area with the fastest-growing epidemic is Eastern Europe, especially the Russian Federation where in 2002 around a million people had HIV and there were an estimated 250,000 new infections, with intravenous drug use a key contributor to this ?gure. Seventy-?ve per cent of cases occurred in men, with male-to-male sexual transmission an important cause of infection, though heterosexual activity is a rising cause of infection.
At the end of 2002 the UK had an estimated 55,900 HIV-infected adults aged between 15 and 59. More than 3,600 individuals were newly diagnosed with the infection in 2000, the highest annual ?gure since the epidemic started
– in 1998 the ?gure was 2,817 and in 1999 just over 3,000 (Department of Health and Communicable Disease Surveillance Centre). The incidence of AIDS in the UK has declined sharply since the introduction of highly active antiretroviral therapy (HAART) and HIV-related deaths have also fallen: in 2002 there were 777 reported new AIDS cases and 395 deaths, compared with 1,769 and 1,719 respectively in 1995. (Sources: UNAIDS and WHO, AIDS Epidemic Update, December 2001; Public Health Laboratory Services AIDS and STD Centre Communicable Disease Surveillance and Scottish Centre for Infection and Environmental Health, Quarterly Surveillance Tables.)
Poverty is strongly linked to the spread of AIDS, for various reasons including lack of health education; lack of e?ective public-health awareness; women having little control over sexual behaviour and contraception; and, by comparison with the developed world, little or no access to antiretroviral drugs.
Pathogenesis The cellular target of HIV infection is a subset of white blood cells called T-lymphocytes (see LYMPHOCYTE) which carry the CD4 surface receptor. These so-called ‘helper T-cells’ are vital to the function of cell-mediated immunity. Infection of these cells leads to their destruction (HIV replicates at an enormous rate – 109) and over the course of several years the body is unable to generate suf?cient new cells to keep pace. This leads to progressive destruction of the body’s immune capabilities, evidenced clinically by the development of opportunistic infection and unusual tumours.
Monitoring of clinical progression It is possible to measure the number of viral particles present in the plasma. This gives an accurate guide to the likely progression rate, which will be slow in those individuals with fewer than 10,000 particles per ml of plasma but progressively more rapid above this ?gure. The main clinical monitoring of the immune system is through the numbers of CD4 lymphocytes in the blood. The normal count is around 850 cells per ml and, without treatment, eventual progression to AIDS is likely in those individuals whose CD4 count falls below 500 per ml. Opportunistic infections occur most frequently when the count falls below 200 per ml: most such infections are treatable, and death is only likely when the CD4 count falls below 50 cells per ml when infection is developed with organisms that are di?cult to treat because of their low intrinsic virulence.
Simple, cheap and highly accurate tests are available to detect HIV antibodies in the serum. These normally occur within three months of infection and remain the cornerstone of the diagnosis.
Clinical features Most infected individuals have a viral illness some three weeks after contact with HIV. The clinical features are often non-speci?c and remain undiagnosed but include a ?ne red rash, large lymph nodes, an in?uenza-like illness, cerebral involvement and sometimes the development of opportunistic infections. The antibody test may be negative at this stage but there are usually high levels of virus particles in the blood. The antibody test is virtually always positive within three months of infection. HIV infection is often subsequently asymptomatic for a period of ten years or more, although in most patients progressive immune destruction is occurring during this time and a variety of minor opportunistic infections such as HERPES ZOSTER or oral thrush (see CANDIDA) do occur. In addition, generalised LYMPHADENOPATHY is present in a third of patients and some suffer from severe malaise, weight loss, night sweats, mild fever, ANAEMIA or easy bruising due to THROMBOCYTOPENIA.
The presentation of opportunistic infection is highly variable but usually involves either the CENTRAL NERVOUS SYSTEM, the gastrointestinal tract or the LUNGS. Patients may present with a sudden onset of a neurological de?cit or EPILEPSY due to a sudden onset of a STROKE-like syndrome, or epilepsy due to a space-occupying lesion in the brain – most commonly TOXOPLASMOSIS. In late disease, HIV infection of the central nervous system itself may produce progressive memory loss, impaired concentration and mental slowness called AIDS DEMENTIA. A wide variety of opportunistic PROTOZOA or viruses produces DYSPHAGIA, DIARRHOEA and wasting. In the respiratory system the commonest opportunistic infection associated with AIDS, pneumonia, produces severe shortness of breath and sometimes CYANOSIS, usually with a striking lack of clinical signs in the chest.
In very late HIV infection, when the CD4 count has fallen below 50 cells per ml, infection with CYTOMEGALOVIRUS may produce progressive retinal necrosis (see EYE, DISORDERS OF) which will lead to blindness if untreated, as well as a variety of gastrointestinal symptoms. At this stage, infection with atypical mycobacteria is also common, producing severe anaemia, wasting and fevers. The commonest tumour associated with HIV is Kaposi’s sarcoma which produces purplish skin lesions. This and nonHodgkin’s lymphoma (see LYMPHOMA), which is a hundred times more frequent among HIV-positive individuals than in the general population, are likely to be associated with or caused by opportunistic viral infections.
Prevention There is, as yet, no vaccine to prevent HIV infection. Vaccine development has been hampered
by the large number of new HIV strains generated through frequent mutation and recombination.
because HIV can be transmitted as free virus and in infected cells.
because HIV infects helper T-cells – the very cells involved in the immune response. There are, however, numerous research pro
grammes underway to develop vaccines that are either prophylactic or therapeutic. Vaccine-development strategies have included: recombinant-vector vaccines, in which a live bacterium or virus is genetically modi?ed to carry one or more of the HIV genes; subunit vaccines, consisting of small regions of the HIV genome designed to induce an immune response without infection; modi?ed live HIV, which has had its disease-promoting genes removed; and DNA vaccines – small loops of DNA (plasmids) containing viral genes – that make the host cells produce non-infectious viral proteins which, in turn, trigger an immune response and prime the immune system against future infection with real virus.
In the absence of an e?ective vaccine, preventing exposure remains the chief strategy in reducing the spread of HIV. Used properly, condoms are an extremely e?ective method of preventing exposure to HIV during sexual intercourse and remain the most important public-health approach to countering the further acceleration of the AIDS epidemic. The spermicide nonoxynol-9, which is often included with condoms, is known to kill HIV in vitro; however, its e?ectiveness in preventing HIV infection during intercourse is not known.
Public-health strategies must be focused on avoiding high-risk behaviour and, particularly in developing countries, empowering women to have more control over their lives, both economically and socially. In many of the poorer regions of the world, women are economically dependent on men and refusing sex, or insisting on condom use, even when they know their partners are HIV positive, is not a straightforward option. Poverty also forces many women into the sex industry where they are at greater risk of infection.
Cultural problems in gaining acceptance for universal condom-use by men in some developing countries suggests that other preventive strategies should also be considered. Microbicides used as vaginal sprays or ‘chemical condoms’ have the potential to give women more direct control over their exposure risk, and research is underway to develop suitable products.
Epidemiological studies suggest that male circumcision may o?er some protection against HIV infection, although more research is needed before this can be an established public-health strategy. Globally, about 70 per cent of infected men have acquired the virus through unprotected vaginal sex; in these men, infection is likely to have occurred through the penis with the mucosal epithelia of the inner surface of the foreskin and the frenulum considered the most likely sites for infection. It is suggested that in circumcised men, the glans may become keratinised and thus less likely to facilitate infection. Circumcision may also reduce the risk of lesions caused by other sexually transmitted disease.
Treatment AIDS/HIV treatment can be categorised as speci?c therapies for the individual opportunistic infections – which ultimately cause death – and highly active antiretroviral therapy (HAART) designed to reduce viral load and replication. HAART is also the most e?ective way of preventing opportunistic infections, and has had a signi?cant impact in delaying the onset of AIDS in HIV-positive individuals in developed countries.
Four classes of drugs are currently in use. Nucleoside analogues, including ZIDOVUDINE and DIDANOSINE, interfere with the activity of the unique enzyme of the retrovirus reverse transcriptase which is essential for replication. Nucleotide analogues, such as tenofovir, act in the same way but require no intracellular activation. Non-nucleoside reverse transcriptase inhibitors, such as nevirapine and EFAVIRENZ, act by a di?erent mechanism on the same enzyme. The most potent single agents against HIV are the protease inhibitors, such as lopinavir, which render a unique viral enzyme ineffective. These drugs are used in a variety of combinations in an attempt to reduce the plasma HIV viral load to below detectable limits, which is achieved in approximately 90 per cent of patients who have not previously received therapy. This usually also produces a profound rise in CD4 count. It is likely, however, that such treatments need to be lifelong – and since they are associated with toxicities, long-term adherence is di?cult. Thus the optimum time for treatment intervention remains controversial, with some clinicians believing that this should be governed by the viral load rising above 10,000 copies, and others that it should primarily be designed to prevent the development of opportunistic infections – thus, that initiation of therapy should be guided more by the CD4 count.
It should be noted that the drug regimens have been devised for infection with HIV-1; it is not known how e?ective they are at treating infection with HIV-2.
HIV and pregnancy An HIV-positive woman can transmit the virus to her fetus, with the risk of infection being particularly high during parturition; however, the risk of perinatal HIV transmission can be reduced by antiviral drug therapy. In the UK, HIV testing is available to all women as part of antenatal care. The bene?ts of antenatal HIV testing in countries where antiviral drugs are not available are questionable. An HIV-positive woman might be advised not to breast feed because of the risks of transmitting HIV via breastmilk, but there may be a greater risk associated with not breast feeding at all. Babies in many poor communities are thought to be at high risk of infectious diseases and malnutrition if they are not breast fed and may thus be at greater overall risk of death during infancy.
Counselling Con?dential counselling is an essential part of AIDS management, both in terms of supporting the psychological wellbeing of the individual and in dealing with issues such as family relations, sexual partners and implications for employment (e.g. for health-care workers). Counsellors must be particularly sensitive to culture and lifestyle issues. Counselling is essential both before an HIV test is taken and when the results are revealed.
Health-care workers Health-care workers may be at risk of occupational exposure to HIV, either through undertaking invasive procedures or through accidental exposure to infected blood from a contaminated needle (needlestick injury). Needlestick injuries are frequent in health care – as many as 600,000 to 800,000 are thought to occur annually in the United States. Transmission is much more likely where the worker has been exposed to HIV through a needlestick injury or deep cut with a contaminated instrument than through exposure of mucous membranes to contaminated blood or body ?uids. However, even where exposure occurs through a needlestick injury, the risk of seroconversion is much lower than with a similar exposure to hepatitis C or hepatitis B. A percutaneous exposure to HIV-infected blood in a health-care setting is thought to carry a risk of about one infection per 300 injuries (one in 1,000 for mucous-membrane exposure), compared with one in 30 for hepatitis C, and one in three for hepatitis B (when the source patient is e-antigen positive).
In the event of an injury, health-care workers are advised to report the incident immediately where, depending on a risk assessment, they may be o?ered post-exposure prophylaxis (PEP). They should also wash the contaminated area with soap and water (but without scrubbing) and, if appropriate, encourage bleeding at the site of injury. PEP, using a combination of antiretroviral drugs (in a similar regimen to HAART – see above), is thought to greatly reduce the chances of seroconversion; it should be commenced as soon as possible, preferably within one or two hours of the injury. Although PEP is available, safe systems of work are considered to o?er the greatest protection. Double-gloving (latex gloves remove much of the blood from the surface of the needle during a needlestick), correct use of sharps containers (for used needles and instruments), avoiding the resheathing of used needles, reduction in the number of blood samples taken from a patient, safer-needle devices (such as needles that self-blunt after use) and needleless drug administration are all thought to reduce the risk of exposure to HIV and other blood-borne viruses. Although there have been numerous cases of health-care workers developing HIV through occupational exposure, there is little evidence of health-care workers passing HIV to their patients through normal medical procedures.... aids/hiv
Habitat: Cultivated as an annual all over the country. The most important onion-growing states are Maharashtra, Tamil Nadu, Andhra Pradesh., Karnataka and Madhya Pradesh.
English: Onion.Ayurvedic: Palaandu, Durgandh.Unani: Piyaaz.Siddha/Tamil: Venkaayam.Action: Antibiotic, antibacterial, antisclerotic, anticoagulant, anti-inflammatory, antiasthmatic, expectorant, carminative, anti- spasmodic, diuretic, hypotensive, antidiabetic.
Key application: For the prevention of atherosclerosis (German Commission E) and age-dependent changes in the blood vessels, and loss of appetite (WHO).The official onion bulb of the Pharmacopoeia of the People's Republic of China is a different species, Allium macrostemon Bge., than that of the German Commission E monographs, A. cepa. Chinese onion is used for cough, dyspnoea, angina pectoris and dysentery.Scallions or Spring Onion of Chinese medicine are equated with Allium fistulosum.Onion bulbs contain a volatile oil with sulphurous constituents, including allylpropyldisulphide; sulphur- containing compounds, including al- licin, alliin; flavonoids; phenolic acids and sterols.Hypoglycaemic activity of the onion is attributed to the allylpropyldisul- phide and allicin. Diphenylamine, isolated from mature bulbs, also exhibits potent antihyperglycaemic activity.Alliin and allicin have an inhibitory effect on platelet aggregation. Antibiotic activity is due mainly to alli-cin.Regular use of onion (50 g/day) reduces insulin requirement of a diabetic patient from 40 to 20 units a day.Thiosulphinates, isolated from onion juice, exhibited antiasthmatic activity in vivo.Dosage: Juice of bulb—10-20 ml. (CCRAS.)... allium cepaNutritional Profile Energy value (calories per serving): Low Protein: High Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: Moderate Fiber: Very high Sodium: Low Major vitamin contribution: Vitamin A, folate, vitamin C Major mineral contribution: Calcium
About the Nutrients in This Food Broccoli is very high-fiber food, an excellent source of vitamin A, the B vitamin folate, and vitamin C. It also has some vitamin E and vitamin K, the blood-clotting vitamin manufactured primarily by bacteria living in our intestinal tract. One cooked, fresh broccoli spear has five grams of dietary fiber, 2,500 IU vitamin A (108 percent of the R DA for a woman, 85 percent of the R DA for a man), 90 mcg folate (23 percent of the R DA), and 130 mg vitamin C (178 percent of the R DA for a woman, 149 percent of the R DA for a man).
The Most Nutritious Way to Serve This Food Raw. Studies at the USDA Agricultural Research Center in Beltsville, Maryland, show that raw broccoli has up to 40 percent more vitamin C than broccoli that has been cooked or frozen.
Diets That May Restrict or Exclude This Food Antiflatulence diet Low-fiber diet
Buying This Food Look for: Broccoli with tightly closed buds. The stalk, leaves, and florets should be fresh, firm, and brightly colored. Broccoli is usually green; some varieties are tinged with purple. Avoid: Broccoli with woody stalk or florets that are open or turning yellow. When the green chlorophyll pigments fade enough to let the yellow carotenoids underneath show through, the buds are about to bloom and the broccoli is past its prime.
Storing This Food Pack broccoli in a plastic bag and store it in the refrigerator or in the vegetable crisper to protect its vitamin C. At 32°F, fresh broccoli can hold onto its vitamin C for as long as two weeks. Keep broccoli out of the light; like heat, light destroys vitamin C.
Preparing This Food First, rinse the broccoli under cool running water to wash off any dirt and debris clinging to the florets. Then put the broccoli, florets down, into a pan of salt water (1 tsp. salt to 1 qt. water) and soak for 15 to 30 minutes to drive out insects hiding in the florets. Then cut off the leaves and trim away woody section of stalks. For fast cooking, divide the broccoli up into small florets and cut the stalk into thin slices.
What Happens When You Cook This Food The broccoli stem contains a lot of cellulose and will stay firm for a long time even through the most vigorous cooking, but the cell walls of the florets are not so strongly fortified and will soften, eventually turning to mush if you cook the broccoli long enough. Like other cruciferous vegetables, broccoli contains mustard oils (isothiocyanates), natural chemicals that break down into a variety of smelly sulfur compounds (including hydrogen sulfide and ammonia) when the broccoli is heated. The reaction is more intense in aluminum pots. The longer you cook broccoli, the more smelly compounds there will be, although broccoli will never be as odorous as cabbage or cauliflower. Keeping a lid on the pot will stop the smelly molecules from floating off into the air but will also accelerate the chemical reaction that turns green broccoli olive-drab. Chlorophyll, the pigment that makes green vegetables green, is sensitive to acids. When you heat broccoli, the chlorophyll in its florets and stalk reacts chemically with acids in the broccoli or in the cooking water to form pheophytin, which is brown. The pheophytin turns cooked broccoli olive-drab or (since broccoli contains some yellow carotenes) bronze. To keep broccoli green, you must reduce the interaction between the chlorophyll and the acids. One way to do this is to cook the broccoli in a large quantity of water, so the acids will be diluted, but this increases the loss of vitamin C.* Another alternative is to leave the lid off the pot so that the hydrogen atoms can float off into the air, but this allows the smelly sulfur compounds to escape, too. The best way is probably to steam the broccoli quickly with very little water, so it holds onto its vitamin C and cooks before there is time for reac- tion between chlorophyll and hydrogen atoms to occur.
How Other Kinds of Processing Affect This Food Freezing. Frozen broccoli usually contains less vitamin C than fresh broccoli. The vitamin is lost when the broccoli is blanched to inactivate catalase and peroxidase, enzymes that would otherwise continue to ripen the broccoli in the freezer. On the other hand, according to researchers at Cornell University, blanching broccoli in a microwave oven—two cups of broccoli in three tablespoons of water for three minutes at 600 –700 watts—nearly doubles the amount of vitamin C retained. In experiments at Cornell, frozen broccoli blanched in a microwave kept 90 percent of its vitamin C, compared to 56 percent for broccoli blanched in a pot of boiling water on top of a stove.
Medical Uses and/or Benefits Protection against some cancers. Naturally occurring chemicals (indoles, isothiocyanates, glucosinolates, dithiolethiones, and phenols) in Brussels sprouts, broccoli, cabbage, cauli- flower, and other cruciferous vegetables appear to reduce the risk of some forms of cancer, perhaps by preventing the formation of carcinogens in your body or by blocking cancer- causing substances from reaching or reacting with sensitive body tissues or by inhibiting the transformation of healthy cells to malignant ones. All cruciferous vegetables contain sulforaphane, a member of a family of chemicals known as isothiocyanates. In experiments with laboratory rats, sulforaphane appears to increase the body’s production of phase-2 enzymes, naturally occurring substances that inacti- vate and help eliminate carcinogens. At the Johns Hopkins University in Baltimore, Maryland, 69 percent of the rats injected with a chemical known to cause mammary cancer developed tumors vs. only 26 percent of the rats given the carcinogenic chemical plus sulforaphane. To get a protective amount of sulforaphane from broccoli you would have to eat about two pounds a week. But in 1997, Johns Hopkins researchers discovered that broccoli seeds and three-day-old broccoli sprouts contain a compound converted to sulforaphane when the seed and sprout cells are crushed. Five grams of three-day-old sprouts contain as much sulphoraphane as 150 grams of mature broccoli. * Broccoli will lose large amounts of vitamin C if you cook it in water t hat is cold when you start. As it boils, water releases ox ygen t hat would ot her wise dest roy vitamin C, so you can cut t he vitamin loss dramat ically simply by lett ing t he water boil for 60 seconds before adding t he broccoli. Vision protection. In 2004, the Johns Hopkins researchers updated their findings on sulfora- phane to suggest that it may also protect cells in the eyes from damage due to ultraviolet light, thus reducing the risk of macular degeneration, the most common cause of age-related vision loss. Lower risk of some birth defects. Up to two or every 1,000 babies born in the United States each year may have cleft palate or a neural tube (spinal cord) defect due to their mothers’ not having gotten adequate amounts of folate during pregnancy. The current R DA for folate is 180 mcg for a woman, 200 mcg for a man, but the FDA now recommends 400 mcg for a woman who is or may become pregnant. Taking a folate supplement before becoming pregnant and continuing through the first two months of pregnancy reduces the risk of cleft palate; taking folate through the entire pregnancy reduces the risk of neural tube defects. Broccoli is a good source of folate. One raw broccoli spear has 107 mcg folate, more than 50 percent of the R DA for an adult. Possible lower risk of heart attack. In the spring of 1998, an analysis of data from the records for more than 80,000 women enrolled in the long-running Nurses’ Health Study at Harvard School of Public Health/Brigham and Women’s Hospital, in Boston, demonstrated that a diet providing more than 400 mcg folate and 3 mg vitamin B6 daily, either from food or supple- ments, might reduce a woman’s risk of heart attack by almost 50 percent. Although men were not included in the study, the results were assumed to apply to them as well. However, data from a meta-analysis published in the Journal of the American Medical Association in December 2006 called this theory into question. Researchers at Tulane Univer- sity examined the results of 12 controlled studies in which 16,958 patients with preexisting cardiovascular disease were given either folic acid supplements or placebos (“look-alike” pills with no folic acid) for at least six months. The scientists, who found no reduction in the risk of further heart disease or overall death rates among those taking folic acid, concluded that further studies will be required to ascertain whether taking folic acid supplements reduces the risk of cardiovascular disease. Possible inhibition of the herpes virus. Indoles, another group of chemicals in broccoli, may inhibit the growth of some herpes viruses. In 2003, at the 43rd annual Interscience Confer- ence on Antimicrobial Agents and Chemotherapy, in Chicago, researchers from Stockholm’s Huddinge University Hospital, the University of Virginia, and Northeastern Ohio University reported that indole-3-carbinol (I3C) in broccoli stops cells, including those of the herpes sim- plex virus, from reproducing. In tests on monkey and human cells, I3C was nearly 100 percent effective in blocking reproduction of the HSV-1 (oral and genital herpes) and HSV-2 (genital herpes), including one strain known to be resistant to the antiviral drug acyclovir (Zovirax).
Adverse Effects Associated with This Food Enlarged thyroid gland. Cruciferous vegetables, including broccoli, contain goitrin, thio- cyanate, and isothiocyanate, chemical compounds that inhibit the formation of thyroid hormones and cause the thyroid to enlarge in an attempt to produce more. These chemicals, known collectively as goitrogens, are not hazardous for healthy people who eat moderate amounts of cruciferous vegetables, but they may pose problems for people who have thyroid problems or are taking thyroid medication. False-positive test for occult blood in the stool. The guaiac slide test for hidden blood in feces relies on alphaguaiaconic acid, a chemical that turns blue in the presence of blood. Broccoli contains peroxidase, a natural chemical that also turns alphaguaiaconic acid blue and may produce a positive test in people who do not actually have blood in the stool.
Food/Drug Interactions Anticoagulants Broccoli is rich in vitamin K, the blood-clotting vitamin produced natu- rally by bacteria in the intestines. Consuming large quantities of this food may reduce the effectiveness of anticoagulants (blood thinners) such as warfarin (Coumadin). One cup of drained, boiled broccoli contains 220 mcg vitamin K, nearly four times the R DA for a healthy adult.... broccoli
Hin: Akasgaddah;
Mal: Kadamba, KollankovaTam: Akashagarudan, Gollankovai;Tel: Murudonda, NagadondaCorallocarpus is a prostrate or climbing herb distributed in Punjab, Sind, Gujarat, Deccan, Karnataka and Sri Lanka. It is monoecious with large root which is turnip-shaped and slender stem which is grooved, zigzag and glabrous. Tendrils are simple, slender and glabrous. Leaves are sub-orbicular in outline, light green above and pale beneath, deeply cordate at the base, angled or more or less deeply 3-5 lobed. Petiole is long and glabrous. Male flowers are small and arranged at the tip of a straight stiff glabrous peduncle. Calyx is slightly hairy, long and rounded at the base. Corolla is long and greenish yellow. Female flowers are usually solitary with short, stout and glabrous peduncles. Fruit is stalked, long, ellipsoid or ovoid. Seeds are pyriform, turgid, brown and with a whitish corded margin. It is prescribed in later stages of dysentery and old veneral complaints. For external use in chronic rheumatism, it is made into a liniment with cumin seed, onion and castor oil. It is used in case of snakebite where it is administered internally and applied to the bitten part. The root is given in syphilitic rheumatism and later stages of dysentery. The plant is bitter, sweet, alexipharmic and emetic. The root is said to possess alterative and laxative properties (Kirtikar and Basu, 1988). Root contains a bitter principle like Breyonin (Chopra et al, 1980).Agrotechnology: Cucurbits can be successfully grown during January-March and September- December. For the rainfed crop, sowing can also be started after the receipt of the first few showers.Pits of 60cm diameter and 30-45cm depth are to be taken at the desired spacing. Well rotten FYM or vegetable mixture is to be mixed with topsoil in the pit and seeds are to be sown at 4-5/pit. Unhealthy plants are to be removed after 2 weeks and retained 2-3 plants/pit. FYM is to be applied at 20-25t/ha as basal dose along with half dose of N (35kg/ha) and full dose of P (25kg) and K (25kg). The remaining dose of N (35kg) can be applied in 2 equal split doses at fortnightly intervals. During the initial stages of growth, irrigation is to be given at an interval of 3-4 days and at alternate days during flowering and fruiting periods. For trailing cucumber, pumpkin and melon, dried twigs are to be spread on the ground. Bitter gourd, bottle gourd, snake gourd and ash gourd are to be trailed on Pandals. Weeding and raking of the soil are to be conducted at the time of fertilizer application. Earthing up may be done during rainy season. The most dreaded pest of cucurbits is fruit flies which can be controlled by using fruit traps, covering the fruits with polythene, cloth or paper bags, removal and destruction of affected fruits and lastly spraying with Carbaryl or Malathion 0. 2% suspension containing sugar or jaggery at 10g/l at fortnightly intervals after fruit set initiation. During rainy season, downy mildew and mosaic diseases are severe in cucurbits. The former can be checked by spraying Mancozeb 0.2%. The spread of mosaic can be checked by controlling the vectors using Dimethoate or Phosphamidon 0.05% and destruction of affected plants and collateral hosts. Harvesting to be done at least 10 days after insecticide or fungicide application (KAU,1996).... cucurbitsOccupational health includes both mental and physical health. It is about compliance with health-and-safety-at-work legislation (and common law duties) and about best practice in providing work environments that reduce risks to health and safety to lowest practicable levels. It includes workers’ ?tness to work, as well as the management of the work environment to accommodate people with disabilities, and procedures to facilitate the return to work of those absent with long-term illness. Occupational health incorporates several professional groups, including occupational physicians, occupational health nurses, occupational hygienists, ergonomists, disability managers, workplace counsellors, health-and-safety practitioners, and workplace physiotherapists.
In the UK, two key statutes provide a framework for occupational health: the Health and Safety at Work, etc. Act 1974 (HSW Act); and the Disability Discrimination Act 1995 (DDA). The HSW Act states that employers have a duty to protect the health, safety and welfare of their employees and to conduct their business in a way that does not expose others to risks to their health and safety. Employees and self-employed people also have duties under the Act. Modern health-and-safety legislation focuses on assessing and controlling risk rather than prescribing speci?c actions in di?erent industrial settings. Various regulations made under the HSW Act, such as the Control of Substances Hazardous to Health Regulations, the Manual Handling Operations Regulations and the Noise at Work Regulations, set out duties with regard to di?erent risks, but apply to all employers and follow the general principles of risk assessment and control. Risks should be controlled principally by removing or reducing the hazard at source (for example, by substituting chemicals with safer alternatives, replacing noisy machinery, or automating tasks to avoid heavy lifting). Personal protective equipment, such as gloves and ear defenders, should be seen as a last line of defence after other control measures have been put in place.
The employment provisions of the DDA require employers to avoid discriminatory practice towards disabled people and to make reasonable adjustments to working arrangements where a disabled person is placed at a substantial disadvantage to a non-disabled person. Although the DDA does not require employers to provide access to rehabilitation services – even for those injured or made ill at work – occupational-health practitioners may become involved in programmes to help people get back to work after injury or long-term illness, and many businesses see the retention of valuable sta? as an attractive alternative to medical retirement or dismissal on health grounds.
Although a major part of occupational-health practice is concerned with statutory compliance, the workplace is also an important venue for health promotion. Many working people rarely see their general practitioner and, even when they do, there is little time to discuss wider health issues. Occupational-health advisers can ?ll in this gap by providing, for example, workplace initiatives on stopping smoking, cardiovascular health, diet and self-examination for breast and testicular cancers. Such initiatives are encouraged because of the perceived bene?ts to sta?, to the employing organisation and to the wider public-health agenda. Occupational psychologists recognise the need for the working population to achieve a ‘work-life balance’ and the promotion of this is an increasing part of occupational health strategies.
The law requires employers to consult with their sta? on health-and-safety matters. However, there is also a growing understanding that successful occupational-health management involves workers directly in the identi?cation of risks and in developing solutions in the workplace. Trade unions play an active role in promoting occupational health through local and national campaigns and by training and advising elected workplace safety representatives.
Occupational medicine The branch of medicine that deals with the control, prevention, diagnosis, treatment and management of ill-health and injuries caused or made worse by work, and with ensuring that workers are ?t for the work they do.
Occupational medicine includes: statutory surveillance of workers’ exposure to hazardous agents; advice to employers and employees on eliminating or reducing risks to health and safety at work; diagnosis and treatment/management of occupational illness; advice on adapting the working environment to suit the worker, particularly those with disabilities or long-term health problems; and advice on the return to work and, if necessary, rehabilitation of workers absent through illness. Occupational physicians may play a wider role in monitoring the health of workplace populations and in advising employers on controlling health hazards where ill-health trends are observed. They may also conduct epidemiological research (see EPIDEMIOLOGY) on workplace diseases.
Because of the occupational physician’s dual role as adviser to both employer and employee, he or she is required to be particularly diligent with regards to the individual worker’s medical CONFIDENTIALITY. Occupational physicians need to recognise in any given situation the context they are working in, and to make sure that all parties are aware of this.
Occupational medicine is a medical discipline and thus is only part of the broader ?eld of occupational health. Although there are some speci?c clinical duties associated with occupational medicine, such as diagnosis of occupational disease and medical screening, occupational physicians are frequently part of a multidisciplinary team that might include, for example, occupational-health nurses, healthand-safety advisers, ergonomists, counsellors and hygienists. Occupational physicians are medical practitioners with a post-registration quali?cation in occupational medicine. They will have completed a period of supervised in-post training. In the UK, the Faculty of Occupational Medicine of the Royal College of Physicians has three categories of membership, depending on quali?cations and experience: associateship (AFOM); membership (MFOM); and fellowship (FFOM).
Occupational diseases Occupational diseases are illnesses that are caused or made worse by work. In their widest sense, they include physical and mental ill-health conditions.
In diagnosing an occupational disease, the clinician will need to examine not just the signs and symptoms of ill-health, but also the occupational history of the patient. This is important not only in discovering the cause, or causes, of the disease (work may be one of a number of factors), but also in making recommendations on how the work should be modi?ed to prevent a recurrence – or, if necessary, in deciding whether or not the worker is able to return to that type of work. The occupational history will help in deciding whether or not other workers are also at risk of developing the condition. It will include information on:
the nature of the work.
how the tasks are performed in practice.
the likelihood of exposure to hazardous agents (physical, chemical, biological and psychosocial).
what control measures are in place and the extent to which these are adhered to.
previous occupational and non-occupational exposures.
whether or not others have reported similar symptoms in relation to the work. Some conditions – certain skin conditions,
for example – may show a close relationship to work, with symptoms appearing directly only after exposure to particular agents or possibly disappearing at weekends or with time away from work. Others, however, may be chronic and can have serious long-term implications for a person’s future health and employment.
Statistical information on the prevalence of occupational disease in the UK comes from a variety of sources, including o?cial ?gures from the Industrial Injuries Scheme (see below) and statutory reporting of occupational disease (also below). Neither of these o?cial schemes provides a representative picture, because the former is restricted to certain prescribed conditions and occupations, and the latter suffers from gross under-reporting. More useful are data from the various schemes that make up the Occupational Diseases Intelligence Network (ODIN) and from the Labour Force Survey (LFS). ODIN data is generated by the systematic reporting of work-related conditions by clinicians and includes several schemes. Under one scheme, more than 80 per cent of all reported diseases by occupational-health physicians fall into just six of the 42 clinical disease categories: upper-limb disorders; anxiety, depression and stress disorders; contact DERMATITIS; lower-back problems; hearing loss (see DEAFNESS); and ASTHMA. Information from the LFS yields a similar pattern in terms of disease frequency. Its most recent survey found that over 2 million people believed that, in the previous 12 months, they had suffered from an illness caused or made worse by work and that
19.5 million working days were lost as a result. The ten most frequently reported disease categories were:
stress and mental ill-health (see MENTAL ILLNESS): 515,000 cases.
back injuries: 508,000.
upper-limb and neck disorders: 375,000.
lower respiratory disease: 202,000.
deafness, TINNITUS or other ear conditions: 170,000.
lower-limb musculoskeletal conditions: 100,000.
skin disease: 66,000.
headache or ‘eyestrain’: 50,000.
traumatic injury (includes wounds and fractures from violent attacks at work): 34,000.
vibration white ?nger (hand-arm vibration syndrome): 36,000. A person who develops a chronic occu
pational disease may be able to sue his or her employer for damages if it can be shown that the employer was negligent in failing to take reasonable care of its employees, or had failed to provide a system of work that would have prevented harmful exposure to a known health hazard. There have been numerous successful claims (either awarded in court, or settled out of court) for damages for back and other musculoskeletal injuries, hand-arm vibration syndrome, noise-induced deafness, asthma, dermatitis, MESOTHELIOMA and ASBESTOSIS. Employers’ liability (workers’ compensation) insurers are predicting that the biggest future rise in damages claims will be for stress-related illness. In a recent study, funded by the Health and Safety Executive, about 20 per cent of all workers – more than 5 million people in the UK – claimed to be ‘very’ or ‘extremely’ stressed at work – a statistic that is likely to have a major impact on the long-term health of the working population.
While victims of occupational disease have the right to sue their employers for damages, many countries also operate a system of no-fault compensation for the victims of prescribed occupational diseases. In the UK, more than 60 diseases are prescribed under the Industrial Injuries Scheme and a person will automatically be entitled to state compensation for disability connected to one of these conditions, provided that he or she works in one of the occupations for which they are prescribed. The following short list gives an indication of the types of diseases and occupations prescribed under the scheme:
CARPAL TUNNEL SYNDROME connected to the use of hand-held vibrating tools.
hearing loss from (amongst others) use of pneumatic percussive tools and chainsaws, working in the vicinity of textile manufacturing or woodworking machines, and work in ships’ engine rooms.
LEPTOSPIROSIS – infection with Leptospira (various listed occupations).
viral HEPATITIS from contact with human blood, blood products or other sources of viral hepatitis.
LEAD POISONING, from any occupation causing exposure to fumes, dust and vapour from lead or lead products.
asthma caused by exposure to, among other listed substances, isocyanates, curing agents, solder ?ux fumes and insects reared for research.
mesothelioma from exposure to asbestos.
In the UK, employers and the self-employed have a duty to report all occupational injuries (if the employee is o? work for three days or more as a result), diseases or dangerous incidents to the relevant enforcing authority (the Health and Safety Executive or local-authority environmental-health department) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). Despite this statutory duty, comparatively few diseases are reported so that ?gures generated from RIDDOR reports do not give a useful indication of the scale of occupational diseases in the UK. The statutory reporting of injuries is much better, presumably because of the clear and acute relationship between a workplace accident and the resultant injury. More than 160,000 injuries are reported under RIDDOR every year compared with just 2,500 or so occupational diseases, a gross underestimate of the true ?gure.
There are no precise ?gures for the number of people who die prematurely because of work-related ill-health, and it would be impossible to gauge the exact contribution that work has on, for example, cardiovascular disease and cancers where the causes are multifactorial. The toll would, however, dwarf the number of deaths caused by accidents at work. Around 250 people are killed by accidents at work in the UK each year – mesothelioma, from exposure to asbestos at work, alone kills more than 1,300 people annually.
The following is a sample list of occupational diseases, with brief descriptions of their aetiologies.
Inhaled materials
PNEUMOCONIOSIS covers a group of diseases which cause ?brotic lung disease following the inhalation of dust. Around 250–300 new cases receive bene?t each year – mostly due to coal dust with or without silica contamination. SILICOSIS is the more severe disease. The contraction in the size of the coal-mining industry as well as improved dust suppression in the mines have diminished the importance of this disease, whereas asbestos-related diseases now exceed 1,000 per year. Asbestos ?bres cause a restrictive lung disease but also are responsible for certain malignant conditions such as pleural and peritoneal mesothelioma and lung cancer. The lung-cancer risk is exacerbated by cigarette-smoking.
Even though the use of asbestos is virtually banned in the UK, many workers remain at risk of exposure because of the vast quantities present in buildings (much of which is not listed in building plans). Carpenters, electricians, plumbers, builders and demolition workers are all liable to exposure from work that disturbs existing asbestos. OCCUPATIONAL ASTHMA is of increasing importance – not only because of the recognition of new allergic agents (see ALLERGY), but also in the number of reported cases. The following eight substances are most frequently linked to occupational asthma (key occupations in brackets): isocyanates (spray painters, electrical processors); ?our and grain (bakers and farmers); wood dust (wood workers); glutaraldehyde (nurses, darkroom technicians); solder/colophony (welders, electronic assembly workers); laboratory animals (technicians, scientists); resins and glues (metal and electrical workers, construction, chemical processors); and latex (nurses, auxiliaries, laboratory technicians).
The disease develops after a short, symptomless period of exposure; symptoms are temporally related to work exposures and relieved by absences from work. Removal of the worker from exposure does not necessarily lead to complete cessation of symptoms. For many agents, there is no relationship with a previous history of ATOPY. Occupational asthma accounts for about 10 per cent of all asthma cases. DERMATITIS The risk of dermatitis caused by an allergic or irritant reaction to substances used or handled at work is present in a wide variety of jobs. About three-quarters of cases are irritant contact dermatitis due to such agents as acids, alkalis and solvents. Allergic contact dermatitis is a more speci?c response by susceptible individuals to a range of allergens (see ALLERGEN). The main occupational contact allergens include chromates, nickel, epoxy resins, rubber additives, germicidal agents, dyes, topical anaesthetics and antibiotics as well as certain plants and woods. Latex gloves are a particular cause of occupational dermatitis among health-care and laboratory sta? and have resulted in many workers being forced to leave their profession through ill-health. (See also SKIN, DISEASES OF.)
Musculoskeletal disorders Musculoskeletal injuries are by far the most common conditions related to work (see LFS ?gures, above) and the biggest cause of disability. Although not all work-related, musculoskeletal disorders account for 36.5 per cent of all disabilities among working-age people (compared with less than 4 per cent for sight and hearing impairment). Back pain (all causes – see BACKACHE) has been estimated to cause more than 50 million days lost every year in sickness absence and costs the UK economy up to £5 billion annually as a result of incapacity or disability. Back pain is a particular problem in the health-care sector because of the risk of injury from lifting and moving patients. While the emphasis should be on preventing injuries from occurring, it is now well established that the best way to manage most lower-back injuries is to encourage the patient to continue as normally as possible and to remain at work, or to return as soon as possible even if the patient has some residual back pain. Those who remain o? work on long-term sick leave are far less likely ever to return to work.
Aside from back injuries, there are a whole range of conditions affecting the upper limbs, neck and lower limbs. Some have clear aetiologies and clinical signs, while others are less well de?ned and have multiple causation. Some conditions, such as carpal tunnel syndrome, are prescribed diseases in certain occupations; however, they are not always caused by work (pregnant and older women are more likely to report carpal tunnel syndrome irrespective of work) and clinicians need to be careful when assigning work as the cause without ?rst considering the evidence. Other conditions may be revealed or made worse by work – such as OSTEOARTHRITIS in the hand. Much attention has focused on injuries caused by repeated movement, excessive force, and awkward postures and these include tenosynovitis (in?ammation of a tendon) and epicondylitis. The greatest controversy surrounds upper-limb disorders that do not present obvious tissue or nerve damage but nevertheless give signi?cant pain and discomfort to the individual. These are sometimes referred to as ‘repetitive strain injury’ or ‘di?use RSI’. The diagnosis of such conditions is controversial, making it di?cult for sufferers to pursue claims for compensation through the courts. Psychosocial factors, such as high demands of the job, lack of control and poor social support at work, have been implicated in the development of many upper-limb disorders, and in prevention and management it is important to deal with the psychological as well as the physical risk factors. Occupations known to be at particular risk of work-related upper-limb disorders include poultry processors, packers, electronic assembly workers, data processors, supermarket check-out operators and telephonists. These jobs often contain a number of the relevant exposures of dynamic load, static load, a full or excessive range of movements and awkward postures. (See UPPER LIMB DISORDERS.)
Physical agents A number of physical agents cause occupational ill-health of which the most important is occupational deafness. Workplace noise exposures in excess of 85 decibels for a working day are likely to cause damage to hearing which is initially restricted to the vital frequencies associated with speech – around 3–4 kHz. Protection from such noise is imperative as hearing aids do nothing to ameliorate the neural damage once it has occurred.
Hand-arm vibration syndrome is a disorder of the vascular and/or neural endings in the hands leading to episodic blanching (‘white ?nger’) and numbness which is exacerbated by low temperature. The condition, which is caused by vibrating tools such as chain saws and pneumatic hammers, is akin to RAYNAUD’S DISEASE and can be disabling.
Decompression sickness is caused by a rapid change in ambient pressure and is a disease associated with deep-sea divers, tunnel workers and high-?ying aviators. Apart from the direct effects of pressure change such as ruptured tympanic membrane or sinus pain, the more serious damage is indirectly due to nitrogen bubbles appearing in the blood and blocking small vessels. Central and peripheral nervous-system damage and bone necrosis are the most dangerous sequelae.
Radiation Non-ionising radiation from lasers or microwaves can cause severe localised heating leading to tissue damage of which cataracts (see under EYE, DISORDERS OF) are a particular variety. Ionising radiation from radioactive sources can cause similar acute tissue damage to the eyes as well as cell damage to rapidly dividing cells in the gut and bone marrow. Longer-term effects include genetic damage and various malignant disorders of which LEUKAEMIA and aplastic ANAEMIA are notable. Particular radioactive isotopes may destroy or induce malignant change in target organs, for example, 131I (thyroid), 90Sr (bone). Outdoor workers may also be at risk of sunburn and skin cancers. OTHER OCCUPATIONAL CANCERS Occupation is directly responsible for about 5 per cent of all cancers and contributes to a further 5 per cent. Apart from the cancers caused by asbestos and ionising radiation, a number of other occupational exposures can cause human cancer. The International Agency for Research on Cancer regularly reviews the evidence for carcinogenicity of compounds and industrial processes, and its published list of carcinogens is widely accepted as the current state of knowledge. More than 50 agents and processes are listed as class 1 carcinogens. Important occupational carcinogens include asbestos (mesothelioma, lung cancer); polynuclear aromatic hydrocarbons such as mineral oils, soots, tars (skin and lung cancer); the aromatic amines in dyestu?s (bladder cancer); certain hexavalent chromates, arsenic and nickel re?ning (lung cancer); wood and leather dust (nasal sinus cancer); benzene (leukaemia); and vinyl chloride monomer (angiosarcoma of the liver). It has been estimated that elimination of all known occupational carcinogens, if possible, would lead to an annual saving of 5,000 premature deaths in Britain.
Infections Two broad categories of job carry an occupational risk. These are workers in contact with animals (farmers, veterinary surgeons and slaughtermen) and those in contact with human sources of infection (health-care sta? and sewage workers).
Occupational infections include various zoonoses (pathogens transmissible from animals to humans), such as ANTHRAX, Borrelia burgdorferi (LYME DISEASE), bovine TUBERCULOSIS, BRUCELLOSIS, Chlamydia psittaci, leptospirosis, ORF virus, Q fever, RINGWORM and Streptococcus suis. Human pathogens that may be transmissible at work include tuberculosis, and blood-borne pathogens such as viral hepatitis (B and C) and HIV (see AIDS/HIV). Health-care workers at risk of exposure to infected blood and body ?uids should be immunised against hapatitis B.
Poisoning The incidence of occupational poisonings has diminished with the substitution of noxious chemicals with safer alternatives, and with the advent of improved containment. However, poisonings owing to accidents at work are still reported, sometimes with fatal consequences. Workers involved in the application of pesticides are particularly at risk if safe procedures are not followed or if equipment is faulty. Exposure to organophosphate pesticides, for example, can lead to breathing diffculties, vomiting, diarrhoea and abdominal cramps, and to other neurological effects including confusion and dizziness. Severe poisonings can lead to death. Exposure can be through ingestion, inhalation and dermal (skin) contact.
Stress and mental health Stress is an adverse reaction to excessive pressures or demands and, in occupational-health terms, is di?erent from the motivational impact often associated with challenging work (some refer to this as ‘positive stress’). Stress at work is often linked to increasing demands on workers, although coping can often prevent the development of stress. The causes of occupational stress are multivariate and encompass job characteristics (e.g. long or unsocial working hours, high work demands, imbalance between e?ort and reward, poorly managed organisational change, lack of control over work, poor social support at work, fear of redundancy and bullying), as well as individual factors (such as personality type, personal circumstances, coping strategies, and availability of psychosocial support outside work). Stress may in?uence behaviours such as smoking, alcohol consumption, sleep and diet, which may in turn affect people’s health. Stress may also have direct effects on the immune system (see IMMUNITY) and lead to a decline in health. Stress may also alter the course and response to treatment of conditions such as cardiovascular disease. As well as these general effects of stress, speci?c types of disorder may be observed.
Exposure to extremely traumatic incidents at work – such as dealing with a major accident involving multiple loss of life and serious injury
(e.g. paramedics at the scene of an explosion or rail crash) – may result in a chronic condition known as post-traumatic stress disorder (PTSD). PTSD is an abnormal psychological reaction to a traumatic event and is characterised by extreme psychological discomfort, such as anxiety or panic when reminded of the causative event; sufferers may be plagued with uncontrollable memories and can feel as if they are going through the trauma again. PTSD is a clinically de?ned condition in terms of its symptoms and causes and should not be used to include normal short-term reactions to trauma.... occupational health, medicine and diseases
Pregnancy lasts about 280 days and is calculated from the ?rst day of the last menstrual period – see MENSTRUATION. Pregnancy-testing kits rely on the presence of the hormone beta HUMAN CHORIONIC GONADOTROPHIN (b HCG) which is excreted in the woman’s urine as early as 30 days from the last menstrual period. The estimated date of delivery can be accurately estimated from the size of the developing fetus measured by ULTRASOUND (see also below) between seven and 24 weeks. ‘Term’ refers to the time that the baby is due; this can range from 38 weeks to 41 completed weeks.
Physical changes occur in early pregnancy – periods stop and the abdomen enlarges. The breasts swell, with the veins becoming prominent and the nipples darkening. About two in three women will have nausea with a few experiencing such severe vomiting as to require hospital admission for rehydration.
Antenatal care The aim of antenatal care is to ensure a safe outcome for both mother and child; it is provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in Edinburgh in the 1930s with the recognition that all aspects of pregnancy – normal and abnormal – warranted surveillance. Cooperation between general practitioners, midwives and obstetricians is now established, with pregnancies that are likely to progress normally being cared for in the community and only those needing special intervention being cared for in a hospital setting.
The initial visit (or booking) in the ?rst half of pregnancy will record the history of past events and the results of tests, with the aim of categorising the patients into normal or not. Screening tests including blood checks and ultrasound scans are a routine part of antenatal care. The ?rst ultrasound scan is done at about 11 weeks to date the pregnancy, with a further one done at 20 weeks – the anomaly scan – to assess the baby’s structure. Some obstetric units will check the growth of the baby with one further scan later in the pregnancy or, in the case of twin pregnancies (see below), many scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES MELLITUS, sickle-cell disease and THALASSAEMIA, as well as for the blood group. Evidence of past infections is also looked for; tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for human immunode?ciency virus (see AIDS/ HIV below) and HEPATITIS are being o?ered as optional, although there is compelling evidence that knowledge of the mother’s infection status is bene?cial to the baby.
Traditional antenatal care consists of regular appointments, initially every four weeks until 34 weeks, then fortnightly or weekly. At each visit the mother’s weight, urine and blood pressure are checked, and assessment of fetal growth and position is done by palpating the uterus. Around two-thirds of pregnancies and labours are normal: in the remainder, doctors and midwives need to increase the frequency of surveillance so as to prevent or deal with maternal and fetal problems.
Common complications of pregnancy
Some of the more common complications of pregnancy are listed below.
As well as early detection of medical complications, antenatal visits aim to be supportive and include emotional and educational care. Women with uncomplicated pregnancies are increasingly being managed by midwives and general practitioners in the community and only coming to the hospital doctors should they develop a problem. A small number will opt for a home delivery, but facilities for providing such a service are not always available in the UK.
Women requiring more intensive surveillance have their management targeted to the speci?c problems encountered. Cardiologists will see mothers-to-be with heart conditions, and those at risk of diabetes are cared for in designated clinics with specialist sta?. Those women needing more frequent surveillance than standard antenatal care can be looked after in maternity day centres. These typically include women with mildly raised blood pressure or those with small babies. Fetal medicine units have specialists who are highly skilled in ultrasound scanning and specialise in the diagnosis and management of abnormal babies still in the uterus. ECTOPIC PREGNANCY Chronic abdominal discomfort early in pregnancy may be caused by unruptured ectopic pregnancy, when, rarely, the fertilised OVUM starts developing in the Fallopian tube (see FALLOPIAN TUBES) instead of the uterus. The patient needs hospital treatment and LAPAROSCOPY. A ruptured ectopic pregnancy causes acute abdominal symptoms and collapse, and the woman will require urgent abdominal surgery. URINARY TRACT INFECTIONS These affect around 2 per cent of pregnant women and are detected by a laboratory test of a mid-stream specimen of urine. In pregnancy, symptoms of these infections do not necessarily resemble those experienced by non-pregnant women. As they can cause uterine irritability and possible premature labour (see below), it is important to ?nd and treat them appropriately. ANAEMIA is more prevalent in patients who are vegetarian or on a poor diet. Iron supplements are usually given to women who have low concentrations of HAEMOGLOBIN in their blood (less than 10.5 g/dl) or who are at risk of becoming low in iron, from bleeding, twin pregnancies and those with placenta previa (see below). ANTEPARTUM HAEMORRHAGE Early in pregnancy, vaginal bleedings may be due to a spontaneous or an incomplete therapeutic ABORTION. Bleeding from the genital tract between 24 completed weeks of pregnancy and the start of labour is called antepartum haemorrhage. The most common site is where the PLACENTA is attached to the wall of the uterus. If the placenta separates before delivery, bleeding occurs in the exposed ‘bed’. When the placenta is positioned in the upper part of the uterus it is called an abruption. PLACENTA PRAEVIA is sited in the lower part and blocks or partly blocks the cervix (neck of the womb); it can be identi?ed at about the 34th week. Ten per cent of episodes of antepartum bleeding are caused by placenta previa, and it may be associated with bleeding at delivery. This potentially serious complication is diagnosed by ultrasound scanning and may require a caesarean section (see below) at delivery. INCREASED BLOOD PRESSURE, associated with protein in the urine and swelling of the limbs, is part of a condition known as PRE-ECLAMPSIA. This occurs in the second half of pregnancy in about 1 in 10 women expecting their ?rst baby, and is mostly very mild and of no consequence to the pregnancy. However, some women can develop extremely high blood pressures which can adversely affect the fetus and cause epileptic-type seizures and bleeding disorders in the mother. This serious condition is called ECLAMPSIA. For this reason a pregnant woman with raised blood pressure or PROTEIN in her urine is carefully evaluated with blood tests, often in the maternity day assessment unit. The condition can be stopped by delivery of the baby, and this will be done if the mother’s or the fetus’s life is in danger. If the condition is milder, and the baby not mature enough for a safe delivery, then drugs can be used to control the blood pressure. MISCARRIAGE Also called spontaneous abortion, miscarriage is the loss of the fetus. There are several types:
threatened miscarriage is one in which some vaginal bleeding occurs, the uterus is enlarged, but the cervix remains closed and pregnancy usually proceeds.
inevitable miscarriage usually occurs before the 16th week and is typi?ed by extensive blood loss through an opened cervix and cramp-like abdominal pain; some products of conception are lost but the developing placental area (decidua) is retained and an operation may be necessary to clear the womb.
missed miscarriages, in which the embryo dies and is absorbed, but the decidua (placental area of uterine wall) remains and may cause abdominal discomfort and discharge of old blood.
THERAPEUTIC ABORTION is performed on more than 170,000 women annually in England and Wales. Sometimes the woman may not have arranged the procedure through the usual health-care channels, so that a doctor may see a patient with vaginal bleeding, abdominal discomfort or pain, and open cervix – symptoms which suggest that the decidua and a blood clot have been retained; these retained products will need to be removed by curettage.
Septic abortions are now much less common in Britain than before the Abortion Act (1967) permitted abortion in speci?ed circumstances. The cause is the passage of infective organisms from the vagina into the uterus, with Escherichia coli and Streptococcus faecalis the most common pathogenic agents. The woman has abdominal pain, heavy bleeding, usually fever and sometimes she is in shock. The cause is usually an incomplete abortion or one induced in unsterile circumstances. Antibiotics and curettage are the treatment. INTRAUTERINE GROWTH RETARDATION describes a slowing of the baby’s growth. This can be diagnosed by ultrasound scanning, although there is a considerable margin of error in estimates of fetal weight. Trends in growth are favoured over one-o? scan results alone. GESTATIONAL DIABETES is a condition that is more common in women who are overweight or have a family member with diabetes. If high concentrations of blood sugar are found, e?orts are made to correct it as the babies can become very fat (macrosomia), making delivery more di?cult. A low-sugar diet is usually enough to control the blood concentration of sugars; however some women need small doses of INSULIN to achieve control. FETAL ABNORMALITIES can be detected before birth using ultrasound. Some of these defects are obvious, such as the absence of kidneys, a condition incompatible with life outside the womb. These women can be o?ered a termination of their pregnancy. However, more commonly, the pattern of problems can only hint at an abnormality and closer examination is needed, particularly in the diagnosis of chromosomal deformities such as DOWN’S (DOWN) SYNDROME (trisomy 21 or presence of three 21 chromosomes instead of two).
Chromosomal abnormalities can be de?nitively diagnosed only by cell sampling such as amniocentesis (obtaining amniotic ?uid – see AMNION – from around the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a small part of the placenta) – another technique which can be done from 12 weeks onwards. Both have a small risk of miscarriage associated with them; consequently, they are con?ned to women at higher risk of having an abnormal fetus.
Biochemical markers present in the pregnant woman’s blood at di?erent stages of pregnancy may have undergone changes in those carrying an abnormal fetus. The ?rst such marker to be routinely used was a high concentration of alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the spinal cord). Fuller research has identi?ed a range of diagnostic markers which are useful, and, in conjunction with other factors such as age, ethnic group and ultrasound ?ndings, can provide a predictive guide to the obstetrician – in consultation with the woman – as to whether or not to proceed to an invasive test. These tests include pregnancy-associated plasma protein assessed from a blood sample taken at 12 weeks and four blood tests at 15–22 weeks – alphafetol protein, beta human chorionic gonadotrophin, unconjugated oestriol and inhibin A. Ultrasound itself can reveal physical ?ndings in the fetus, which can be more common in certain abnormalities. Swelling in the neck region of an embryo in early pregnancy (increased nuchal thickness) has good predictive value on its own, although its accuracy is improved in combination with the biochemical markers. The e?ectiveness of prenatal diagnosis is rapidly evolving, the aim being to make the diagnosis as early in the pregnancy as possible to help the parents make more informed choices. MULTIPLE PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of triplets is one in 10,000 and quadruplets around one in 500,000. Racial variations occur, with African women having a prevalence rate of one in 30 deliveries for twins and Japanese women a much lower rate than the UK ?gure. Multiple pregnancies occur more often in older women, and in the UK the prevalence of fertility treatments, many of these being given to older women, has raised the incidence. There is now an o?cial limit of three eggs being transferred to a woman undergoing ASSISTED CONCEPTION (gamete intrafallopian transfer, or GIFT).
Multiple pregnancies are now usually diagnosed as a result of routine ultrasound scans between 16 and 20 weeks of pregnancy. The increased size of the uterus results in the mother having more or worse pregnancy-related conditions such as nausea, abdominal discomfort, backache and varicose veins. Some congenital abnormalities in the fetus occur more frequently in twins: NEURAL TUBE defects, abnormalities of the heart and the incidence of TURNER’S SYNDROME and KLINEFELTER’S SYNDROME are examples. Such abnormalities may be detected by ultrasound scans or amniocentesis. High maternal blood pressure and anaemia are commoner in women with multiple pregnancies (see above).
The growth rates of multiple fetuses vary, but the di?erence between them and single fetuses are not that great until the later stages of pregnancy. Preterm labour is commoner in multiple pregnancies: the median length of pregnancy is 40 weeks for singletons, 37 for twins and 33 for triplets. Low birth-weights are usually the result of early delivery rather than abnormalities in growth rates. Women with multiple pregnancies require more frequent and vigilant antenatal assessments, with their carers being alert to the signs of preterm labour occurring. CEPHALOPELVIC DISPROPORTION Disparity between the size of the fetus and the mother’s pelvis is not common in the UK but is a signi?cant problem in the developing world. Disparity is classi?ed as absolute, when there is no possibility of delivery, and relative, when the baby is large but delivery (usually after a dif?cult labour) is possible. Causes of absolute disparity include: a large baby – heavier than 5 kg at birth; fetal HYDROCEPHALUS; and an abnormal maternal pelvis. The latter may be congenital, the result of trauma or a contraction in pelvic size because of OSTEOMALACIA early in life. Disproportion should be suspected if in late pregnancy the fetal head has not ‘engaged’ in the pelvis. Sometimes a closely supervised ‘trial of labour’ may result in a successful, if prolonged, delivery. Otherwise a caesarean section (see below) is necessary. UNUSUAL POSITIONS AND PRESENTATIONS OF THE BABY In most pregnant women the baby ?ts into the maternal pelvis head-?rst in what is called the occipito-anterior position, with the baby’s face pointing towards the back of the pelvis. Sometimes, however, the head may face the other way, or enter the pelvis transversely – or, rarely, the baby’s neck is ?exed backwards with the brow or face presenting to the neck of the womb. Some malpositions will correct naturally; others can be manipulated abdominally during pregnancy to a better position. If, however, the mother starts labour with the baby’s head badly positioned or with the buttocks instead of the head presenting (breech position), the labour will usually be longer and more di?cult and may require intervention using special obstetric forceps to assist in extracting the baby. If progress is poor and the fetus distressed, caesarean section may be necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV) should be taking antiviral drugs in the ?nal four to ?ve months of pregnancy, so as to reduce the risk of infecting the baby in utero and during birth by around 50 per cent. Additional antiviral treatment is given before delivery; the infection risk to the baby can be further reduced – by about 40 per cent – if delivery is by caesarean section. The mother may prefer to have the baby normally, in which case great care should be taken not to damage the baby’s skin during delivery. The infection risk to the baby is even further reduced if it is not breast fed. If all preventive precautions are taken, the overall risk of the infant becoming infected is cut to under 5 per cent.
Premature birth This is a birth that takes place before the end of the normal period of gestation, usually before 37 weeks. In practice, however, it is de?ned as a birth that takes place when the baby weighs less than 2·5 kilograms (5••• pounds). Between 5 and 10 per cent of babies are born prematurely, and in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is the most common known cause; others include hypertension, chronic kidney disease, heart disease and diabetes mellitus. Multiple pregnancy is another cause. In the vast majority of cases the aim of management is to prolong the pregnancy and so improve the outlook for the unborn child. This consists essentially of rest in bed and sedation, but there are now several drugs, such as RITODRINE, that may be used to suppress the activity of the uterus and so help to delay premature labour. Prematurity was once a prime cause of infant mortality but modern medical care has greatly improved survival rates in developing countries.
Labour Also known by the traditional terms parturition, childbirth or delivery, this is the process by which the baby and subsequently the placenta are expelled from the mother’s body. The onset of labour is often preceded by a ‘show’ – the loss of the mucus and blood plug from the cervix, or neck of the womb; this passes down the vagina to the exterior. The time before the beginning of labour is called the ‘latent phase’ and characteristically lasts 24 hours or more in a ?rst pregnancy. Labour itself is de?ned by regular, painful contractions which cause dilation of the neck of the womb and descent of the fetal head. ‘Breaking of the waters’ is the loss of amniotic ?uid vaginally and can occur any time in the delivery process.
Labour itself is divided into three stages: the ?rst is from the onset of labour to full (10 cm) dilation of the neck of the womb. This stage varies in length, ideally taking no more than one hour per centimetre of dilation. Progress is monitored by regular vaginal examinations, usually every four hours. Fetal well-being is observed by intermittent or continuous monitoring of the fetal heart rate in relation to the timing and frequency of the contractions. The print-out is called a cardiotocograph. Abnormalities of the fetal heart rate may suggest fetal distress and may warrant intervention. In women having their ?rst baby (primigravidae), the common cause of a slow labour is uncoordinated contractions which can be overcome by giving either of the drugs PROSTAGLANDIN or OXYTOCIN, which provoke contractions of the uterine muscle, by an intravenous drip. Labours which progress slowly or not at all may be due to abnormal positioning of the fetus or too large a fetus, when prostaglandin or oxytocin is used much more cautiously.
The second stage of labour is from full cervical dilation to the delivery of the baby. At this stage the mother often experiences an irresistible urge to push the baby out, and a combination of strong coordinated uterine contractions and maternal e?ort gradually moves the baby down the birth canal. This stage usually lasts under an hour but can take longer. Delay, exhaustion of the mother or distress of the fetus may necessitate intervention by the midwife or doctor. This may mean enlarging the vaginal opening with an EPISIOTOMY (cutting of the perineal outlet – see below) or assisting the delivery with specially designed obstetric forceps or a vacuum extractor (ventouse). If the cervix is not completely dilated or open and the head not descended, then an emergency caesarean section may need to be done to deliver the baby. This procedure involves delivering the baby and placenta through an incision in the mother’s abdomen. It is sometimes necessary to deliver by planned or elective caesarean section: for example, if the placenta is low in the uterus – called placenta praevia – making a vaginal delivery dangerous.
The third stage occurs when the placenta (or afterbirth) is delivered, which is usually about 10–20 minutes after the baby. An injection of ergometrine and oxytocin is often given to women to prevent bleeding.
Pain relief in labour varies according to the mother’s needs. For uncomplicated labours, massage, reassurance by a birth attendant, and a warm bath and mobilisation may be enough for some women. However, some labours are painful, particularly if the woman is tired or anxious or is having her ?rst baby. In these cases other forms of analgesia are available, ranging from inhalation of NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and regional local anaesthetic (see ANAESTHESIA).
Once a woman has delivered, care continues to ensure her and the baby’s safety. The midwives are involved in checking that the uterus returns to its normal size and that there is no infection or heavy bleeding, as well as caring for stitches if needed. The normal blood loss after birth is called lochia and generally is light, lasting up to six weeks. Midwives o?er support with breast feeding and care of the infant and will visit the parents at home routinely for up to two weeks.
Some complications of labour All operative deliveries in the UK are now done in hospitals, and are performed if a spontaneous birth is expected to pose a bigger risk to the mother or her child than a specialist-assisted one. Operative deliveries include caesarean section, forceps-assisted deliveries and those in which vacuum extraction (ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, which is used to deliver over 15 per cent of babies in Britain, are cephalopelvic disproportion and extensive placenta praevia, both discussed above. Otherwise the decision to undertake caesarean section depends on the clinical judgement of the specialist and the views of the mother. The rise in the proportion of this type of intervention (from 5 per cent in the 1930s to its present level of over 23 per cent
P
of the 600,000 or so annual deliveries in England) has been put down to defensive medicine
– namely, the doctor’s fear of litigation (initiated often because the parents believe that the baby’s health has suffered because the mother had an avoidably di?cult ‘natural’ labour). In Britain, over 60 per cent of women who have had a caesarean section try a vaginal delivery in a succeeding pregnancy, with about two-thirds of these being successful. Indications for the operation include:
absolute and relative cephalopelvic disproportion.
placenta previa.
fetal distress.
prolapsed umbilical cord – this endangers the viability of the fetus because the vital supply of oxygen and nutrients is interrupted.
malpresentation of the fetus such as breech or transverse lie in the womb.
unsatisfactory previous pregnancies or deliveries.
a request from the mother.
Caesarean sections are usually performed using regional block anaesthesia induced by a spinal or epidural injection. This results in loss of feeling in the lower part of the body; the mother is conscious and the baby not exposed to potential risks from volatile anaesthetic gases inhaled by the mother during general anaesthesia. Post-operative complications are higher with general anaesthesia, but maternal anxiety and the likelihood that the operation might be complicated and di?cult are indications for using it. A general anaesthetic may also be required for an acute obstetric emergency. At operation the mother’s lower abdomen is opened and then her uterus opened slowly with a transverse incision and the baby carefully extracted. A transverse incision is used in preference to the traditional vertical one as it enables the woman to have a vaginal delivery in any future pregnancy with a much smaller risk of uterine rupture. Women are usually allowed to get up within 24 hours and are discharged after four or ?ve days. FORCEPS AND VENTOUSE DELIVERIES Obstetric forceps are made in several forms, but all are basically a pair of curved blades shaped so that they can obtain a purchase on the baby’s head, thus enabling the operator to apply traction and (usually) speed up delivery. (Sometimes they are used to slow down progress of the head.) A ventouse or vacuum extractor comprises an egg-cup-shaped metal or plastic head, ranging from 40 to 60 mm in diameter with a hollow tube attached through which air is extracted by a foot-operated vacuum pump. The instrument is placed on the descending head, creating a negative pressure on the skin of the scalp and enabling the operator to pull the head down. In mainland Europe, vacuum extraction is generally preferred to forceps for assisting natural deliveries, being used in around 5 per cent of all deliveries. Forceps have a greater risk of causing damage to the baby’s scalp and brain than vacuum extraction, although properly used, both types should not cause any serious damage to the baby.
Episiotomy Normal and assisted deliveries put the tissues of the genital tract under strain. The PERINEUM is less elastic than the vagina and, if it seems to be splitting as the baby’s head
moves down the birth canal, it may be necessary to cut the perineal tissue – a procedure called an episiotomy – to limit damage. This is a simple operation done under local anaesthetic. It should be done only if there is a speci?c indication; these include:
to hasten the second stage of labour if the fetus is distressed.
to facilitate the use of forceps or vacuum extractor.
to enlarge a perineum that is restricted because of unyielding tissue, perhaps because of a scar from a previous labour. Midwives as well as obstetricians are trained
to undertake and repair (with sutures) episiotomies.
(For organisations which o?er advice and information on various aspects of childbirth, including eclampsia, breast feeding and multiple births, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)... pregnancy and labour
Hin: Munguskajur
It is seen wild in Assam and Khasi hills in India. Its root is diuretic and narcotic.8. S. stramoniifolium Jacq., syn. S. ferox auct. non Linn.San: Garbhada;Hin: Rambaigan;Mal: Anachunda;Tam: Anaichundai;Tel: MulakaIt is observed in India in the states of Assam, Maharashtra, Karnataka and Tamil Nadu. Its berries contain glycoalkaloids such as solasonine and solasodine. Its roots and berries are bechic, antiasthmatic, antirheumatic, antiviral, anticancerous and spermicidal.9. S. surattense Burm. F. syn. S. xanthocarpum schrad. & Wendl., S. jacquinii Willd.Eng: Yellow-berried nightshade; San: Kantakari, Nidigdhika;Hin: Remgani,Kateli;Mal: Kantakarichunda;Tam: Kantankattiri;Kan: Nelagulli;Tel: CallamulagaIt is found throughout India and Pakistan in dry situations as weed on roadsides and wastelands. It is prickly, diffuse, bright green, suffrutescent, perennial undershrub, with zigzag branches. Leaves are ovate-oblong, hairy on both sides and armed on the midrib and the nerves. Flowers are bluish purple, in extra-axillary cymes. Fruits are glabrous, globular drooping berry, yellow or white with green veins, surrounded by the calyx. Seeds are many, small, reniform, smooth and yellowish brown.The whole plant is useful in vitiated conditions of vata and kapha, helminthiasis, dental caries, inflammations, flatulence, constipation, dyspepsia, anorexia, leprosy, skin diseases, hypertension, fever, cough, asthma, bronchitis, hiccough, lumbago, haemorrhoids and epilepsy. The plant is bitter, acrid, thermogenic, anthelmintic, antiinflammatory, anodyne, digestive, carminative, appetiser, stomachic, depurative, sudorific, febrifuge, expectorant, laxative, stimulant, diuretic, rejuvenating, emmenagogue and aphrodisac. Fruits contain solasonine, solamargine and solasodine.10. S. torvum Sw.Eng: West Indian Turkey Berry;Hin,Ben: Titbaigan;Mal: Kattuchunda;Kan: Kadu Sunde;Tam: Sundaikai, Amarakai;Tel: Kundavustic, Kotuvestu; Ass: HathibhekuriIt is seen throughout tropical India, particularly in Orissa, Bihar and Manipur. The plant is CVS active and used in splenomegaly. Fruits and leaves contain solasonine, solasodine, jurubine, jurubidine, torvonin, torvogenin, chlorogenin, paniculogenin, sisalogenone, neosolaspigenin and solaspigenin.11. S. trilobatum Linn.Eng: Climbing Brinjal; San: Alarka;Mal: Tutavalam;Tam: Tuduvalai;Kan: Mullumusta;Tel: TelavusteIt is mostly seen in South and Western India. The plant contains alkamine and solamarine. The berry and flowers are bechic and used in bronchitis. The alkaloid solamarine is antibiotic and possesses antitumour activity.12. S. viarum Dunal, syn. S. Khasianum C. B. ClarkeHin: Kantakari
It is widely distributed in Khasi, Jaintia and Naga hills of Assam and Manipur upto 2000m and in Sikkim, West Bengal, Orissa and in the Niligiris. The plant and berries contain solasonine (which on hydrolysis yields solasodine), solamargine, khasianine, nantigenin, solasodine, diosgenin and saponin-solakhasianin. The plant is spasmolytic and CNS active. The berry is a source of solasodine used in the synthesis of corticosteroidal hormones.Agrotechnology: The agrotechnology for the solanaceous group of plants are almost similar. They come up very well in tropical and subtropical climate upto 2000m altitude. They can be raised on a variety of soils good in organic matter. Propagation is by seeds. The seedlings are first raised in the nursery and transplanted to the main field 30-45 days after sowing when the plants attain 8-10cm height. During rainy season, planting is done on ridges while during summer in furrows, at a spacing ranging from 30-90cm depending upon the stature and spreading habit of the plant. The transplanted seedlings should be given temporary shade for 2-4 days during summer. FYM or compost at 20-25t/ha is applied at the time of land preparation. A moderate fertiliser dose of 75:40:40 N, P2O5, K2O/ha may be given. P is given as basal dose, N and K are applied in 2-3 split doses. One or two intercultural operations are needed to control weeds. The plants need earthing up after weeding and topdressing. Irrigation is needed at 3-4 days interval during summer and on alternate days during fruiting period. Plants need staking to avoid lodging due to heavy bearing. Shoot borers, mealy bugs, leaf webbers and miners are noted on the crop, which can be controlled by spraying mild insecticides. Root knot nematode, wilting and mosaic diseases are also noted on the crop. Field sanitation, crop rotation and burning of crop residues are recommended.... solanumsAcute gastritis is an in?ammatory reaction of the gastric mucosa to various precipitating factors, ranging from physical and chemical injury to infections. Acute gastritis (especially of the antral mucosas) may well represent a reaction to infection by a bacterium called Helicobacter pylori. The in?ammatory changes usually go after appropriate antibiotic treatment for the H. pylori infection. Acute and chronic in?ammation occurs in response to chemical damage of the gastric mucosa. For example, REFLUX of duodenal contents may predispose to in?ammatory acute and chronic gastritis. Similarly, multiple small erosions or single or multiple ulcers have resulted from consumption of chemicals, especialy aspirin and antirheumatic NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS).
Acute gastritis may cause anorexia, nausea, upper abdominal pain and, if erosive, haemorrhage. Treatment involves removal of the o?ending cause.
Chronic gastritis Accumulation of cells called round cells in the gastric mucosal characterises chronic gastritis. Most patients with chronic gastritis have no symptoms, and treatment of H. pylori infection usually cures the condition.
Atrophic gastritis A few patients with chronic gastritis may develop atrophic gastritis. With or without in?ammatory change, this disorder is common in western countries. The incidence increases with age, and more than 50 per cent of people over 50 may have it. A more complete and uniform type of ATROPHY, called ‘gastric atrophy’, characterises a familial disease called PERNICIOUS ANAEMIA. The cause of the latter disease is not known but it may be an autoimmune disorder.
Since atrophy of the corpus mucosa results in loss of acid- and pepsin-secreting cells, gastric secretion is reduced or absent. Patients with pernicious anaemia or severe atrophic gastritis of the corpus mucosa may secrete too little intrinsic factor for absorption of vitamin B12 and so can develop severe neurological disease (subacute combined degeneration of the spinal cord).
Patients with atrophic gastritis often have bacterial colonisation of the upper alimentary tract, with increased concentration of nitrite and carcinogenic N-nitroso compounds. These, coupled with excess growth of mucosal cells, may be linked to cancer. In chronic corpus gastritis, the risk of gastric cancer is about 3–4 times that of the general population.
Postgastrectomy mucosa The mucosa of the gastric remnant after surgical removal of the distal part of the stomach is usually in?amed and atrophic, and is also premalignant, with the risk of gastric cancer being very much greater than for patients with duodenal ulcer who have not had surgery.
Stress gastritis Acute stress gastritis develops, sometimes within hours, in individuals who have undergone severe physical trauma, BURNS (Curling ulcers), severe SEPSIS or major diseases such as heart attacks, strokes, intracranial trauma or operations (Cushing’s ulcers). The disorder presents with multiple super?cial erosions or ulcers of the gastric mucosa, with HAEMATEMESIS and MELAENA and sometimes with perforation when the acute ulcers erode through the stomach wall. Treatment involves inhibition of gastric secretion with intravenous infusion of an H2-receptorantagonist drug such as RANITIDINE or FAMOTIDINE, so that the gastric contents remain at a near neutral pH. Despite treatment, a few patients continue to bleed and may then require radical gastric surgery.
Gastric ulcer Gastric ulcers were common in young women during the 19th century, markedly fell in frequency in many western countries during the ?rst half of the 20th century, but remained common in coastal northern Norway, Japan, in young Australian women, and in some Andean populations. During the latter half of this century, gastric ulcers have again become more frequent in the West, with a peak incidence between 55 and 65 years.
The cause is not known. The two factors most strongly associated with the development of duodenal ulcers – gastric-acid production and gastric infection with H. pylori bacteria – are not nearly as strongly associated with gastric ulcers. The latter occur with increased frequency in individuals who take aspirin or NSAIDs. In healthy individuals who take NSAIDs, as many as 6 per cent develop a gastric ulcer during the ?rst week of treatment, while in patients with rheumatoid arthritis who are being treated long term with drugs, gastric ulcers occur in 20–40 per cent. The cause is inhibition of the enzyme cyclo-oxygenase, which in turn inhibits the production of repair-promoting PROSTAGLANDINS.
Gastric ulcers occur especially on the lesser curve of the stomach. The ulcers may erode through the whole thickness of the gastric wall, perforating into the peritoneal cavity or penetrating into liver, pancreas or colon.
Gastric ulcers usually present with a history of epigastric pain of less than one year. The pain tends to be associated with anorexia and may be aggravated by food, although patients with ‘prepyloric’ ulcers may obtain relief from eating or taking antacid preparations. Patients with gastric ulcers also complain of nausea and vomiting, and lose weight.
The principal complications of gastric ulcer are haemorrhage from arterial erosion, or perforation into the peritoneal cavity resulting in PERITONITIS, abscess or ?stula.
Aproximately one in two gastric ulcers heal ‘spontaneously’ in 2–3 months; however, up to 80 per cent of the patients relapse within 12 months. Repeated recurrence and rehealing results in scar tissue around the ulcer; this may cause a circumferential narrowing – a condition called ‘hour-glass stomach’.
The diagnosis of gastric ulcer is con?rmed by ENDOSCOPY. All patients with gastric ulcers should have multiple biopsies (see BIOPSY) to exclude the presence of malignant cells. Even after healing, gastric ulcers should be endoscopically monitored for a year.
Treatment of gastric ulcers is relatively simple: a course of one of the H2 RECEPTOR ANTAGONISTS heals gastric ulcers in 3 months. In patients who relapse, long-term inde?nite treatment with an H2 receptor antagonist such as ranitidine may be necessary since the ulcers tend to recur. Recently it has been claimed that gastric ulcers can be healed with a combination of a bismuth salt or a gastric secretory inhibitor
for example, one of the PROTON PUMP INHIBITORS such as omeprazole or lansoprazole
together with two antibiotics such as AMOXYCILLIN and METRONIDAZOLE. The long-term outcome of such treatment is not known. Partial gastrectomy, which used to be a regular treatment for gastric ulcers, is now much more rarely done unless the ulcer(s) contain precancerous cells.
Cancer of the stomach Cancer of the stomach is common and dangerous and, worldwide, accounts for approximately one in six of all deaths from cancer. There are marked geographical di?erences in frequency, with a very high incidence in Japan and low incidence in the USA. In the United Kingdom around 33 cases per 100,000 population are diagnosed annually. Studies have shown that environmental factors, rather than hereditary ones, are mainly responsible for the development of gastric cancer. Diet, including highly salted, pickled and smoked foods, and high concentrations of nitrate in food and drinking water, may well be responsible for the environmental effects.
Most gastric ulcers arise in abnormal gastric mucosa. The three mucosal disorders which especially predispose to gastric cancer include pernicious anaemia, postgastrectomy mucosa, and atrophic gastritis (see above). Around 90 per cent of gastric cancers have the microscopic appearance of abnormal mucosal cells (and are called ‘adenocarcinomas’). Most of the remainder look like endocrine cells of lymphoid tissue, although tumours with mixed microscopic appearance are common.
Early gastric cancer may be symptomless and, in countries like Japan with a high frequency of the disease, is often diagnosed during routine screening of the population. In more advanced cancers, upper abdominal pain, loss of appetite and loss of weight occur. Many present with obstructive symptoms, such as vomiting (when the pylorus is obstructed) or di?culty with swallowing. METASTASIS is obvious in up to two-thirds of patients and its presence contraindicates surgical cure. The diagnosis is made by endoscopic examination of the stomach and biopsy of abnormal-looking areas of mucosa. Treatment is surgical, often with additional chemotherapy and radiotherapy.... stomach, diseases of
Adoption declined as the availability of babies fell with the introduction of the Abortion Act 1968, improving contraceptive services and increasing acceptability of single parenthood.
However, with 10 per cent of couples suffering infertility, the demand continued, leading to the adoption of those previously perceived as di?cult to place – i.e. physically, intellectually and/or emotionally disabled children and adolescents, those with terminal illness, and children of ethnic-minority groups.
Recent controversies regarding homosexual couples as adoptive parents, adoption of children with or at high risk of HIV/AIDS, transcultural adoption, and the increasing use of intercountry adoption to ful?l the needs of childless couples have provoked urgent consideration of the ethical dilemmas of adoption and its consequences for the children, their adoptive and birth families and society generally.
Detailed statistics have been unavailable since 1984 but in general there has been a downward trend with relatively more older children being placed. Detailed reasons for adoption (i.e. interfamily, step-parent, intercountry, etc.) are not available but approximately one-third are adopted from local-authority care.
In the UK all adoptions (including interfamily and step-parent adoption) must take place through a registered adoption agency which may be local-authority-based or provided by a registered voluntary agency. All local authorities must act as agencies, the voluntary agencies often providing specialist services to promote and support the adoption of more di?cult-to-place children. Occasionally an adoption allowance will be awarded.
Adoption orders cannot be granted until a child has resided with its proposed adopters for 13 weeks. In the case of newborn infants the mother cannot give formal consent to placement until the baby is six weeks old, although informal arrangements can be made before this time.
In the UK the concept of responsibility of birth parents to their children and their rights to continued involvement after adoption are acknowledged by the Children Act 1989. However, in all discussions the child’s interests remain paramount. The Act also recognises adopted children’s need to have information regarding their origins.
BAAF – British Agencies for Adoption and Fostering – is the national organisation of adoptive agencies, both local authority and voluntary sector. The organisation promotes and provides training service, development and research; has several specialist professional subgroups (i.e. medical, legal, etc.); and produces a quarterly journal.
Adoption UK is an e?ective national support network of adoptive parents who o?er free information, a ‘listening ear’ and, to members, a quarterly newsletter.
National Organisation for Counselling Adoptees and their Parents (NORCAP) is concerned with adopted children and birth parents who wish to make contact.
The Registrar General operates an Adoption Contact Register for adopted persons and anyone related to that person by blood, half-blood or marriage. Information can be obtained from the O?ce of Population Censuses and Surveys. For the addresses of these organisations, see Appendix 2.... child adoption
Habitat: Annual grass introduced into India from South Africa; cultivated in tropical and subtropical low-lying areas where rainfall is less than 125 cm.
English: Giant Rhodes, RhodesGrass.Folk: Rhoolsoohullu (Karnataka).Action: A proteinaceous factor, phytotrophin, isolated from the grass, was found to have antigenic properties similar to those of animal sex hormones and human chorionic gonadotrophin.
A related species, Chloris incompleta Roth., known as Bamnaa in Rajasthan and Mathania in Uttar Pradesh, has been equated with Ayurvedic classical herbs Manthaanakand Trnaaddhip. Another species, C. virgata Benth. & Hook. f., known as Gharaniyaa-ghass in Rajasthan, is used for the treatment of colds and rheumatism.... chloris gayanaChronic bronchitis is typi?ed by chronic productive cough for at least three months in two successive years (provided other causes such as TUBERCULOSIS, lung cancer and chronic heart failure have been excluded). The characteristics of emphysema are abnormal and permanent enlargement of the airspaces (alveoli) at the furthermost parts of the lung tissue. Rupture of alveoli occurs, resulting in the creation of air spaces with a gradual breakdown in the lung’s ability to oxygenate the blood and remove carbon dioxide from it (see LUNGS). Asthma results in in?ammation of the airways with the lining of the BRONCHIOLES becoming hypersensitive, causing them to constrict. The obstruction may spontaneously improve or do so in response to bronchodilator drugs. If an asthmatic patient’s airway-obstruction is characterised by incomplete reversibility, he or she is deemed to have a form of COPD called asthmatic bronchitis; sufferers from this disorder cannot always be readily distinguished from those people who have chronic bronchitis and/ or emphysema. Symptoms and signs of emphysema, chronic bronchitis and asthmatic bronchitis overlap, making it di?cult sometimes to make a precise diagnosis. Patients with completely reversible air?ow obstruction without the features of chronic bronchitis or emphysema, however, are considered to be suffering from asthma but not from COPD.
The incidence of COPD has been increasing, as has the death rate. In the UK around 30,000 people with COPD die annually and the disorder makes up 10 per cent of all admissions to hospital medical wards, making it a serious cause of illness and disability. The prevalence, incidence and mortality rates increase with age, and more men than women have the disorder, which is also more common in those who are socially disadvantaged.
Causes The most important cause of COPD is cigarette smoking, though only 15 per cent of smokers are likely to develop clinically signi?cant symptoms of the disorder. Smoking is believed to cause persistent airway in?ammation and upset the normal metabolic activity in the lung. Exposure to chemical impurities and dust in the atmosphere may also cause COPD.
Signs and symptoms Most patients develop in?ammation of the airways, excessive growth of mucus-secreting glands in the airways, and changes to other cells in the airways. The result is that mucus is transported less e?ectively along the airways to eventual evacuation as sputum. Small airways become obstructed and the alveoli lose their elasticity. COPD usually starts with repeated attacks of productive cough, commonly following winter colds; these attacks progressively worsen and eventually the patient develops a permanent cough. Recurrent respiratory infections, breathlessness on exertion, wheezing and tightness of the chest follow. Bloodstained and/or infected sputum are also indicative of established disease. Among the symptoms and signs of patients with advanced obstruction of air?ow in the lungs are:
RHONCHI (abnormal musical sounds heard through a STETHOSCOPE when the patient breathes out).
marked indrawing of the muscles between the ribs and development of a barrel-shaped chest.
loss of weight.
CYANOSIS in which the skin develops a blue tinge because of reduced oxygenation of blood in the blood vessels in the skin.
bounding pulse with changes in heart rhythm.
OEDEMA of the legs and arms.
decreasing mobility.
Some patients with COPD have increased ventilation of the alveoli in their lungs, but the levels of oxygen and carbon dioxide are normal so their skin colour is normal. They are, however, breathless so are dubbed ‘pink pu?ers’. Other patients have reduced alveolar ventilation which lowers their oxygen levels causing cyanosis; they also develop COR PULMONALE, a form of heart failure, and become oedematous, so are called ‘blue bloaters’.
Investigations include various tests of lung function, including the patient’s response to bronchodilator drugs. Exercise tests may help, but radiological assessment is not usually of great diagnostic value in the early stages of the disorder.
Treatment depends on how far COPD has progressed. Smoking must be stopped – also an essential preventive step in healthy individuals. Early stages are treated with bronchodilator drugs to relieve breathing symptoms. The next stage is to introduce steroids (given by inhalation). If symptoms worsen, physiotherapy – breathing exercises and postural drainage – is valuable and annual vaccination against INFLUENZA is strongly advised. If the patient develops breathlessness on mild exertion, has cyanosis, wheezing and permanent cough and tends to HYPERVENTILATION, then oxygen therapy should be considered. Antibiotic treatment is necessary if overt infection of the lungs develops.
Complications Sometimes rupture of the pulmonary bullae (thin-walled airspaces produced by the breakdown of the walls of the alveoli) may cause PNEUMOTHORAX and also exert pressure on functioning lung tissue. Respiratory failure and failure of the right side of the heart (which controls blood supply to the lungs), known as cor pulmonale, are late complications in patients whose primary problem is emphysema.
Prognosis This is related to age and to the extent of the patient’s response to bronchodilator drugs. Patients with COPD who develop raised pressure in the heart/lung circulation and subsequent heart failure (cor pulmonale) have a bad prognosis.... chronic obstructive pulmonary disease (copd)
Symptoms. A small lump comes to light while washing, a discharge from the nipple, change in nipple size and colour, irregular contour of the breast surface. Though tissue change is likely to be a cyst, speedy diagnosis and treatment are necessary. Some hospital physicians and surgeons are known to view favourably supportive herbal aids, and do not always think in terms of radical mastectomy. Dr Finlay Ellingwood, Chicago physician (1916) cured a case by injection of one dram Echinacea root extract twice a week into the surrounding tissues.
The condition is believed to be due to a number of causes including suppression of ovulation and oestrogen secretion in pregnant and lactating women. A high fat diet is suspected of interference with the production of oestrogen. Some women are constitutionally disposed to the condition which may be triggered by trauma or emotional shock. Increase in incidence in older women has been linked with excessive sugar consumption. “Consumption overwhelms the pancreas which has to ‘push it out’ to all parts of the body (when broken down by the digestive process) whether they need it or not. The vital organs are rationed according to their requirements of nutrients from the diet. What is left over has to ‘go into store elsewhere’. And the breast is forced to take its share and store it. If it gets too much, for too long, it may rebel!” (Stephen Seely, Department of Bacteriology and Virology, Manchester)
“Women who nurse their babies less than one month are at an increased risk for breast cancer. The longer a woman breast-feeds – no matter what her age – the more the risk decreases. (Marion Tompson, co-founder, The La Leche League, in the American Journal of Epidemiology)
Lactation reduces the risk of pre-menopausal breast cancer. (Newcomb P.A. et al New England Journal of Medicine, 330 1994)
There is currently no treatment to cure metastatic breast cancer. In spite of chemotherapy, surgery and radiotherapy survival rate has not diminished. Herbs not only have a palliative effect but, through their action on hormone function offer a positive contribution towards overcoming the condition. Their activity has been widely recorded in medical literature. Unlike cytotoxic drugs, few have been known to cause alopecia, nausea, vomiting or inflammation of the stomach.
Treatment by a general medical practitioner or oncologist.
Special investigations. Low radiation X-ray mammography to confirm diagnosis. Test for detection of oestrogen receptor protein.
Treatment. Surgery may be necessary. Some patients may opt out from strong personal conviction, choosing a rigid self-disciplined approach – the Gentle Way. Every effort is made to build up the body’s natural defences (immune system).
An older generation of herbalists believed tissue change could follow a bruise on the breast, which should not be neglected but immediately painted with Tincture Arnica or Tincture Bellis perennis.
Vincristine, an alkaloid from Vinca rosea (Catharanthus roseus) is used by the medical profession as an anti-neoplastic and anti-mitotic agent to inhibit cell division.
Of possible therapeutic value. Blue Flag root, Burdock root, Chaparral, Clivers, Comfrey root, Echinacea, Figwort, Gotu Kola, Marshmallow root, Mistletoe, Myrrh, Prickly Ash bark, Red Clover, Thuja, Wild Violet, Yellow Dock.
Tea. Equal parts: Red Clover, Clivers, Gotu Kola, Wild Violet. 1 heaped teaspoon to each cup boiling water; infuse 5-15 minutes. 3 or more cups daily.
Decoctions. Echinacea, Blue Flag root, Queen’s Delight, Yellow Dock.
Tablets/capsules. Blue Flag root, Echinacea, Poke root, Mistletoe.
Formula. Echinacea 2; Gotu Kola 1; Poke root 1; Mistletoe 1; Vinca rosea 1. Mix. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. Thrice daily and at bedtime. According to progress of the disease, increase dosage as tolerated.
Maria Treben’s tea. Parts: Marigold (3), Yarrow 1; Nettles 1. Mix. 2 teaspoons to each cup boiling water. 1 cup as many times daily as tolerated.
William Boericke, M.D. recommends Houseleek. E.H. Ruddock M.D. favours Figwort.
Topical. Treatments believed to be of therapeutic value or for use as a soothing application.
(1) Cold poultice: Comfrey root.
(2) Poultice of fresh Marshmallow root pulped in juicer.
(3) Injection of Extract Greater Celandine (Chelidonium), locally, gained a reputation in the Eclectic school.
(4) The action of Blood root (Sanguinaria) is well known as a paint or injection.
(5) Ragwort poultice: 2oz Ragwort boiled in half a pint potato water for 15 minutes. See: POULTICE.
(6) Popular Russian traditional remedy: Badiaga (Spongilla fluviatilis), fresh water sponge gathered in the autumn; dried plant rubbed to a powder. Poultice.
(7) Maria Treben’s Poultice: Carefully washed fresh Plantain leaves, pulped, and applied direct to the lesion.
(8) If lymph glands are affected, apply Plantain poultice to glands.
(9) Dr Brandini’s treatment. Dr Brandini, Florence, used 4 grains Citric Acid (prepared from lemons) in 1oz (30ml) water for ulcerated cancer of the breast considered incurable. “The woman’s torments were so distressing that neither she nor other patients could get any rest. Applying lint soaked in the solution, relief was instantaneous. Repeated, it was successful.”
(10) Circuta leaves. Simmered till soft and mixed with Slippery Elm bark powder as a poultice morning and night.
(11) Decoction. Simmer gently Yellow Dock roots, fine cut or powdered, 1oz to 1 pint, 20 minutes. Saturate lint or suitable material and apply.
(12) Yellow Dock ointment. Half ounce Lobelia seed, half ounce Yellow Dock root powder. Baste into an ointment base. See: OINTMENT BASE.
(13) Infusion, for use as a wash. Equal parts: Horsetail, Red Clover, Raspberry leaves. 1oz to 1 pint boiling water infuse 15 minutes.
(14) Dr Christopher’s Ointment. Half an ounce White Oak, half an ounce Garden Sage, half an ounce Tormentil, half an ounce Horsetail, half an ounce Lemon Balm. Method: Boil gently half an hour in quart water, strain. Reduce to half a pint by simmering. Add half a pound honey. Bring to boil. Skim off scum. Allow cool. Apply: twice daily on sores.
(15) Dr Finlay Ellingwood. Poke root juice. “Fresh juice from the stems, leaves and roots applied directly to diseased tissue. Exercises a selective action; induces liquefaction and promotes removal, sometimes healing the open wound and encouraging scar formation. Masses of such tissue have been known to be destroyed in a few weeks with only a scar, with no other application but the fresh juice. Produces pain at first, but is otherwise harmless.”
(16) Lesion painted with Mandrake resin. (American Podophyllum)
(17) Dust affected parts with Comfrey powder. Mucilage from Comfrey powder or crushed root with the aid of a little milk. See: COMFREY.
(18) Dr Samuel Thomson’s Cancer Plaster. “Take heads of Red Clover and fill a kettle. Boil in water for one hour. Remove and fill kettle with fresh flower heads. Boil as before in the same liquor. Strain and press heads to express all the liquor. Simmer over a low fire till of the consistency of tar. It must not burn. Spread over a piece of suitable material.”
(19) Wipe affected area with cut Houseleek. (Dr Wm Boericke)
(20) Chinese Herbalism. Take 1-2 Liang pulverised liao-ko-wang (Wickstroemia indica), mix with cold boiled water or rice wine for local compress. Also good for mastitis.
(21) Italian women once used an old traditional remedy – Fenugreek tea.
(22) A clinical trial of Vitamin D provided encouraging results. Patients with locally advanced breast cancer were given a highly active Vitamin D analogue cream to rub on their tumours. “It was effective in one third of the tumours,” said Professor Charles Coombes, clinical oncologist, Charing Cross Hospital, London.
Diet. “A diet rich in cereal products (high in dietary fibre) and green leafy vegetables (antioxidants) would appear to offer women some protection against breast cancer due to the relation between fibre and oestrogen metabolism. Meat-free diet. In a study of 75 adolescent girls, vegetarians were found to have higher levels of a hormone that women suffering from breast cancer often lack. (Cancer Research) Supplements. Daily. Chromium. Selenium (600mcg). Zinc chelate (100mg morning and evening). Beta carotene. “Low levels of Selenium and Vitamins A and E are shown in breast cancer cases.” (British Journal of Cancer 49: 321-324, 1984).
Vitamins A and D inhibit virus penetration in healthy cell walls. Multivitamin combinations should not include Vitamin B12, production of which in the body is much increased in cancerous conditions. Vitamins B-complex and C especially required.
Note: A link between sugar consumption and breast cancer has been reported by some authorities who suggest that countries at the top of the mortality table are the highest also in sugar consumption; the operative factor believed to be insulin.
Screening. Breast screening should be annual from the age of forty.
General. Mothers are encouraged to breast-feed children for the protection it offers against mammary malignancy. (Am.J. Obstet. Gyn. 15/9/1984. 150.)
Avoidance of stress situations by singing, playing an instrument. Adopt relaxation techniques, spiritual healing and purposeful meditation to arouse the immune system; intensive visualisation. Avoid the carcinogens: smoking, alcohol.
Information. Breast Cancer Care. Free Help Line. UK Telephone: 0500 245345. ... cancer - breast
Annual death rates (deaths per million at risk) vary widely between occupations, ranging from 5 in clothing and footwear manufacture to about 1,650 in offshore oil and gas industries.
More than 1,000 per year are due to work-related diseases, mainly pneumoconiosis and cancers.... occupational mortality
Habitat: Warm and damp areas up to about 2,000 m, both wild and cultivated as an annual grass.
English: Job's Tears.Ayurvedic: Gavedhukaa.Siddha/Tamil: Kaatu Kunthumani.Folk: Garaheduaa, Gargari.Action: Fruits—a decoction is used for catarrhal affections of the air passage and inflammation of the urinary tract. Seed— diuretic. Root—used in menstrual disorders. Leaves—used as a drink for inducing fertility in women.
The seeds contain trans-ferulyl stig- mastanol and trans-ferulyl campes- tanol, which form part of an ovulation- inducing drug. Seed extract—immu- no-enhancer, used for the prevention of cancer and infections. Seeds exhibit anti-tumour and anticomplimenta- ry activities. Seeds contain coixeno- lides, a mixed ester of palmitoleic and vaccenic acids, which is an anticancer agent.The bigger var. of the grass is equated with Coix gigantea Koenig ex Roxb., also known as Gavedhukaa and Gar- gari.... coix lacryma-jobiAlso called acute coryza or upper respiratory infection, the common cold is characterised by in?ammation of any or all of the airways – NOSE, sinuses (see SINUS), THROAT, LARYNX, TRACHEA and bronchi (see BRONCHUS). Most common, however, is the ‘head cold’, which is con?ned to the nose and throat, with initial symptoms presenting as a sore throat, runny nose and sneezing. The nasal discharge may become thick and yellow – a sign of secondary bacterial infection – while the patient often develops watery eyes, aching muscles, a cough, headache, listlessness and the shivers. PYREXIA (raised temperature) is usual. Colds can also result in a ?are-up of pre-existing conditions, such as asthma, bronchitis or ear infections. Most colds are self-limiting, resolving in a week or ten days, but some patients develop secondary bacterial infections of the sinuses, middle ear (see EAR), trachea, or LUNGS.
Treatment Symptomatic treatment with ANTIPYRETICS and ANALGESICS is usually su?cient; ANTIBIOTICS should not be taken unless there is de?nite secondary infection or unless the patient has an existing chest condition which could be worsened by a cold. Cold victims should consult a doctor only if symptoms persist or if they have a pre-existing condition, such as asthma which could be exacerbated by a cold.
Most colds result from breathing-in virus-containing droplets that have been coughed or sneezed into the atmosphere, though the virus can also be picked up from hand-to-hand contact or from articles such as hand towels. Prevention is, therefore, di?cult, given the high infectivity of the viruses. No scienti?cally proven, generally applicable preventive measures have yet been devised, but the incidence of the infection falls from about seven to eight years – schoolchildren may catch as many as eight colds annually – to old age, the elderly having few colds. So far, despite much research, no e?ective vaccines have been produced.... cold, common
Abnormal prion proteins accumulate in the brain and the spinal cord, damaging neurones (see NEURON(E)) and producing small cavities. Diagnosis can be made by tonsil (see TONSILS) biopsy, although work is under way to develop a diagnostic blood test. Abnormal prion proteins are unusually resistant to inactivation by chemicals, heat, X-RAYS or ULTRAVIOLET RAYS (UVR). They are resistant to cellular degradation and can convert normal prion proteins into abnormal forms. Human prion diseases, along with scrapie in sheep and BSE in cattle, belong to a group of disorders known as transmissible spongiform encephalopathies. Abnormal prion proteins can transfer from one animal species to another, and variant CJD has occurred as a result of consumption of meat from cattle infected with BSE.
From 1995 to 1999, a scienti?c study of tonsils and appendixes removed at operation suggested that the prevalence of prion carriage may be as high as 120 per million. It is not known what percentage of these might go on to develop disease.
One precaution is that, since 2003, all surgical instruments used in brain biopsies have had to be quarantined and disposable instruments are now used in tonsillectomy.
Measures have also been introduced to reduce the risk of transmission of CJD from transfusion of blood products.
In the past, CJD has also been acquired from intramuscular injections of human cadaveric pituitary-derived growth hormone and corneal transplantation.
The most common form of CJD remains the sporadic variety, although the eventual incidence of variant CJD may not be known for many years.... creutzfeldt-jakob disease (cjd)
Barrier methods These involve a physical barrier which prevents sperm (see SPERMATOZOON) from reaching the cervix (see CERVIX UTERI). Barrier methods reduce the risk of spreading sexually transmitted diseases, and the sheath is the best protection against HIV infection (see AIDS/HIV) for sexually active people. The e?ciency of barrier methods is improved if they are used in conjunction with a spermicidal foam or jelly, but care is needed to ensure that the preparation chosen does not damage the rubber barrier or cause an allergic reaction in the users. CONDOM OR SHEATH This is the most commonly used barrier contraceptive. It consists of a rubber sheath which is placed over the erect penis before intromission and removed after ejaculation. The failure rate, if properly used, is about 4 per cent. DIAPHRAGM OR CAP A rubber dome that is inserted into the vagina before intercourse and ?ts snugly over the cervix. It should be used with an appropriate spermicide and is removed six hours after intercourse. A woman must be measured to ensure that she is supplied with the correct size of diaphragm, and the ?t should be checked annually or after more than about 7 lbs. change in weight. The failure rate, if properly used, is about 2 per cent.
Non-barrier methods These do not provide a physical barrier between sperm and cervix and so do not protect against sexually transmitted diseases, including HIV. COITUS INTERRUPTUS This involves the man’s withdrawing his penis from the vagina before ejaculation. Because some sperm may leak before full ejaculation, the method is not very reliable. SAFE PERIOD This involves avoiding intercourse around the time when the woman ovulates and is at risk of pregnancy. The safe times can be predicted using temperature charts to identify the rise in temperature before ovulation, or by careful assessment of the quality of the cervical mucus. This method works best if the woman has regular menstrual cycles. If used carefully it can be very e?ective but requires a highly disciplined couple to succeed. It is approved by the Catholic church.
SPERMICIDAL GELS, CREAMS, PESSARIES, ETC.
These are supposed to prevent pregnancy by killing sperm before they reach the cervix, but they are unreliable and should be used only in conjunction with a barrier method.
INTRAUTERINE CONTRACEPTIVE DEVICE (COIL) This is a small metal or plastic shape, placed inside the uterus, which prevents pregnancy by disrupting implantation. Some people regard it as a form of abortion, so it is not acceptable to all religious groups. There is a risk of pelvic infection and eventual infertility in women who have used coils, and in many countries their use has declined substantially. Coils must be inserted by a specially trained health worker, but once in place they permit intercourse at any time with no prior planning. Increased pain and bleeding may be caused during menstruation. If severe, such symptoms may indicate that the coil is incorrectly sited, and that its position should be checked. HORMONAL METHODS Steroid hormones have dominated contraceptive developments during the past 40 years, with more than 200 million women worldwide taking or having taken ‘the pill’. In the past 20 years, new developments have included modifying existing methods and devising more e?ective ways of delivering the drugs, such as implants and hormone-releasing devices in the uterus. Established hormonal contraception includes the combined oestrogen and progesterone and progesterone-only contraceptive pills, as well as longer-acting depot preparations. They modify the woman’s hormonal environment and prevent pregnancy by disrupting various stages of the menstrual cycle, especially ovulation. The combined oestrogen and progesterone pills are very e?ective and are the most popular form of contraception. Biphasic and triphasic pills contain di?erent quantities of oestrogen and progesterone taken in two or three phases of the menstrual cycle. A wide range of preparations is available and the British National Formulary contains details of the commonly used varieties.
The main side-e?ect is an increased risk of cardiovascular disease. The lowest possible dose of oestrogen should be used, and many preparations are phasic, with the dose of oestrogen varying with the time of the cycle. The progesterone-only, or ‘mini’, pill does not contain any oestrogen and must be taken at the same time every day. It is not as e?ective as the combined pill, but failure rates of less than 1-per-100 woman years can be achieved. It has few serious side-effects, but may cause menstrual irregularities. It is suitable for use by mothers who are breast feeding.
Depot preparations include intramuscular injections, subcutaneous implants, and intravaginal rings. They are useful in cases where the woman cannot be relied on to take a pill regularly but needs e?ective contraception. Their main side-e?ect is their prolonged action, which means that users cannot suddenly decide that they would like to become pregnant. Skin patches containing a contraceptive that is absorbed through the skin have recently been launched.
HORMONAL CONTRACEPTION FOR MEN There is a growing demand by men worldwide for hormonal contraception. Development of a ‘male pill’, however, has been slow because of the potentially dangerous side-effects of using high doses of TESTOSTERONE (the male hormone) to suppress spermatogenesis. Progress in research to develop a suitable ANDROGEN-based combination product is promising, including the possibility of long-term STEROID implants. STERILISATION See also STERILISATION – Reproductive sterilisation. The operation is easier and safer to perform on men than on women. Although sterilisation can sometimes be reversed, this cannot be guaranteed and couples should be counselled in advance that the method is irreversible. There is a small but definite failure rate with sterilisation, and this should also be made clear before the operation is performed. POSTCOITAL CONTRACEPTION Also known as emergency contraception or the ‘morning after pill’, postcoital contraception can be e?ected by two di?erent hormonal methods. Levonorgesterol (a synthetic hormone similar to the natural female sex hormone PROGESTERONE) can be used alone, with one pill being taken within 72 hours of unprotected intercourse, but preferably as soon as possible, and a second one 12 hours after the ?rst. Alternatively, a combined preparation comprising ETHINYLESTRADIOL and levonorgesterol can be taken, also within 72 hours of unprotected intercourse. The single constituent pill has fewer side-effects than the combined version. Neither version should be taken by women with severe liver disease or acute PORPHYRIAS, but the ethinylestradiol/levonorgesterol combination is unsuitable for women with a history of THROMBOSIS.
In the UK the law allows women over the age of 16 to buy the morning-after pill ‘over the counter’ from a registered pharmacist.... contraception
Crohn’s disease is rare in the developing world, but in the western world the incidence is increasing and is now 6–7 per 100,000 population. Around 80,000 people in the UK have the disorder with more than 4,000 new cases occurring annually. Commonly Crohn’s disease starts in young adults, but a second incidence surge occurs in people over 70 years of age. Both genetic and environmental factors are implicated in the disease – for example, if one identical twin develops the disease, the second twin stands a high chance of being affected; and 10 per cent of sufferers have a close relative with in?ammatory bowel disease. Among environmental factors are low-residue, high-re?ned-sugar diets, and smoking.
Symptoms and signs of Crohn’s disease depend on the site affected but include abdominal pain, diarrhoea (sometimes bloody), ANOREXIA, weight loss, lethargy, malaise, ANAEMIA, and sore tongue and lips. An abdominal mass may be present. Complications can be severe, including life-threatening in?ammation of the colon (which may cause TOXAEMIA), perforation of the colon and the development of ?stulae between the bowel and other organs in the abdomen or pelvis. If Crohn’s disease persists for a decade or more there is an increased risk of the victim developing colon cancer. Extensive investigations are usually necessary to diagnose the disease; these include blood tests, bacteriological studies, ENDOSCOPY and biopsy, and barium X-ray examinations.
Treatment As with ulcerative colitis, treatment is aimed primarily at controlling symptoms. Physicians, surgeons, radiologists and dietitians usually adopt a team approach, while counsellors and patient support groups are valuable adjuncts in a disease that is typically lifelong. Drug treatment is aimed at settling the acute phase and preventing relapses. CORTICOSTEROIDS, given locally to the affected gut or orally, are used initially and the effects must be carefully monitored. If steroids do not work, the immunosuppressant agent AZATHIOPRINE should be considered. Antidiarrhoeal drugs may occasionally be helpful but should not be taken during an acute phase. The anti-in?ammatory drug SULFASALAZINE can be bene?cial in mild colitis. A new generation of genetically engineered anti-in?ammatory drugs is now available, and these selective immunosuppressants may prove of value in the treatment of Crohn’s disease.
Diet is important and professional guidance is advisable. Some patients respond to milk- or wheat-free diets, but the best course for most patients is to eat a well-balanced diet, avoiding items that the sufferer knows from experience are poorly tolerated. Of those patients with extensive disease, as many as 80 per cent may require surgery to alleviate symptoms: a section of affected gut may be removed or, as a lifesaving measure, a bowel perforation dealt with.
(See APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP – Colitis; Crohn’s disease.)... crohn’s disease
The two most common causes of death in the UK are diseases of the circulatory system (including strokes and heart disease) and cancer.
Overall annual death rates among women in the UK at the start of the 21st century were
7.98 per 1,000 population, and among men,
5.58 per 1,000. Comparable ?gures at the start of the 20th century were 16.3 for women and
18.4 for men. The death rates in 1900 among infants up to the age of four were 47.9 per 1,000 females and 57 per 1,000 males. By 2003 these numbers had fallen to 5.0 and 5.8 respectively. All these ?gures give a crude indication of how the health of Britain’s population has improved in the past century.
Death rates and ?gures on the causes of deaths are essential statistics in the study of EPIDEMIOLOGY which, along with information on the incidence of illnesses and injuries, provides a temporal and geographical map of changing health patterns in communities. Such information is valuable in planning preventive health measures (see PUBLIC HEALTH) and in identifying the natural history of diseases – knowledge that often contributes to the development of preventive measures and treatments for those diseases.... death, causes of
Treatment This involves the urgent correction of dehydration, using intravenous saline and dextrose feeds initially, with continuing replacement as required. Antibiotics are not indicated unless systemic spread of bacterial infection is likely. (See also FOOD POISONING.)... gastroenteritis
The Council is funded by doctors’ annual fees and is responsible to the Privy Council. Substantial reforms of the GMC’s structure and functions have been and are still being undertaken to ensure that it operates e?ectively in today’s rapidly evolving medical and social environment. In particular, the Council has strengthened its supervisory and disciplinary functions, and among many changes has proposed the regular revalidation of doctors’ professional abilities on a periodic basis. The Medical Register, maintained by the GMC, is intended to enable the public to identify whom it is safe to approach to obtain medical services. Entry on the Register shows that the doctor holds a recognised primary medical quali?cation and is committed to upholding the profession’s values. Under revalidation requirements being ?nalised, in addition to holding an initial quali?cation, doctors wishing to stay on the Register will have to show their continuing ?tness to practise according to the professional attributes laid down by the GMC.
Once revalidation is fully established, there will be four categories of doctor:
Those on the Register who successfully show their ?tness to practise on a regular basis.
Those whose registration is limited, suspended or removed as a result of the Council’s disciplinary procedures.
Those who do not wish to stay on the Register or retain any links with the GMC.
Those, placed on a supplementary list, who do not wish to stay on the main Register but who want to retain a formal link with the medical profession through the Council. Such doctors will not be able to practise or prescribe.... general medical council (gmc)
Staphylococcal food poisoning occurs after food such as meat products, cold meats, milk, custard and egg products becomes contaminated before or after cooking, usually through incorrect handling by humans who carry S. aureus. The bacteria produce an ENTEROTOXIN which causes the symptoms of food poisoning 1–8 hours after ingestion. The toxin can withstand heat; thus, subsequent cooking of contaminated food will not prevent illness.
Heat-resistant strains of Cl. perfringens cause food poisoning associated with meat dishes, soups or gravy when dishes cooked in bulk are left unrefrigerated for long periods before consumption. The bacteria are anaerobes (see ANAEROBE) and form spores; the anaerobic conditions in these cooked foods allow the germinated spores to multiply rapidly during cooling, resulting in heavy contamination. Once ingested the bacteria produce enterotoxin in the intestine, causing symptoms within 8–24 hours.
Many di?erent types of Salmonella (about 2,000) cause food poisoning or ENTERITIS, from eight hours to three days after ingestion of food in which they have multiplied. S. brendeny, S. enteritidis, S. heidelberg, S. newport and S. thompson are among those commonly causing enteritis. Salmonella infections are common in domesticated animals such as cows, pigs and poultry whose meat and milk may be infected, although the animals may show no symptoms. Duck eggs may harbour Salmonella (usually S. typhimurium), arising from surface contamination with the bird’s faeces, and foods containing uncooked or lightly cooked hen’s eggs, such as mayonnaise, have been associated with enteritis. The incidence of human S. enteritidis infection has been increasing, by more than 15-fold in England and Wales annually, from around 1,100 a year in the early 1980s to more than 32,000 at the end of the 1990s, but has since fallen to about 10,000. A serious source of infection seems to be poultry meat and hen’s eggs.
Although Salmonella are mostly killed by heating at 60 °C for 15 minutes, contaminated food requires considerably longer cooking and, if frozen, must be completely thawed beforehand, to allow even cooking at a su?cient temperature.
Enteritis caused by Campylobacter jejuni is usually self-limiting, lasting 1–3 days. Since reporting of the disease began in 1977, in England and Wales its incidence has increased from around 1,400 cases initially to nearly 13,000 in 1982 and to over 42,000 in 2004. Outbreaks have been associated with unpasteurised milk: the main source seems to be infected poultry.
ESCHERICHIA COLI O157 was ?rst identi?ed as a cause of food poisoning in the early 1980s, but its incidence has increased sharply since, with more than 1,000 cases annually in the United Kingdom in the late 1990s. The illness can be severe, with bloody diarrhoea and life-threatening renal complications. The reservoir for this pathogen is thought to be cattle, and transmission results from consumption of raw or undercooked meat products and raw dairy products. Cross-infection of cooked meat by raw meat is a common cause of outbreaks of Escherichia coli O157 food poisoning. Water and other foods can be contaminated by manure from cattle, and person-to-person spread can occur, especially in children.
Food poisoning associated with fried or boiled rice is caused by Bacillus cereus, whose heat-resistant spores survive cooking. An enterotoxin is responsible for the symptoms, which occur 2–8 hours after ingestion and resolve after 8–24 hours.
Viruses are emerging as an increasing cause of some outbreaks of food poisoning from shell?sh (cockles, mussels and oysters).
The incidence of food poisoning in the UK rose from under 60,000 cases in 1991 to nearly 79,000 in 2004. Public health measures to control this rise include agricultural aspects of food production, implementing standards of hygiene in abattoirs, and regulating the environment and process of industrial food production, handling, transportation and storage.... food poisoning
2. It is mostly acquired as a result of sexual activity; some cases are caused by simplex type
1. After initial infection the virus lies latent in the dorsal nerve root ganglion (of the spinal cord) which enervates the affected area of the skin. Latent virus is never cured and reactivation results in either a recurrence of symptoms or in asymptomatic shedding of the virus which then infects a sexual partner. Around 30,000 cases of genital herpes are reported annually from clinics dealing with SEXUALLY TRANSMITTED DISEASES (STDS) in England, but there are also many unrecognised (by either patient or doctor) infections. Patients may have a history of painful attacks of ulceration of the genitals for many years before seeking medical advice. All patients with a ?rst episode of the infection should be given oral antiviral treatment, and those who suffer more than six attacks a year should be considered for suppressive antiviral treatment. ACICLOVIR, valaciclovir and famciclovir are all e?ective antiviral drugs. If a woman in the ?nal three months of her pregnancy contracts herpes genitalis, this can have serious consequences for the baby as he or she will be at risk of herpes encephalitis after delivery.... herpes genitalis
About 80 per cent of patients survive an acute stroke and they are at risk of a further episode within a few weeks and months; about 10 per cent in the ?rst year and 5 per cent a year after that. HYPERTENSION, smoking, HYPERLIPIDAEMIA and raised concentration of blood sugar, along with OBESITY, are signi?cant pointers to further strokes and preventive steps to reduce these factors are worthwhile, although the reduction in risk is hard to assess. Even so, the affected person should stop smoking, greatly reduce alcohol intake, check for and have treated diabetes, reduce weight and exercise regularly. In any case, a diet rich in fresh fruit and vegetables and low in fat and salt, exercise and the avoidance of smoking may reduce the risk of having a ?rst stroke.
The evidence is inconclusive that patients with ischaemic stroke should be treated with antihypertensives. Furthermore, neither the starting blood pressure nor the best drug regimen or its starting time are generally agreed. Studies on the most e?ective methods of preventing and treating stroke are continuing; meanwhile available evidence suggests that an active approach to prevention of primary and secondary hypertension will bene?t patients and usually be cost-e?ective.... ischaemic stroke
Several diseases and conditions are treated under separate headings. (See APPENDICITIS; CHOLERA; COLITIS; CONSTIPATION; CROHN’S DISEASE; DIARRHOEA; DYSENTERY; ENTERIC FEVER; HAEMORRHOIDS; HERNIA; INFLAMMATORY BOWEL DISEASE (IBD); ILEITIS; INTUSSUSCEPTION; IRRITABLE BOWEL SYNDROME (IBS); PERITONITIS; RECTUM, DISEASES OF; ULCERATIVE COLITIS.)
In?ammation of the outer surface is called peritonitis, a serious disease. That of the inner surface is known generally as enteritis, in?ammation of special parts receiving the names of colitis, appendicitis, irritable bowel syndrome (IBS) and in?ammatory bowel disease (IBD). Enteritis may form the chief symptom of certain infective diseases: for example in typhoid fever (see ENTERIC FEVER), cholera and dysentery. It may be acute, although not connected with any de?nite organism, when, if severe, it is a very serious condition, particularly in young children. Or it may be chronic, especially as the result of dysentery, and then constitutes a less serious if very troublesome complaint.
Perforation of the bowel may take place as the result either of injury or of disease. Stabs and other wounds which penetrate the abdomen may damage the bowel, and severe blows or crushes may tear it without any external wound. Ulceration, as in typhoid fever, or, more rarely, in TUBERCULOSIS, may cause an opening in the bowel-wall also. Again, when the bowel is greatly distended above an obstruction, faecal material may accumulate and produce ulcers, which rupture with the ordinary movements of the bowels. Whatever the cause, the symptoms are much the same.
Symptoms The contents of the bowel pass out through the perforation into the peritoneal cavity, and set up a general peritonitis. In consequence, the abdomen is painful, and after a few hours becomes extremely tender to the touch. The abdomen swells, particularly in its upper part, owing to gas having passed also into the cavity. Fever and vomiting develop and the person passes into a state of circulatory collapse or SHOCK. Such a condition may be fatal if not properly treated.
Treatment All food should be withheld and the patient given intravenous ?uids to resuscitate them and then to maintain their hydration and electrolyte balance. An operation is urgently necessary, the abdomen being opened in the middle line, the perforated portion of bowel found, the perforation stitched up, and appropriate antibiotics given.
Obstruction means a stoppage to the passage down the intestine of partially digested food. Obstruction may be acute, when it comes on suddenly with intense symptoms; or it may be chronic, when the obstructing cause gradually increases and the bowel becomes slowly more narrow until it closes altogether; or subacute, when obstruction comes and goes until it ends in an acute attack. In chronic cases the symptoms are milder in degree and more prolonged.
Causes Obstruction may be due to causes outside the bowel altogether, for example, the pressure of tumours in neighbouring organs, the twisting around the bowel of bands produced by former peritonitis, or even the twisting of a coil of intestine around itself so as to cause a kink in its wall. Chronic causes of the obstruction may exist in the wall of the bowel itself: for example, a tumour, or the contracting scar of an old ulcer. The condition of INTUSSUSCEPTION, where part of the bowel passes inside of the part beneath it, in the same way as one turns the ?nger of a glove outside in, causes obstruction and other symptoms. Bowel within a hernia may become obstructed when the hernia strangulates. Finally some body, such as a concretion, or the stone of some large fruit, or even a mass of hardened faeces, may become jammed within the bowel and stop up its passage.
Symptoms There are four chief symptoms: pain, vomiting, constipation and swelling of the abdomen.
Treatment As a rule the surgeon opens the abdomen, ?nds the obstruction and relieves it or if possible removes it altogether. It may be necessary to form a COLOSTOMY or ILEOSTOMY as a temporary or permanent measure in severe cases.
Tumours are rare in the small intestine and usually benign. They are relatively common in the large intestine and are usually cancerous. The most common site is the rectum. Cancer of the intestine is a disease of older people; it is the second most common cancer (after breast cancer) in women in the United Kingdom, and the third most common (after lung and prostate) in men. Around 25,000 cases of cancer of the large intestine occur in the UK annually, about 65 per cent of which are in the colon. A history of altered bowel habit, in the form of increasing constipation or diarrhoea, or an alternation of these, or of bleeding from the anus, in a middle-aged person is an indication for taking medical advice. If the condition is cancer, then the sooner it is investigated and treated, the better the result.... intestine, diseases of
In the United Kingdom, the 1993 Education Act refers to ‘learning diffculties’: generalised (severe or moderate), or speci?c (e.g. DYSLEXIA, dyspraxia [or APRAXIA], language disorder). The 1991 Social Security (Disability Living Allowance) Regulations use the term ‘severely mentally impaired’ if a person suffers from a state of arrested development or incomplete physical development of the brain which results in severe impairment of intelligence and social functioning. This is distinct from the consequences of DEMENTIA. Though ‘mental handicap’ is widely used, ‘learning disability’ is preferred by the Department of Health.
There is a distinction between impairment (a biological de?cit), disability (the functional consequence) and handicap (the social consequence).
People with profound learning disability are usually unable to communicate adequately and may be seriously movement-impaired. They are totally dependent on others for care and mobility. Those with moderate disability may achieve basic functional literacy (recognition of name, common signs) and numeracy (some understanding of money) but most have a life-long dependency for aspects of self-care (some fastenings for clothes, preparation of meals, menstrual hygiene, shaving) and need supervision for outdoor mobility.
Children with moderate learning disability develop at between half and three-quarters of the normal rate, and reach the standard of an average child of 8–11 years. They become independent for self-care and public transport unless they have associated disabilities. Most are capable of supervised or sheltered employment. Living independently and raising a family may be possible.
Occurrence Profound learning disability affects about 1 in 1,000; severe learning disability 3 in 1,000; and moderate learning disability requiring special service, 1 per cent. With improved health care, survival of people with profound or severe learning disability is increasing.
Causation Many children with profound or severe learning disability have a diagnosable biological brain disorder. Forty per cent have a chromosome disorder – see CHROMOSOMES (three quarters of whom have DOWN’S (DOWN) SYNDROME); a further 15 per cent have other genetic causes, brain malformations or recognisable syndromes. About 10 per cent suffered brain damage during pregnancy (e.g. from CYTOMEGALOVIRUS (CMV) infection) or from lack of oxygen during labour or delivery. A similar proportion suffer postnatal brain damage from head injury – accidental or otherwise – near-miss cot death or drowning, cardiac arrest, brain infection (ENCEPHALITIS or MENINGITIS), or in association with severe seizure disorders.
Explanations for moderate learning disability include Fragile X or other chromosome abnormalities in a tenth, neuro?bromatosis (see VON RECKLINGHAUSEN’S DISEASE), fetal alcohol syndrome and other causes of intra-uterine growth retardation. Genetic counselling should be considered for children with learning disability. Prenatal diagnosis is sometimes possible. In many children, especially those with mild or moderate disability, no known cause may be found.
Medical complications EPILEPSY affects 1 in 20 with moderate, 1 in 3 with severe and 2 in 3 with profound learning disability, although only 1 in 50 with Down’s syndrome is affected. One in 5 with severe or profound learning disability has CEREBRAL PALSY.
Psychological and psychiatric needs Over half of those with profound or severe – and many with moderate – learning disability show psychiatric or behavioural problems, especially in early years or adolescence. Symptoms may be atypical and hard to assess. Psychiatric disorders include autistic behaviour (see AUTISM) and SCHIZOPHRENIA. Emotional problems include anxiety, dependence and depression. Behavioural problems include tantrums, hyperactivity, self-injury, passivity, masturbation in public, and resistance to being shaved or helped with menstrual hygiene. There is greater vulnerability to abuse with its behavioural consequences.
Respite and care needs Respite care is arranged with link families for children or sta?ed family homes for adults where possible. Responsibility for care lies with social services departments which can advise also about bene?ts.
Education Special educational needs should be met in the least restrictive environment available to allow access to the national curriculum with appropriate modi?cation and support. For older children with learning disability, and for young children with severe or profound learning disability, this may be in a special day or boarding school. Other children can be provided for in mainstream schools with extra classroom support. The 1993 Education Act lays down stages of assessment and support up to a written statement of special educational needs with annual reviews.
Pupils with learning disability are entitled to remain at school until the age of 19, and most with severe or profound learning disability do so. Usually those with moderate learning disability move to further education after the age of 16.
Advice is available from the Mental Health Foundation, the British Institute of Learning Disabilities, MENCAP (Royal Society for Mentally Handicapped Children and Adults), and ENABLE (Scottish Society for the Mentally Handicapped).... learning disability
According to the type of cells that predominate, leukaemia may be classi?ed as acute or chronic lymphoblastic leukaemia or myeloid leukaemia. Acute lymphoblastic leukaemia (ALL) is mostly a disease of childhood and is rare after the age of 25. Acute myeloid leukaemia is most common in children and young adults, but may occur at any age. Chronic lymphatic leukaemia occurs at any age between 35 and 80, most commonly in the 60s, and is twice as common in men as in women. Chronic myeloid leukaemia is rare before the age of 25, and most common between the ages of 30 and 65; men and women are equally affected. Around 2,500 patients with acute leukaemia are diagnosed in the United Kingdom, with a similar number annually diagnosed with chronic leukaemia.
Cause Both types of acute leukaemia seem to arise from a MUTATION in a single white cell. The genetically changed cell then goes through an uncontrolled succession of divisions resulting in many millions of abnormal white cells in the blood, bone marrow and other tissues. Possible causes are virus infection, chemical exposure, radiation and genetic background. The cause of chronic lymphocytic leukaemia is not known; the chronic myeloid version may have a genetic background.
Symptoms In acute cases the patient is pale due to anaemia, may have a purpuric rash due to lack of platelets, and may have enlarged lymphatic glands and spleen. The temperature is raised, and the condition may be mistaken for an acute infection (or may ?rst become apparent because the patient develops a severe infection due to a lack of normal white blood cells).
In the chronic type of the disease the onset is gradual, and the ?rst symptoms which occasion discomfort are either swelling of the abdomen and shortness of breath, due to painless enlargement of the spleen; or the enlargement of glands in the neck, armpits and elsewhere; or the pallor, palpitation, and other symptoms of anaemia which often accompany leukaemia. Occasional bleeding from the nose, stomach, gums or bowels may occur, and may be severe. Generally, there is a slight fever.
When the blood is examined microscopically, not only is there an enormous increase in the number of white cells, which may be multiplied 30- or 60-fold, but various immature forms are also found. In the lymphatic form of the disease, most white cells resemble lymphocytes, which, in healthy blood, are present only in small numbers. In the myeloid form, myelocytes, or large immature cells from the bone marrow, which are never present in healthy blood, appear in large numbers, and there may also be large numbers of immature, nucleated erythrocytes.
Treatment This varies according to the type of leukaemia and to the particular condition of the patient. Excellent results are being obtained in the control of ALL using blood transfusions, CHEMOTHERAPY, RADIOTHERAPY and bone-marrow TRANSPLANTATION. In the case of acute leukaemia, the drugs now being used include MERCAPTOPURINE, METHOTREXATE and CYCLOPHOSPHAMIDE. Blood transfusion and CORTICOSTEROIDS play an important part in controlling the condition during the period before a response to chemotherapy can be expected. Chemotherapy has almost completely replaced radiotherapy in the treatment of chronic leukaemia. For the myeloid form, BUSULFAN is the most widely used drug, replaced by hydroxyurea, mercaptopurine, or one of the nitrogen mustard (see NITROGEN MUSTARDS) derivatives in the later stages of the disease. For the lymphatic form, the drugs used are CHLORAMBUCIL, CYCLOPHOSPHAMIDE, and the nitrogen mustard derivatives.
Prognosis Although there is still no guaranteed cure, the outlook in both acute and chronic leukaemia has greatly improved – particularly for the acute form of the disease. Between 70 and 80 per cent of children with acute lymphoblastic leukaemia may be cured; between 20 and 50 per cent of those with acute myeloid leukaemia now have much-improved survival rates. Prognosis of patients with chronic lymphocytic leukaemia is often good, depending on early diagnosis.... leukaemia
In?ammation of the lungs is generally known as PNEUMONIA, when it is due to infection; as ALVEOLITIS when the in?ammation is immunological; and as PNEUMONITIS when it is due to physical or chemical agents.
Abscess of the lung consists of a collection of PUS within the lung tissue. Causes include inadequate treatment of pneumonia, inhalation of vomit, obstruction of the bronchial tubes by tumours and foreign bodies, pulmonary emboli (see EMBOLISM) and septic emboli. The patient becomes generally unwell with cough and fever. BRONCHOSCOPY is frequently performed to detect any obstruction to the bronchi. Treatment is with a prolonged course of antibiotics. Rarely, surgery is necessary.
Pulmonary oedema is the accumulation of ?uid in the pulmonary tissues and air spaces. This may be caused by cardiac disease (heart failure or disease of heart valves – see below, and HEART, DISEASES OF) or by an increase in the permeability of the pulmonary capillaries allowing leakage of ?uid into the lung tissue (see ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)).
Heart failure (left ventricular failure) can be caused by a weakness in the pumping action of the HEART leading to an increase in back pressure which forces ?uid out of the blood vessels into the lung tissue. Causes include heart attacks and HYPERTENSION (high blood pressure). Narrowed or leaking heart valves hinder the ?ow of blood through the heart; again, this produces an increase in back pressure which raises the capillary pressure in the pulmonary vessels and causes ?ooding of ?uid into the interstitial spaces and alveoli. Accumulation of ?uid in lung tissue produces breathlessness. Treatments include DIURETICS and other drugs to aid the pumping action of the heart. Surgical valve replacement may help when heart failure is due to valvular heart disease.
Acute respiratory distress syndrome Formerly known as adult respiratory distress syndrome (ARDS), this produces pulmonary congestion because of leakage of ?uid through pulmonary capillaries. It complicates a variety of illnesses such as sepsis, trauma, aspiration of gastric contents and di?use pneumonia. Treatment involves treating the cause and supporting the patient by providing oxygen.
Collapse of the lung may occur due to blockage of a bronchial tube by tumour, foreign body or a plug of mucus which may occur in bronchitis or pneumonia. Air beyond the blockage is absorbed into the circulation, causing the affected area of lung to collapse. Collapse may also occur when air is allowed into the pleural space – the space between the lining of the lung and the lining of the inside of the chest wall. This is called a pneumothorax and may occur following trauma, or spontaneously
– for example, when there is a rupture of a subpleural air pocket (such as a cyst) allowing a communication between the airways and the pleural space. Lung collapse by compression may occur when ?uid collects in the pleural space (pleural e?usion): when this ?uid is blood, it is known as a haemothorax; if it is due to pus it is known as an empyema. Collections of air, blood, pus or other ?uid can be removed from the pleural space by insertion of a chest drain, thus allowing the lung to re-expand.
Tumours of the lung are the most common cause of cancer in men and, along with breast cancer, are a major cause of cancer in women. Several types of lung cancer occur, the most common being squamous cell carcinoma, small- (or oat-) cell carcinoma, adenocarcinoma, and large-cell carcinoma. All but the adenocarcinoma have a strong link with smoking. Each type has a di?erent pattern of growth and responds di?erently to treatment. More than 30,000 men and women die of cancer of the trachea, bronchus and lung annually in England and Wales.
The most common presenting symptom is cough; others include haemoptisis (coughing up blood), breathlessness, chest pain, wheezing and weight loss. As well as spreading locally in the lung – the rate of spread varies – lung cancer commonly spawns secondary growths in the liver, bones or brain. Diagnosis is con?rmed by X-rays and bronchoscopy with biopsy.
Treatment Treatment for the two main categories of lung cancer – small-cell and nonsmall-cell cancer – is di?erent. Surgery is the only curative treatment for the latter and should be considered in all cases, even though fewer than half undergoing surgery will survive ?ve years. In those patients unsuitable for surgery, radical RADIOTHERAPY should be considered. For other patients the aim should be the control of symptoms and the maintenance of quality of life, with palliative radiotherapy one of the options.
Small-cell lung cancer progresses rapidly, and untreated patients survive for only a few months. Because the disease is often widespread by the time of diagnosis, surgery is rarely an option. All patients should be considered for CHEMOTHERAPY which improves symptoms and prolongs survival.
Wounds of the lung may cause damage to the lung and, by admitting air into the pleural cavity, cause the lung to collapse with air in the pleural space (pneumothorax). This may require the insertion of a chest drain to remove the air from the pleural space and allow the lung to re-expand. The lung may be wounded by the end of a fractured rib or by some sharp object such as a knife pushed between the ribs.... lungs, diseases of
Hodgkin’s disease The incidence is around four new cases per 100,000 population annually, with slightly more men than women contracting it. The ?rst incidence peak is in age group 20–35 and the second in age group 50–
70. The cause of Hodgkin’s is not known, although it is more common in patients from small families and well-educated backgrounds. The disease is three times more likely to occur in people who have had glandular fever (see MONONUCLEOSIS) but no link with the EPSTEIN BARR VIRUS has been established (see Burkitt’s lymphoma, below)
The disease is characterised histologically by the presence of large malignant lymphoid cells (Reed-Sternberg cells) in the lymph glands.
Clinically the lymph glands are enlarged, rubbery but painless; usually those in the neck or just above the CLAVICLE are affected. Spread is to adjacent lymph glands and in young people a mass of enlarged glands may develop in the MEDIASTINUM. The SPLEEN is affected in about one-third of patients with the disorder. Treatment is either with RADIOTHERAPY, CHEMOTHERAPY or both, depending on when the disease is diagnosed and the nature of the abnormal lymph cells. Cure rates are good, especially if the lymphoma is diagnosed early.
Non-Hodgkin’s lymphoma (NHL) This varies in its malignancy depending on the nature and activity of the abnormal lymph cells. The disease is hard to classify histologically, so various classi?cation systems have been evolved. High- and low-grade categories are recognised according to the rate of proliferation of abnormal lymph cells. No single causative factor has been identi?ed, although viral and bacterial infections have been linked to NHL, and genetic and immunological factors may be implicated. The incidence is higher than that of Hodgkin’s disease, at 12 new cases per 100,000 population a year, and the median age of diagnosis is 65–70 years. Suppression of the immune system that ocurs in people with HIV infection has been linked with a marked rise in the incidence of non-Hodgkin’s lymphoma and Hodgkin’s disease.
Most patients have painless swelling of one or more groups of lymph nodes in the neck or groin, and the liver and spleen may enlarge. As other organs can also be affected, patients may present with a wide range of symptoms, including fever, itching and weight loss. If NHL occurs in a single group of lymph nodes, radiotherapy is the treatment of choice; more extensive in?ltration of glands will require chemotherapy – and sometimes both types of treatment will be necessary. If these treatments fail, BONE MARROW TRANSPLANT may be carried out. Prognosis is good for low-grade NHL (75 per cent of patients survive ?ve years or more); in more severe types the survival rate is 40–50 per cent for two years.
Another variety of lymphoma is found in children in Africa, sometimes called after Burkitt, the Irish surgeon who ?rst identi?ed it. Burkitt’s lymphoma is a rapidly growing malignant tumour occurring in varying sites, and the Epstein Barr virus has a role in its origin and growth. A non-African variety of Burkitt’s lymphoma is now also recognised. CYTOTOXIC drug therapy is e?ective.... lymphoma
Epidemiology There has been a dramatic fall in the number of sufferers from 1986, when more than 80,000 cases were reported. This is due to the introduction in 1988 of the measles, mumps and rubella vaccine (MMR VACCINE – see also IMMUNISATION); 1990, when the proportion of children immunised reached 90 per cent, was the ?rst year in which no deaths from measles were reported. Even so, fears of side-effects of the vaccine against measles – including scienti?cally unproven and discredited claims of a link with AUTISM – mean that some children in the UK are not being immunised, and since 2002 local outbreaks of measles have been reported in a few areas of the UK. Side-effects are, however, rare and the government is campaigning to raise the rate of immunisation, with GPs being set targets for their practices.
There are few diseases as infectious as measles, and its rapid spread in epidemics is no doubt due to the fact that this viral infection is most potent in the earlier stages. Hence the dif?culty of timely isolation, and the readiness with which the disease is spread, which is mostly by infected droplets. In developing countries measles results in the death of more than a million children annually.
Symptoms The incubation period, during which the child is well, lasts 7–21 days. Initial symptoms are CATARRH, conjunctivitis (see EYE, DISORDERS OF), fever and a feeling of wretchedness. Then Koplik spots – a classic sign of measles – appear on the roof of the mouth and lining of the cheeks. The macular body rash, typical of measles, appears 3–5 days later. Common complications include otitis media (see under EAR, DISEASES OF) and PNEUMONIA. Measles ENCEPHALITIS can cause permanent brain damage. A rare event is a gradual dementing disease (see DEMENTIA) called subacute sclerosing panenecephalitis (SSPE).
Treatment Isolation of the patient and treatment of any secondary bacterial infection, such as pneumonia or otitis, with antibiotics. Children usually run a high temperature which can be relieved with cool sponging and antipyretic drugs. Calamine lotion may alleviate any itching.... measles
A range of research investigations has developed within medical education. These apply to course monitoring, audit, development and validation, assessment methodologies and the application of educationally appropriate principles at undergraduate and postgraduate levels. Research is undertaken by medical educationalists whose backgrounds include teaching, social sciences and medicine and related health-care specialties, and who will hold a medical or general educational diploma, degree or other appropriate postgraduate quali?cation.
Development and validation for all courses are an important part of continuing accreditation processes. The relatively conservative courses at both undergraduate and postgraduate levels, including diplomas and postgraduate quali?cations awarded by the specialist medical royal colleges (responsible for standards of specialist education) and universities, have undergone a range of reassessment and rede?nition driven by the changing needs of the individual practitioner in the last decade. The stimuli to change aspects of medical training have come from the government through the former Chief Medical O?cer, Sir Kenneth Calman, and the introduction of new approaches to specialist training (the Calman programme), from the GENERAL MEDICAL COUNCIL (GMC) and its document Tomorrow’s Doctors, as well as from the profession itself through the activities of the British Medical Association and the medical royal colleges. The evolving expectations of the public in their perception of the requirements of a doctor, and changes in education of other groups of health professionals, have also led to pressures for changes.
Consequently, many new departments and units devoted to medical education within university medical schools, royal colleges and elsewhere within higher education have been established. These developments have built upon practice developed elsewhere in the world, particularly in North America, Australia and some European countries. Undergraduate education has seen application of new educational methods, including Problem-Based Learning (PBL) in Liverpool, Glasgow and Manchester; clinical and communications skills teaching; early patient contact; and the extensive adoption of Internet (World Wide Web) support and Computer-Aided Learning (CAL). In postgraduate education – driven by European directives and practices, changes in specialist training and the needs of community medicine – new courses have developed around the membership and fellowship examinations for the royal colleges. Examples of these changes driven by medical education expertise include the STEP course for the Royal College of Surgeons of England, and distance-learning courses for diplomas in primary care and rheumatology, as well as examples of good practice as adopted by the Royal College of General Practitioners.
Continuing Professional Development (CPD) and Continuing Medical Education (CME) are also important aspects of medical education now being developed in the United Kingdom, and are evolving to meet the needs of individuals at all stages of their careers.
Bodies closely involved in medical educational developments and their review include the General Medical Council, SCOPME (the Standing Committee on Postgraduate Medical Education), all the medical royal colleges and medical schools, and the British Medical Association through its Board of Medical Education. The National Health Service (NHS) is also involved in education and is a key to facilitation of CPD/CME as the major employer of doctors within the United Kingdom.
Several learned societies embrace medical education at all levels. These include ASME (the Association for the Study of Medical Education), MADEN (the Medical and Dental Education Network) and AMEE (the Association for Medical Education in Europe). Specialist journals are devoted to research reports relating to medical educational developments
(e.g. Academic Medicine, Health Care Education, Medical Education). The more general medical journals (e.g. British Medical Journal, New England Journal of Medicine, The Lancet, Annals of the Royal College of Surgeons) also carry articles on educational matters. Finally, the World Wide Web (WWW) is a valuable source of information relating to courses and course development and other aspects of modern medical education.
The UK government, which controls the number of students entering medical training, has recently increased the quota to take account of increasing demands for trained sta? from the NHS. More than 5,700 students – 3,300 women and 2,400 men – are now entering UK medical schools annually with nearly 28,600 at medical school in any one year, and an attrition rate of about 8–10 per cent. This loss may in part be due to the changes in university-funding arrangements. Students now pay all or part of their tuition fees, and this can result in medical graduates owing several thousand pounds when they qualify at the end of their ?ve-year basic quali?cation course. Doctors wishing to specialise need to do up to ?ve years (sometimes more) of salaried ‘hands-on’ training in house or registrar (intern) posts.
Though it may be a commonly held belief that most students enter medicine for humanitarian reasons rather than for the ?nancial rewards of a successful medical career, in developed nations the prospect of status and rewards is probably one incentive. However, the cost to students of medical education along with the widespread publicity in Britain about an under-resourced, seriously overstretched health service, with sta? working long hours and dealing with a rising number of disgruntled patients, may be affecting recruitment, since the number of applicants for medical school has dropped in the past year or so. Although there is still competition for places, planners need to bear this falling trend in mind.
Another factor to be considered for the future is the nature of the medical curriculum. In Britain and western Europe, the age structure of a probably declining population will become top-heavy with senior citizens. In the ?nancial interests of the countries affected, and in the personal interests of an ageing population, it would seem sensible to raise the pro?le of preventive medicine – traditionally rather a Cinderella subject – in medical education, thus enabling people to live healthier as well as longer lives. While learning about treatments is essential, the increasing specialisation and subspecialisation of medicine in order to provide expensive, high-technology care to a population, many of whom are suffering from preventable illnesses originating in part from self-indulgent lifestyles, seems insupportable economically, unsatisfactory for patients awaiting treatment, and not necessarily professionally ful?lling for health-care sta?. To change the mix of medical education would be a di?cult long-term task but should be worthwhile for providers and recipients of medical care.... medical education
Habitat: Native to Eurasia; found as winter weed and cultivated for fodder in parts of Punjab, Haryana and Uttar Pradesh.
English: Sweet Clover, Annual Yellow Sweet Clover, Small-flowered Melilot.Ayurvedic: Vana-methikaa.Unani: Ilkil-ul-Malik (yellow- flowered var.).Folk: Ban-Methi, Senji.Action: Plant—astringent, dis- cutient, emollient. Used as poultice or plaster for swellings. The plant gave coumarins—fraxidin, herniarin, umbelliferone and scopoletin.
When fed alone as a green fodder, it exhibits narcotic properties; causes lethargy, tympanitis and is reported to taint the milk of dairy cattle. It may cause even paralysis. The plant contains 3-methoxyflavone, meliter- natin which experimentally inhibited cell growth, induced granularity, retraction and then lysis of cells.... melilotus indicaThrush is characterised by the presence of white patches on the mucous membrane which bleeds if the patch is gently removed. It is caused by the growth of a parasitic mould known as Candida albicans. Antifungal agents usually suppress the growth of candida. Candidal in?ltration of the mucosa is often found in cancerous lesions.
Leukoplakia literally means a white patch. In the mouth it is often due to an area of thickened cells from the horny layer of the epithelium. It appears as a white patch of varying density and is often grooved by dense ?ssures. There are many causes, most of them of minor importance. It may be associated with smoking, SYPHILIS, chronic SEPSIS or trauma from a sharp tooth. Cancer must be excluded.
Stomatitis (in?ammation of the mouth) arises from the same causes as in?ammation elsewhere, but among the main causes are the cutting of teeth in children, sharp or broken teeth, excess alcohol, tobacco smoking and general ill-health. The mucous membrane becomes red, swollen and tender and ulcers may appear. Treatment consists mainly of preventing secondary infection supervening before the stomatitis has resolved. Antiseptic mouthwashes are usually su?cient.
Gingivitis (see TEETH, DISEASES OF) is in?ammation of the gum where it touches the tooth. It is caused by poor oral hygiene and is often associated with the production of calculus or tartar on the teeth. If it is neglected it will proceed to periodontal disease.
Ulcers of the mouth These are usually small and arise from a variety of causes. Aphthous ulcers are the most common; they last about ten days and usually heal without scarring. They may be associated with STRESS or DYSPEPSIA. There is no ideal treatment.
Herpetic ulcers (see HERPES SIMPLEX) are similar but usually there are many ulcers and the patient appears feverish and unwell. This condition is more common in children.
Calculus (a) Salivary: a calculus (stone) may develop in one of the major salivary-gland ducts. This may result in a blockage which will cause the gland to swell and be painful. It usually swells before a meal and then slowly subsides. The stone may be passed but often has to be removed in a minor operation. If the gland behind the calculus becomes infected, then an ABSCESS forms and, if this persists, the removal of the gland may be indicated. (b) Dental, also called TARTAR: this is a calci?ed material which adheres to the teeth; it often starts as the soft debris found on teeth which have not been well cleaned and is called plaque. If not removed, it will gradually destroy the periodontal membrane and result in the loss of the tooth. (See TEETH, DISORDERS OF.)
Ranula This is a cyst-like swelling found in the ?oor of the mouth. It is often caused by mild trauma to the salivary glands with the result that saliva collects in the cyst instead of discharging into the mouth. Surgery may be required.
Mumps is an acute infective disorder of the major salivary glands. It causes painful enlargement of the glands which lasts for about two weeks. (See also main entry for MUMPS.)
Tumours may occur in all parts of the mouth, and may be BENIGN or MALIGNANT. Benign tumours are common and may follow mild trauma or be an exaggerated response to irritation. Polyps are found in the cheeks and on the tongue and become a nuisance as they may be bitten frequently. They are easily excised.
A MUCOCOELE is found mainly in the lower lip.
An exostosis or bone outgrowth is often found in the mid line of the palate and on the inside of the mandible (bone of the lower jaw). This only requires removal if it becomes unduly large or pointed and easily ulcerated.
Malignant tumours within the mouth are often large before they are noticed, whereas those on the lips are usually seen early and are more easily treated. The cancer may arise from any of the tissues found in the mouth including epithelium, bone, salivary tissue and tooth-forming tissue remnants. Oral cancers represent about 5 per cent of all reported malignancies, and in England and Wales around 3,300 people are diagnosed annually as having cancer of the mouth and PHARYNX.
Cancer of the mouth is less common below the age of 40 years and is more common in men. It is often associated with chronic irritation from a broken tooth or ill-?tting denture. It is also more common in those who smoke and those who chew betel leaves. Leukoplakia (see above) may be a precursor of cancer. Spread of the cancer is by way of the lymph nodes in the neck. Early treatment by surgery, radiotherapy or chemotherapy will often be e?ective, except for the posterior of the tongue where the prognosis is very poor. Although surgery may be extensive and potentially mutilating, recent advances in repairing defects and grafting tissues from elsewhere have made treatment more acceptable to the patient.... mouth, diseases of
Nursing is changing rapidly, and today’s nurses are expected to take on an extended role – often performing tasks which were once the sole preserve of doctors, such as diagnosing, prescribing drugs and admitting and discharging patients.
There are four main branches of nursing: adult, child, mental health and learning disability. Student nurses qualify in one of these areas and then apply to go on the nursing register. This is held by nursing’s regulatory body, the Council for Nursing and Midwifery. Nurses are expected to abide by the Council’s Code of Professional Conduct. The organisation’s main role is protecting the public and it is responsible for monitoring standards and dealing with allegations of misconduct. There are more than 637,000 quali?ed nurses on the Council’s register, and this is the main pool from which the NHS and other employers recruit.
The criticisms about nurses’ education being too academic, and persisting problems of recruitment of nurses into the NHS, were among factors prompting a strategic government review of the status, training, pay and career opportunities for nurses and other health professionals. The new model emphasises the practical aspects of the education programme with a better response to the needs of patients and the NHS. It also o?ers nurses a more ?exible career path and education linked more closely with practice development and research, so as to provide greater scope for continuing professional education and development.
About 60 per cent of RNs work in NHS hospitals and community trusts. But an increasing number are choosing to work elsewhere, either in the private sector or in jobs such as school nursing, occupational health or for NHS Direct, the nurse-led telephone helpline. Others have dropped out of nursing altogether. The health service is facing a shortage of quali?ed nurses and many trust employers have resorted to overseas recruitment drives. The government has launched a major nurse recruitment and retention campaign and is promoting family-friendly employment practices to lure those with a nursing quali?cation currently working outside the NHS back into the workforce. Nursing is a mainly female profession and a third of nurses work part-time.
Nurses’ pay has for long compared unfavourably with other professional employment opportunities, despite being determined by an independent Pay Review Body. With the recruitment of nurses a perennial problem, the government’s strategy, Making a Di?erence, is to set up a new pay system o?ering greater ?exibility and opportunities for nurses and other health-service sta?. In 2005, a newly quali?ed sta? nurse earned around £16,000 a year, while one of the new grade of consultant nurses could command an annual salary of between £27,000 and £42,000. Nurse consultants were introduced in spring 2000 as a means of allowing nurses to progress up the career ladder while maintaining a clinical role.
The nurse of today is increasingly likely to be part of a multidisciplinary team, working alongside a range of other professionals from doctors and physiotherapists to social workers and teachers. A further sign of the times is that many registered nurses are being asked to act in a supervisory role, delegating tasks to nonregistered nurses working as health-care assistants and auxiliaries. In recognition of the latter’s increasing role, the Royal College of Nursing, the main professional association and trade union for nurses, has now agreed to extend membership to health-care assistants with a Scottish/National Vocational Quali?cation at level three.
Midwifery Midwives (see MIDWIFE) are practitioners who o?er advice and support to women before, during and after pregnancy. They are regulated by the Council for Nursing and Midwifery (formerly the UK Central Council for Nursing, Midwifery and Health Visiting). Registered nurses can take an 18month course to become a midwife, and there is also a three-year programme for those who wish to enter the profession directly. Midwifery courses lead to a diploma or degree-level quali?cation. Most midwives work for the NHS and, as with nursing, there are problems recruiting and retaining sta?.
Health visiting Health visitors are registered nurses who work in the community with a range of groups including families, the homeless and older people. They focus on preventing ill-health and o?er advice on a range of topics from diet to child behavioural problems. They are employed by health trusts, primary-care groups and primary-care trusts.... nursing
Pancreatic cancer The incidence of pancreatic cancer is rising: around 7,000 cases are now diagnosed annually in the UK, accounting for 1–2 per cent of all malignancies. There is an established association with heavy cigarette-smoking, and the cancer is twice as common in patients with diabetes mellitus as compared with the general population. Cancer of the pancreas is hard to diagnose; by the time symptoms occur the tumour may be di?cult to treat surgically – with PALLIATIVE bypass surgery the only procedure.
Chronic pancreatitis may be painless; it leads to pancreatic failure causing MALABSORPTION SYNDROME and diabetes mellitus, and the pancreas becomes calci?ed with shadowing on X-RAYS. The malabsorption is treated by a low-fat diet with pancreatic enzyme supplements; the diabetes with insulin; and pain is treated appropriately. Surgery may be required.
Acute pancreatitis An uncommon disease of the pancreas which may start gradually or suddenly, usually accompanied by severe abdominal pain which often radiates through to the back. Biliary tract disease and alcohol account for 80 per cent of patients admitted with acute pancreatitis, while other causes include drugs (see AZATHIOPRINE and DIURETICS) and infections such as MUMPS. Patients are acutely ill with TACHYCARDIA, fever and low blood pressure; many go into SHOCK. The condition may be mistaken for a perforated PEPTIC ULCER, except that in acute pancreatitis the blood concentration of AMYLASE is raised. The main complication is the formation of a PSEUDOCYST. Treatment includes intravenous feeding, ANTICHOLINERGIC drugs and ANALGESICS. Regular measurements of blood GLUCOSE, CALCIUM, amylase and blood gases are required. Abdominal ULTRASOUND may identify gall-stones (see under GALL-BLADDER, DISEASES OF). If the patient deteriorates, he or she should be admitted for intensive care as haemorrhagic pancreatic necrosis may be developing. LAPAROTOMY and DEBRIDEMENT may be called for. Mortality is 5–10%.... pancreas, disorders of
Prostatitis This can be either acute or chronic. Acute prostatitis is caused by a bacterial infection, while chronic prostatitis may follow on from an acute attack, arise insidiously, or be non-bacterial in origin.
Symptoms Typically the patient has pain in the PERINEUM, groins, or supra pubic region, and pain on EJACULATION. He may also have urinary frequency, and urgency.
Treatment Acute and chronic prostatitis are treated with a prolonged course of antibiotics. Patients with chronic prostatitis may also require anti-in?ammatory drugs, and antidepressants.
Prostatic enlargement This is the result of benign prostatic hyperplasia (BPH), causing enlargement of the prostate. The exact cause of this enlargement is unknown, but it affects 50 per cent of men between 40 and 59 years and 95 per cent of men over 70 years.
Symptoms These are urinary hesitancy, poor urinary stream, terminal dribbling, frequency and urgency of urination and the need to pass urine at night (nocturia). The diagnosis is made from the patient’s history; a digital examination of the prostate gland via the rectum to assess enlargement; and analysis of the urinary ?ow rate.
Treatment This can be with tablets, which either shrink the prostate – an anti-androgen drug such as ?nasteride – or relax the urinary sphincter muscle during urination. For more severe symptoms the prostate can be removed surgically, by transurethral resection of prostate (TURP), using either electrocautery or laser energy. A new treatment is the use of microwaves to heat up and shrink the enlarged gland.
Cancer Cancer of the prostate is the fourth most common cause of death from cancer in northern European males: more than 10,000 cases are diagnosed every year in the UK and the incidence is rising by 3 per cent annually.
Little is known about the cause, but the majority of prostate cancers require the male hormones, androgens, to grow.
Symptoms These are similar to those resulting from benign prostatic hypertrophy (see above). Spread of the cancer to bones can cause pain. The use of a blood test measuring the amount of an ANTIGEN, PROSTATE SPECIFIC ANTIGEN (PSA), can be helpful in making the diagnosis – as can an ULTRASOUND scan of the prostate.
Treatment This could be surgical, with removal of the prostate (either via an abdominal incision, total prostatectomy, or transurethrally), or could be by radiotherapy. In more advanced cancers, treatment with anti-androgen drugs, such as cyprotexone acetate or certain oestrogens, is used to inhibit the growth of the cancer.... prostate gland, diseases of
The concept of the dose-response is important for understanding the risk of exposure to a particular substance. This is embodied in a statement by Paracelsus (c.1493–1541): ‘All substances are poisons; there is none which is not a poison. The right dose di?erentiates a poison and a remedy.’
Poisoning may occur in a variety of ways: deliberate – SUICIDE, substance abuse or murder; accidental – including accidental overdose of medicines; occupational; and environmental
– including exposure during ?re.
Ingestion is the most common route of exposure, but poisoning may also occur through inhalation, absorption through the skin, by injection and through bites and stings of venomous animals. Poisoning may be described as acute, where a single exposure produces clinical effects with a relatively rapid onset; or chronic, where prolonged or repeated exposures may produce clinical effects which may be insidious in onset, cumulative and in some cases permanent.
Diagnosis of poisoning is usually by circumstantial evidence or elimination of other causes of the clinical condition of the patient. Some substances (e.g. opioids) produce a characteristic clinical picture in overdose that can help with diagnosis. In some patients laboratory analysis of body ?uids or the substance taken may be useful to determine or con?rm the o?ending agent. Routine assays are not necessary. For a very small number of poisons, such as paracetamol, aspirin, iron and lead, the management of the patient may depend on measuring the amount of poison in the bloodstream.
Accurate statistics on the incidence of poisoning in the UK are lacking. Mortality ?gures are more reliable than morbidity statistics; annually, well over 100,000 cases of poisoning are admitted to hospital. The annual number of deaths from poisoning is relatively small – about 300 – and in most cases patients die before reaching hospital. Currently, CARBON MONOXIDE (CO) is by far the most common cause of death due to poisoning. The most common agents involved in intentional or accidental poisoning are drugs, particularly ANALGESICS, ANTIDEPRESSANT DRUGS and SEDATIVES. Alcohol is also commonly taken by adults, usually in combination with drugs. Children frequently swallow household cleaners, white spirit, plant material – such as belladonna (deadly nightshade) and certain mushrooms; for example, death cap and ?y agaric – aftershave and perfume as well as drugs. If possible, the suspect container, drug or plant should be taken with the victim to the hospital or doctor. The use of child-resistant containers has reduced the number of admissions of children to hospital for treatment. Bixtrex® is an intensely bitter-tasting agent which is often added to products to discourage ingestion; however, not everybody is able to taste it, nor has any bene?cial e?ect been proven.
Treatment of poisoning usually begins with decontamination procedures. For ingested substances this may involve making the patient sick or washing the stomach out (GASTRIC LAVAGE): this is usually only worthwhile if performed soon after ingestion. It should be emphasised that salt (sodium chloride) water must never be given to induce vomiting, since this procedure is dangerous and has caused death. For substances spilt on the skin, the affected area should immediately be thoroughly washed and all contaminated clothing removed. Following eye exposure, the affected eye/s should be thoroughly irrigated with saline or water.
Treatment thereafter is generally symptomatic and supportive, with maintenance of the victim’s respiratory, neurological and cardiovascular systems and, where appropriate, monitoring of their ?uid and electrolyte balance and hepatic and renal function. There are speci?c antidotes for a few substances: the most important of these are PARACETAMOL, iron, cyanide (see CYANIDE POISONING), opioids (see OPIOID), DIGOXIN, insecticides and some heavy metals. Heavy-metal poisoning is treated with CHELATING AGENTS – chemical compounds that form complexes by binding metal ions: desferrioxamine and pencillinamine are two such agents. The number of people presenting with paracetamol overdose – a common drug used for attempted suicide – has fallen sharply since restrictions were placed on its over-thecounter sales.
When a patient presents with an illness thought to be caused by exposure to substances at work, further exposure should be limited or prevented and investigations undertaken to determine the source and extent of the problem. Acutely poisoned workers will usually go to hospital, but those suffering from chronic exposure may attend their GP with non-speci?c symptoms (see OCCUPATIONAL HEALTH, MEDICINE AND DISEASES).
In recent years, legislation has been enacted in the UK to improve safety in the workplace and to ensure that data on the hazardous constituents and effects of chemicals are more readily available. These o?cial controls include the Control of Substances Hazardous to Health (COSHH) and the Chemicals (Hazard Information and Packaging) Regulations (CHIP) and are UK legislation in response to European Union directives.
The National Poisons Information Service is a 24-hour emergency telephone service available to the medical profession and provides information on the likely effects of numerous agents and advice on the management of the poisoned patient. The telephone numbers are available in the medical literature. In the UK this is not a public-access service. People who believe they, or their relatives, have been poisoned should seek medical advice from their GPs or attend their local hospital.
Toxbase The National Poisons Information Service provides a primary clinical toxicology database on the Internet: www.spib.axl.co.uk. This website provides information about routine diagnosis, treatment and management of people exposed to drugs, household products and industrial and agricultural products.
(See also APPENDIX 1: BASIC FIRST AID.)... poisons
Ben: Dalim;
Tam: Madalai, Madalam;Mal: Urumampazham, Matalam, Talimatala m, Matalanarakam; Kan :Dalimbe;Tel: Dadima; Mar: Dalimba;Guj: Dadam; Ass: DalinImportance: Pomegranate has long been esteemed as food and medicine and as a diet in convalescence after diarrhoea. The rind of the fruit is highly effective in chronic diarrhoea and dysentery, dyspepsia, colitis, piles and uterine disorders. The powdered drug boiled with buttermilk is an efficacious reme dy for infantile diarrohoea. The root and stem bark are good for tapeworm and for strengthening the gums. The flowers are useful in vomiting, vitiated conditions of pitta, ophthalmodynia, ulcers, pharyngodynia and hydrocele. An extract of the flowers is very specific for epistaxis. The fruits are useful in anaemia, hyperdipsia, pharyngodynia, ophthalmodynia, pectoral diseases, splenopathy, bronchitis and otalgia. The fruit rind is good for dysentery, diarrhoea and gastralgia. Seeds are good for scabies, hepatopathy and splenopathy. The important preparations using the drug are Dadimadighrtam, Dadimastaka churnam, Hinguvacadi churnam, Hingvadi gulika, etc (Sivarajan et al, 1994, Warrier et al, 1995).Distribution: Pomegranate is a native of Iran, Afghanistan and Baluchistan. It is found growing wild in the warm valleys and outer hills of the Himalaya between 900m and 1800m altitude. It is cultivated throughout India, the largest area being in Maharastra.Botany: Punica granatum Linn. belongs to the family Punicaceace. It is a large deciduous shrub up to 10m in height with smooth dark grey bark and often spinescent branchlets. Leaves are opposite, glabrous, minutely pellucid-punctuate, shining above and bright green beneath. Flowers are scarlet red or sometime yellow, mostly solitary, sometimes 2-4 held together. Stamens are numerous and inserted on the calyx below the petals at various levels. Fruits are globose, crowned by the persistent calyx. Rind is coriaceous and woody, interior septate with membraneous walls containing numerous seeds. Seeds are angular with red, pink or whitish, fleshy testa (Warrier et al, 1995).Agrotechnology: Pomegranate is of deciduous nature in areas where winters are cold, but on the plains it is evergreen. A hot dry summer aids in the production of best fruits. Plants are grown from seeds as well as cuttings. Mature wood pieces cut into lengths of about 30cm are planted for rooting. The rooted plants are planted 4.5-6m apart. When planted close, they form a hedge which also yields fruits. Normal cultivation and irrigation practices are satisfactory for the pomegranate. An application of 30-45kg of FYM annually to each tree helps to produce superior quality fruits. The pomegranate may be trained as a tree with a single stem for 30-45cm or as a bush with 3 or 4 main stems. In either case suckers arising from the roots and similar growths from the trunk and main branches are removed once a year. Shortening of long slender branches and occasional thinning of branches should be done. The fruit has a tough rind and hence transportation loss is minimum (ICAR, 1966).Properties and activity: Pomegranate fruit rind gives an ellagitannin named granatin B, punicalagin, punicalin and ellagic acid. Bark contains the alkaloids such as iso-pelletierine, pseudopelletierine, methyl isopelletierine, methyl pelletierine, pelletierine as well as iso-quercetin, friedelin, D- mannitol and estrone. Flowers give pelargonidin-3, 5-diglucoside apart from sitosterol, ursolic acid, maslinic acid, asiatic acid, sitosterol- -D-glucoside and gallic acid. Seeds give malvidin pentose glycoside. Rind gives pentose glycosides of malvidin and pentunidin. Fluoride, calcium, magnesium, vitamin C and phosphate are also reported from fruits. Leaves give elligatannins-granatins A and B and punicafolin.Rind of fruit is astringent, fruit is laxative. Bark of stem and root is anthelmintic, and febrifuge. Rind of fruit and bark of stem and root is antidiarrhoeal. Pericarp possesses antifertility effect. Fixed oil from seeds are antibacterial. Bark, fruit pulp, flower and leaf are antifungal. Aerial part is CNS depressant, diuretic and hypothermic. The flower buds of pomegranate in combination with other plants showed excellent response to the patients of Giardiasis (Mayer et al, 1977; Singhal et al, 1983).... pomegranateThe major defect in this system is the dif?culty in obtaining reports of adverse reactions. Evidence suggests that at most, about 10 per cent of such reactions are reported. One method of trying to obtain this information is the ‘yellow card’ system. It is so called because it is based on the distribution of yellow cards to all doctors, pharmacists and dentists, on which they are asked to report any adverse reaction happening to someone taking a drug, whether or not they think it is the cause. Alternatively the CSM has a Freephone line and on-line computer facilities (ADROIT) for practitioners to use. Even though the annual number of adverse reactions reported in this way has risen from around 5,000 in 1975 to more than 18,000, this is probably fewer than the number actually occurring.
Two further committees in this safety screen are the Joint Committee on Vaccination and Immunisation and the Adverse Reactions to Vaccines and Immunological Substances Committee.... safety of drugs
Societies vary in the degree to which they tolerate individuals acting intentionally to cause their own death. Apart from among some native peoples, particularly the Innuit, suicide is generally viewed pejoratively in modern societies. Major religious movements, including Catholicism, Judaism and Islam, have traditionally regarded suicide as a sin. Nevertheless, it is a growing phenomenon, particularly among the young, and so has become a serious public health problem. It is estimated that suicide among young people has tripled – at least – during the past 45 years. Worldwide, suicide is the second major cause of death (after tuberculosis) for women between the ages of 15 and 44, and the fourth major killer of men in the same age-group (after tra?c accidents, tuberculosis and violence). The risk of suicide rises sharply in old age. Globally, there are estimated to be between ten and 25 suicide attempts for each completed suicide.
In the United Kingdom, suicide accounts for 20 per cent of all deaths of young people. Around 6,000 suicides are reported annually in the UK, of which approximately 75 per cent are by men. In the late 1990s the suicide rate in England, Wales and Northern Ireland fell, but increased in Scotland and the Republic of Ireland. Attempted suicide became signi?cantly more common, particularly among people under the age of 25: among adolescents in the UK, for example, it is estimated that there are about 19,000 suicide attempts annually. Follow-up studies of teenagers who attempt suicide by an overdose show that up to 11 per cent will succeed in killing themselves over the following few years. In young people, factors linked to suicide and attempted suicide include alcohol or drug abuse, unemployment, physical or sexual abuse, and the fact of being in custody. (In the mid-1990s, 20 per cent of all prison suicides were by people under 21.)
Apart from the young, those at highest risk of dying by suicide include health professionals, pharmacists, vets and farmers. Self-poisoning (see POISONS) is the common method used by health professionals for whom high stress levels, together with relatively easy access to means, are important factors. The World Health Organisation has outlined six basic steps for the prevention of suicide, focusing particularly on reducing the availability of common methods. Although suicide is not a criminal o?ence in the UK, assisting suicide is a crime carrying a potential sentence of 14 years’ imprisonment. There are several dilemmas faced by health professionals if they believe that a patient is considering suicide: one is that the provision of information to the patient may make them an accessory (see below). A dilemma after suicide is the common demand from insurers for medical information, although, ethically, the duty of con?dentiality extends beyond the patient’s death (see ETHICS). (Legally, some disclosure is permitted to those with a claim arising from the patient’s death.) Life-insurance contracts generally render invalid any claim by the heirs on the policy of an individual who commits suicide, so that disclosure by a doctor often creates tensions with the relatives. Non-disclosure of relevant medical information, however, may result in a fraudulent insurance claim being made.
Physician-assisted suicide Although controversial, a special legal exemption applies to doctors in a few countries who assist terminally ill patients to kill themselves. Oregon in the United States legalised physician-assisted suicide in 1997, where it still occurs; assisted suicide was brie?y legal in the Australian Northern Territory in 1996 but the legislation was repealed. (It is also practised, but not legally authorised, in the Netherlands and Switzerland.)
In the UK there have been unsuccessful parliamentary attempts to legalise assisted suicide, such as the 1997 Doctor Assisted Dying Bill. In law, a distinction is made between killing people with their consent (classi?ed as murder) and assisting them to commit suicide (a statutory o?ence under the Suicide Act 1961). The distinction is between acting as a perpetrator and as an accessory. Doctors may be judged to have aided and abetted a suicide if they knowingly provide the means – or even if they simply provide advice about the toxicity of medication and tell patients the lethal dosage. Some argue that the distinction between EUTHANASIA and physician-assisted suicide has no moral or practical relevance, particularly if patients are too disabled to act themselves. In theory, patients retain ultimate control in cases of assisted suicide, whereas control rests with the doctor in euthanasia. Surveys of health professionals appear to indicate a feeling by some that less responsibility or culpability attaches to assisting suicide than to euthanasia. In a recent UK court case (2002), a judge declared that a mentally alert woman on a permanent life-support regime in hospital had a right to ask for the support system to be switched o?. (See also MENTAL ILLNESS.)... suicide
Today, around 40 million new cases are noti?ed annually in the world, and this is probably an underestimate. In the UK the annual incidence of new cases of syphilis diagnosed in NHS genito-urinary medicine clinics has risen from 8.8 to 9.7 per million of male population between 1991 and 1999; among women the ?gures were 4.0 to 4.5 per million. The infection is most common in homosexual men (see HOMOSEXUALITY).
Causes The causative organism is the Treponema pallidum, a long, thread-like wavy organism with pointed tapering ends. It is found in large numbers in the sores in the primary stage of the disease and in the skin lesions in the secondary stage.
Syphilis may be acquired from people already suffering from the disease, or it may be congenital. The acquired form is usually got by sexual intercourse, kissing or other intimate bodily contact. The epithelium covering the general surface of the skin seems to be an e?cient protection, but the infective material penetrates mucous membranes. The acquired form of the disease is infectious from contact with sores, both in its primary and secondary stages; infants suffering from the congenital form are also highly infectious. Accordingly, anyone frequently handling such an infant is at risk of infection, although the mother may handle the baby with impunity.
Symptoms The acquired form of the disease is commonly divided into three stages – primary, secondary, and tertiary (although the latter is much less common than it was 50 years ago). The clinical manifestations are varied and are sometimes confused with those of other diseases. There are several laboratory tests for con?rming the diagnosis.
The incubation period ranges from ten to 90 days, although most frequently it is around four weeks. Then, a small persistent ULCER appears at the site of infection, which is accompanied by a typical cartilaginous hardness of the tissues immediately around and beneath it. This, which is known as the primary sore (or chancre), may be very much in?amed, or it may be so small as to pass almost or quite unnoticed. A few days later, the lymphatic glands in its neighbourhood, and then those all over the body, become swollen and hard. This condition lasts for several weeks before the sore slowly heals and the glands subside. After a variable period – usually about two months from the date of infection – the secondary symptoms appear and resemble the symptoms of an ordinary FEVER, with pyrexia, loss of appetite, vague pains through the body, and a faint red rash seen best upon the front of the chest. People with syphilis are infectious in the primary and secondary stages but not in the latent or tertiary stages.
In untreated or inadequately treated cases, manifestations of the tertiary stage develop after the lapse of some months or even years: this is known as the latent period. These consist in the growth, at various sites throughout the body, of masses of granulation tissue known as gummas. These gummas may appear as hard nodules in the skin, or form tumour-like masses in the muscles, or produce thickening of bones. They may develop in the brain and spinal cord, where their presence causes very serious symptoms. Gummas yield readily, as a rule, to appropriate treatment, and generally disappear speedily.
Still later, effects are apt to follow, such as disease of the arteries, leading to ANEURYSM (see also ARTERIES, DISEASES OF), to STROKE, and to mental deterioration (see MENTAL ILLNESS); also certain nervous diseases, of which tabes dorsalis and general paralysis are the chief.
The congenital form of syphilis, now rare, may affect the child before birth, leading then as a rule to miscarriage or to a stillbirth if born at full time. Alternatively he (or she) may show the ?rst symptoms a few weeks after birth, the appearances then corresponding to the secondary manifestations of the acquired form.
Laboratory con?rmation of a clinical diagnosis is done by identifying active spirochaetes (see SPIROCHAETE) in a smear taken at the site of the initial chancre, and by blood tests such as the treponomal antibody absorption tests. These tests are strongly positive at the secondary stage, and in patients with neurosyphilis the tests may have to be done on CEREBROSPINAL FLUID.
Treatment Any person with syphilis is a source of infection, and should take precautions not to spread it. PENICILLIN is the drug of choice in the disease in all its stages, but resistant strains of the Treponema pallidum have emerged and are causing problems, especially in developing countries. Treatment must be instituted as soon as possible after infection is acquired: (1) a full course of treatment is essential in every case, no matter how mild the disease may appear to be; (2) periodic blood examinations must be carried out on every patient for at least two years after he or she has been apparently cured.
Prevention is important and promiscuous hetero- or homosexual intercourse involves a risk of infection. Condoms provide some, but not complete protection. Infection can be avoided by maintaining a monogamous relationship.... syphilis
Hydrocoele is a collection of ?uid distending one or both sides of the scrotum with ?uid. Treatment is by withdrawal of the ?uid using a sterile syringe and aspiration needle.
Hypogonadism Reduced activity of the testes or ovaries (male and female gonads). The result is impaired development of the secondary sexual characteristics (growth of the genitals, breast and adult hair distribution). The cause may be hereditary or the result of a disorder of the PITUITARY GLAND which produces GONADOTROPHINS that stimulate development of the testes and ovaries.
Varicocoele is distension of the veins of the spermatic cord, especially on the left side, the causes being similar to varicose veins elsewhere (see VEINS, DISEASES OF). The chief symptom is a painful dragging sensation in the testicle, especially after exertion. Wearing a support provides relief; rarely, an operation may be advisable. Low sperm-count may accompany a varicocele, in which case surgical removal may be advisable.
Orchitis or acute in?ammation may arise from CYSTITIS, stone in the bladder, and in?ammation in the urinary organs, especially GONORRHOEA. It may also follow MUMPS. Intense pain, swelling and redness occur; treatment consists of rest, support of the scrotum, analgesics as appropriate, and the administration of antibiotics if a de?nitive microorganism can be identi?ed. In some patients the condition may develop and form an ABSCESS.
Torsion or twisting of the spermatic cord is relatively common in adolescents. About half the cases occur in the early hours of the morning during sleep. Typically felt as pain of varying severity in the lower abdomen or scrotum, the testis becomes hard and swollen. Treatment consists of immediate undoing of the torsion by manipulation. If done within a few hours, no harm should ensue; however, this should be followed within six hours by surgical operation to ensure that the torsion has been relieved and to ?x the testes. Late surgical attention may result in ATROPHY of the testis.
Tuberculosis may occur in the testicle, especially when the bladder is already affected. Causing little pain, the infection is often far advanced before attracting attention. The condition generally responds well to treatment with a combination of antituberculous drugs (see also main entry for TUBERCULOSIS).
Tumours of the testes occur in around 600 males annually in the United Kingdom, and are the second most common form of malignant growth in young males. There are two types: SEMINOMA and TERATOMA. When adequately treated the survival rate for the former is 95 per cent, while that for the latter is 50 per cent.
Injuries A severe blow may lead to SHOCK and symptoms of collapse, usually relieved by rest in bed; however, a HAEMATOMA may develop.... testicle, diseases of
Habitat: South India, Gujarat, Rajasthan, Uttar Pradesh and Haryana.
Ayurvedic: Varshaabhu (related species).Siddha/Tamil: Vellai Sharunnai.Folk: Bisakhaparaa.Action: Root—deobstruent; used for asthma, hepatitis and amenorrhoea. The root, leaf and stem gave positive test for alkaloid. The plant is a good source of zinc (1.077 ± 0.188) and copper (0.416 ± 0.057) mg/100 g.
Synonym: T. monogyna Linn.Family: Aizoaceae.Habitat: Cultivated fields and wastelands.
English: Horse Purslane.Ayurvedic: Varshaabhu, Vrshchira, Vishakharparikaa, Shilaatikaa, Shothaghni, Kshdra. Wrongly equated with Shveta-punarnavaa or Rakta-punarnavaa. Varshaabhu and Punarnavaa are two different herbs. T. portulacastrum is a rainy season annual. Rakta-punarnavaa is equated with Boerhavia diffusa, Shveta-punarnavaa with white- flowered species, B. erecta L. (B. punarnava).Unani: Biskhaparaa.Siddha: Sharunai.Folk: Pathari, Bisakhaparaa.Action: Root—antipyretic, analgesic, spasmolytic, deobstruent, cathartic, anti-inflammatory.
Leaves—diuretic; used in oedema and dropsy. A decoction of the herb is used as an antidote to alcoholic poison.The Ayurvedic Pharmacopoeia ofIn- dia recommends the dried root in diseases of the liver and spleen, anaemia and oedema.Ethanolic extract of the aerial parts exhibited hepatoprotective activity in CCl4-induced intoxication in rats. The acetone-insoluble fraction of the extract is responsible for the activity.The red and white flowers contain an alkaloid trianthemine, also punaranavine. The plant also gave ecdysterone (0.01 g/kg), a potential chemosterilant; nicotinic acid and ascorbic acid. The plant is rich in phosphorus and iron but poor in calcium.The high content of oxalate affects the assimilation of calcium. Carotene (2.3 mg/100 g) has also been reported.Trianthema sp. are used as adulterant of the roots of Boerhavia diffusa.Dosage: Root—2-5 g powder. (API, Vol. IV.)... trianthema portulacastrumThe pioneering success was achieved with transplantation of the kidney in the 1970s; this has been most successful when the transplanted kidney has come from an identical twin. Less successful have been live transplants from other blood relatives, while least successful have been transplants from other live donors and cadaver donors. The results, however, are steadily improving. Thus the one-year functional survival of kidneys transplanted from unrelated dead donors has risen from around 50 per cent to over 80 per cent, and survival rates of 80 per cent after three years are not uncommon. For a well-matched transplant from a live related donor, the survival rate after ?ve years is around 90 per cent. And, of course, if a transplanted kidney fails to function, the patient can always be switched on to some form of DIALYSIS. In the United Kingdom the supply of cadaveric (dead) kidneys for transplantation is only about half that necessary to meet the demand.
Other organs that have been transplanted with increasing success are the heart, the lungs, the liver, bone marrow, and the cornea of the eye. Heart, lung, liver and pancreas transplantations are now carried out in specialist centres. It is estimated that in the United Kingdom, approximately 200 patients a year between the ages of 15 and 55 would bene?t from a liver transplant if an adequate number of donors were available. More than 100 liver transplants are carried out annually in the United Kingdom and one-year-survival rates of up to 80 per cent have been achieved.
The major outstanding problem is how to prevent the recipient’s body from rejecting and destroying the transplanted organ. Such rejection is part of the normal protective mechanism of the body (see IMMUNITY). Good progress has been made in techniques of tissue-typing and immunosuppression to overcome the problem. Drugs are now available that can suppress the immune reactions of the recipient, which are responsible for the rejection of the transplanted organ. Notable among these are CICLOSPORIN A, which revolutionised the success rate, and TACROLIMUS, a macrolide immunosuppressant.
Another promising development is antilymphocytic serum (ALS), which reduces the activity of the lymphocytes (see LYMPHOCYTE) cells which play an important part in maintaining the integrity of the body against foreign bodies.
Donor cards are now available in all general practitioners’ surgeries and pharmacies but, of the millions of cards distributed since 1972, too few have been used. The reasons are complex but include the reluctance of the public and doctors to consider organ donation; poor organisation for recovery of donor kidneys; and worries about the diagnosis of death. A code of practice for procedures relating to the removal of organs for transplantation was produced in 1978, and this code has been revised in the light of further views expressed by the Conference of Medical Royal Colleges and Faculties of the United Kingdom on the Diagnosis of Brain Death. Under the Human Tissue Act 1961, only the person lawfully in possession of the body or his or her designate can authorise the removal of organs from a body. This authorisation may be given orally.
Patients who may become suitable donors after death are those who have suffered severe and irreversible brain damage – since such patients will be dependent upon arti?cial ventilation. Patients with malignant disease or systemic infection, and patients with renal disease, including chronic hypertension, are unsuitable.
If a patient carries a signed donor card or has otherwise recorded his or her wishes, there is no legal requirement to establish lack of objection on the part of relatives – although it is good practice to take account of the views of close relatives. If a relative objects, despite the known request by the patient, sta? will need to judge, according to the circumstances of the case, whether it is wise to proceed with organ removal. If a patient who has died is not known to have requested that his or her organs be removed for transplantation after death, the designated person may only authorise the removal if, having made such reasonable enquiry as may be practical, he or she has no reason to believe (a) that the deceased had expressed an objection to his or her body being so dealt with after death, or (b) that the surviving spouse or any surviving relative of the deceased objects to the body being so dealt with. Sta? will need to decide who is best quali?ed to approach the relatives. This should be someone with appropriate experience who is aware how much the relative already knows about the patient’s condition. Relatives should not normally be approached before death has occurred, but sometimes a relative approaches the hospital sta? and suggests some time in advance that the patient’s organs might be used for transplantation after death. The sta? of hospitals and organ exchange organisations must respect the wishes of the donor, the recipient and their families with respect to anonymity.
Relatives who enquire should be told that some post-mortem treatment of the donor’s body will be necessary if the organs are to be removed in good condition. It is ethical (see ETHICS) to maintain arti?cial ventilation and heartbeat until removal of organs has been completed. This is essential in the case of heart and liver transplants, and many doctors think it is desirable when removing kidneys. O?cial criteria have been issued in Britain to recognise when BRAIN-STEM DEATH has occurred. This is an important protection for patients and relatives when someone with a terminal condition
– usually as a result of an accident – is considered as a possible organ donor.... transplantation
Healthy people are inoculated with vaccine as a protection against a particular disease; this produces ANTIBODIES which will confer immunity against a subsequent attack of the disease. (See IMMUNISATION for programme of immunisation during childhood.)
Vaccines may be divided into two classes: stock vaccines, prepared from micro-organisms known to cause a particular disease and kept in readiness for use against that disease; and autogenous vaccines, prepared from microorganisms which are already in the patient’s body and to which the disease is due. Vaccines intended to protect against the onset of disease are of the former variety.
Autogenous vaccines are prepared by cultivating bacteria found in SPUTUM, URINE and FAECES, and in areas of in?ammation such as BOILS (FURUNCULOSIS). This type of vaccine was introduced by Wright about 1903.
Anthrax vaccine was introduced in 1882 for the protection of sheep and cattle against this disease. A safe and e?ective vaccine for use in human beings has now been evolved. (See ANTHRAX.)
BCG vaccine is used to provide protection against TUBERCULOSIS. (See also separate entry on BCG VACCINE.)
Cholera vaccine was introduced in India about 1894. Two injections are given at an interval of at least a week; this gives a varying degree of immunity for six months. (See CHOLERA.)
Diphtheria vaccine is available in several forms. It is usually given along with tetanus and pertussis vaccine (see below) in what is known as TRIPLE VACCINE. This is given in three doses: the ?rst at the age of two months; the second at three months; and the third at four months, with a booster dose at the age of ?ve years. (See DIPHTHERIA.)
Hay fever vaccine is a vaccine prepared from the pollen of various grasses. It is used in gradually increasing doses for prevention of HAY FEVER in those susceptible to this condition.
In?uenza vaccine A vaccine is now available for protection against INFLUENZA due to the in?uenza viruses A and B. Its use in Britain is customarily based on advice from the health departments according to the type of in?uenza expected in a particular year.
Measles, mumps and rubella (MMR) vaccines are given in combination early in the second year of life. A booster dose may prove necessary, as there is some interference between this vaccine and the most recent form of pertussis vaccine (see below) o?ered to children. Uptake has declined a little because of media reports suggesting a link with AUTISM – for which no reliable medical evidence (and much to the contrary) has been found by investigating epidemiologists. (See also separate entry for each disease, and for MMR VACCINE.)
Pertussis (whooping-cough) vaccine is prepared from Bordetella pertussis, and is usually given along with diphtheria and tetanus in what is known as triple vaccine. (See also WHOOPING-COUGH.)
Plague vaccine was introduced by Ha?kine, and appears to give useful protection, but the duration of protection is relatively short: from two to 20 months. Two injections are given at an interval of four weeks. A reinforcing dose should be given annually to anyone exposed to PLAGUE.
Poliomyelitis vaccine gives a high degree of protection against the disease. This is given in the form of attenuated Sabin vaccine which is taken by mouth – a few drops on a lump of sugar. Reinforcing doses of polio vaccine are recommended on school entry, on leaving school, and on travel abroad to countries where POLIOMYELITIS is ENDEMIC.
Rabies vaccine was introduced by Pasteur in 1885 for administration, during the long incubation period, to people bitten by a mad dog, in order to prevent the disease from developing. (See RABIES.)
Rubella vaccine, usually given with mumps and measles vaccine in one dose – called MMR VACCINE, see also above – now provides protection against RUBELLA (German measles). It also provides immunity for adolescent girls who have not had the disease in childhood and so ensures that they will not acquire the disease during any subsequent pregnancy – thus reducing the number of congenitally abnormal children whose abnormality is the result of their being infected with rubella via their mothers before they were born.
Smallpox vaccine was the ?rst introduced. As a result of the World Health Organisation’s successful smallpox eradication campaign – it declared the disease eradicated in 1980 – there is now no medical justi?cation for smallpox vaccination. Recently, however, there has been increased interest in the subject because of the potential threat from bioterrorism. (See also VACCINATION.)
Tetanus vaccine is given in two forms: (1) In the so-called triple vaccine, combined with diphtheria and pertussis (whooping-cough) vaccine for the routine immunisation of children (see above). (2) By itself to adults who have not been immunised in childhood and who are particularly exposed to the risk of TETANUS, such as soldiers and agricultural workers.
Typhoid vaccine was introduced by Wright and Semple for the protection of troops in the South African War and in India. TAB vaccine, containing Salmonella typhi (the causative organism of typhoid fever – see ENTERIC FEVER) and Salmonella paratyphi A and B (the organisms of paratyphoid fever – see ENTERIC FEVER) has now been replaced by typhoid monovalent vaccine, containing only S. typhi. The change has been made because the monovalent vaccine is less likely to produce painful arms and general malaise, and there is no evidence that the TAB vaccine gave any protection against paratyphoid fever. Two doses are given at an interval of 4–6 weeks, and give protection for 1–3 years.... vaccine
Haemophilus vaccine (HiB) This vaccine was introduced in the UK in 1994 to deal with the annual incidence of about 1,500 cases and 100 deaths from haemophilus MENINGITIS, SEPTICAEMIA and EPIGLOTTITIS, mostly in pre-school children. It has been remarkably successful when given as part of the primary vaccination programme at two, three and four months of age – reducing the incidence by over 95 per cent. A few cases still occur, either due to other subgroups of the organism for which the vaccine is not designed, or because of inadequate response by the child, possibly related to interference from the newer forms of pertussis vaccine (see above) given at the same time.
Meningococcal C vaccine Used in the UK from 1998, this has dramatically reduced the incidence of meningitis and septicaemia due to this organism. Used as part of the primary programme in early infancy, it does not protect against other types of meningococci.
Varicella vaccine This vaccine, used to protect against varicella (CHICKENPOX) is used in a number of countries including the United States and Japan. It has not been introduced into the UK, largely because of concerns that use in infancy would result in an upsurge in cases in adult life, when the disease may be more severe.
Pneumococcal vaccine The pneumococcus is responsible for severe and sometimes fatal childhood diseases including meningitis and septicaemia, as well as PNEUMONIA and other respiratory infections. Vaccines are available but do not protect against all strains and are reserved for special situations – such as for patients without a SPLEEN or those who are immunode?cient.... yellow fever vaccine is prepared from
Symptoms: redness, soreness, itching followed by blisters on the penis or vulva. Blisters ulcerate before crusting over. Lesions on anus of homosexual men.
Treatment by general medical practitioner or hospital specialist.
Alternatives. Sarsaparilla, Echinacea, Chaparral and St John’s Wort often give dramatic relief to itching rash. See entry: ECHINACEA.
Tea. Formula. Equal parts: Clivers, Gotu Kola, Valerian. One heaped teaspoon to each cup boiling water; infuse 5-10 minutes. Dose: 1 cup thrice daily.
Decoction. Combine: Echinacea 2; Valerian 1; Jamaican Dogwood 1. One heaped teaspoon to each cup water gently simmered 20 minutes. Half-1 cup thrice daily.
Tablets/capsules. Poke root. Valerian. Passion flower. St John’s Wort. Echinacea. Chaparral. Pulsatilla. Red Clover.
Powders. Formula. Echinacea 2; Valerian 1; Jamaica Dogwood 1. Dose: 500mg (two 00 capsules or one- third teaspoon) thrice daily.
Tinctures. Formula. Echinacea 2; Sarsaparilla 1; Thuja quarter; Liquorice quarter. Dose: 1-2 teaspoons thrice daily.
Topical. Apply any of the following 3, 4 or more times daily. Pulp or gel of Aloe Vera, Houseleek, Echinacea lotion. Garlic – apply slice of fresh corm as an antihistamine. Yoghurt compresses (improved by pinch of Goldenseal powder). Zinc and Castor oil (impressive record). Apply direct or on tampons. Diet. Porridge oats, or muesli oats.
Supplementation: same as for Shingles.
Prevention. Women should be advised to submit for an annual cytosmear. Information. Herpes Association, 41 North Road, London N7 9DP, UK. Send SAE. ... herpes, genital
FAMILY: Apiaceae (Umbelliferae)
SYNONYMS: T. ammi, Ammi copticum, Carum ajowan, C. copticum, Ptychotis ajowan, ajuan, omum.
GENERAL DESCRIPTION: An annual herb with a greyish-brown seed, which resembles parsley in appearance.
DISTRIBUTION: Chiefly India, also Afghanistan, Egypt, the West Indies and the Seychelle Islands.
OTHER SPECIES: see Botanical Classification section.
HERBAL/FOLK TRADITION: The seeds are used extensively in curry powders and as a general household remedy for intestinal problems. The tincture, essential oil and ‘thymol’ are used in Indian medicine, particularly for cholera.
ACTIONS: Powerful antiseptic and germicide, carminative.
EXTRACTION: Essential oil by steam distillation from the seed.
CHARACTERISTICS: A yellow-orange or reddish liquid with a herbaceous-spicy medicinal odour, much like thyme.
PRINCIPAL CONSTITUENTS: Thymol, pinene, cymene, dipentene, terpinene and carvacrol, among others.
SAFETY DATA: Possible mucous membrane and dermal irritant. Due to high thymol level, should be avoided in pregnancy. Toxicity levels are unknown.
AROMATHERAPY/HOME: USE Not recommended.
OTHER USES: It has been used extensively for the isolation of thymol, but this has largely been replaced by synthetic thymol.... ajowan
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