Strengthening of primary health care: key to deliver inclusive health care.

Inequity and poverty are the root causes of ill health. Access to quality health services on an affordable and equitable basis in many parts of the country remains an unfulfilled aspiration. Disparity in health care is interpreted as compromise in 'Right to Life.' It is imperative to define 'essential health care,' which should be made available to all citizens to facilitate inclusivity in health care. The suggested methods for this include optimal utilization of public resources and increasing public spending on health care. Capacity building through training, especially training of paramedical personnel, is proposed as an essential ingredient, to reduce cost, especially in tertiary care. Another aspect which is considered very important is improvement in delivery system of health care. Increasing the role of 'family physician' in health care delivery system will improve preventive care and reduce cost of tertiary care. These observations underlie the relevance and role of Primary health care as a key to deliver inclusive health care. The advantages of a primary health care model for health service delivery are greater access to needed services; better quality of care; a greater focus on prevention; early management of health problems; and cumulative improvements in health and lower morbidity as a result of primary health care delivery.

An evaluation of palmar flexion creases and dermatoglyphics in leprosy.

The palmar flexion creases and dermatoglyphics of 150 male leprosy patients (100 paucibacillary and 50 multibacillary leprosy) were compared with 50 matched controls. Among palmar dermatoglyphics a significantly high frequency (P less than 0.001) of palmar pattern in thenar/1st interdigital area was noticed on left palm of multibacillary leprosy patients. Slight increase in frequency of distal axial triradii (t' and t'') was also seen on palms of leprosy patients. No difference in values of atd angle and C-line types were observed between patients and controls. Among palmar flexion creases a significantly high frequency of Single Radial Base Crease (SRBC) and lower frequency of Double Radial Base Crease (DRBC) was noticed on palms of leprosy patients as compared to controls (P less than 0.001). The difference mainly exist on left palm. A significantly high frequency of Simian Crease was also observed on palms of multibacillary leprosy patients (P less than 0.001) and paucibacillary leprosy patients (P less than 0.05) as compared to controls.

Epidemiological and clinical aspects of leprosy in Indian armed forces.

Epidemiological and clinical aspects of leprosy in 1911 cases of the disease in armed forces personnel were studied. Typewise distribution of cases was Tuberculoid 53.53%, Lepromatous 20.57%, Indeterminate 8.74%, Borderline 11.67% and Polyneuritic 5.49%. Maximum leprosy cases occurred in those belonging to Uttar Pradesh 17.11%. Maximum number of cases were detected (88.55%) in age group 20-39 years. Incidence of leprosy increased with increased years of service. 11.82% patients were illiterate. 89.85% patients earned Rs. 200 to 499 per month. 56.08% patients had no landed property. Houses of 47.29% cases were located in congested areas. 68.23% patients had to support larger families. In 95.94% cases no family members were examined for leprosy. Diet, smoking and alcohol appear to have had no relation to disease in cases studied. Clinical presentation of cases was classical and typespecific. Skin eruption and loss of sensation were the commonest symptoms. Leprosy lesions were detected on almost all parts of body. Thermal sensation was the commonest modality lost. Ulnar, lateral popliteal and greater auricular were the frequently affected nerves. Amongst complications paralytic deformities were common (16.09%). 545 complications were detected in 1911 cases. While 84.29% patients had put in more than 4 years of service, the source of infection was known only in 0.57% positively (intrafamilial).

Multidrug therapy in hospitalised leprosy cases.

Fifty eight cases including 44 paucibacillary and 14 multibacillary leprosy diagnosed at Command Hospital SC Pune were hospitalised for the entire period of multidrug therapy. 76% cases belonged to high endemic states of India. Reactions occurred in 13 cases during treatment, type I in 10 and type II in three. 7 Multibacillary cases experienced reaction. 69% reaction patients developed reaction within two months of starting MDT and all of them were multibacillary. Usually it took 3-6 months for majority (61.5%) of reactions subside completely. In 65.5% paucibacillary patients activity subsided within twelve months, however 70.5% paucibacillary cases took more than six months to exhibit subsidence of activity. In 13 multibacillary cases activity subsided by 18 months though bacteriological negativity was obtained from fourth to twelve months.

A study of palmar ridge malformation in leprosy.

Palmar ridge malformation of 150 male leprosy patients (50 multibacillary and 100 paucibacillary) were compared with matched controls. Significantly high incidence of ridge malformation was found on the palms of multibacillary leprosy patients. The acquired ridge atrophy was found in 32% multibacillary leprosy, 4.5% paucibacillary leprosy and 0% controls. The congenital ridge dissociation was found in 46% multibacillary leprosy, 20% paucibacillary leprosy and 22% controls. The difference is statistically significant.

Study of finger print patterns in leprosy.

Finger print patterns of 150 male leprosy patients (100 paucibacillary and 50 multibacillary leprosy) were compared with 50 matched controls. Significant differences were found in finger print patterns of multibacillary leprosy patients and controls. No differences in dermatoglyphic patterns were observed between paucibacillary leprosy and controls. The total finger ridge count (TFRC) in both types of leprosy was slightly lower than controls. A significant difference in individual finger ridge count on digit 1 of right hand was noted in paucibacillary leprosy cases as compared to controls.

Tuberculoid granuloma in a clinically normal looking skin.

A case of tuberculoid leprosy showing well defined tuberculoid granuloma in the skin without any morphological changes is reported.

Leprosy with pellagroid features (a case report).

A case of leprosy with pellagroid features is presented. Diagnosis of leprosy was confirmed by bacteriological and histopathological examination. A therapeutic trial with nicotinic acid did not result in any improvement. Occurrence of scaling in leprosy is discussed.

Absence of triradius d on the palm of a leprosy patient.

An extremely rare finding of absence of digital triradius d in a case of borderline tuberculoid leprosy from Maharashtra is reported with review of literature.

Inoculation leprosy subsequent to dog bite. A case report.

Development of leprosy lesion at the site of inoculation or injury is described by many workers off and on. An interesting case of indeterminate leprosy developing at the site of dog bite is being reported.

Quantification of thermal sensory loss in follow up of progress in leprosy.

Thermal sensory perception quantitatively was studied in follow up of 10 lesions (4 TT, 3 BT and 1 Indeterminate case) of cases put on poly therapy as per WHO regime, for 6 months. Significant thermal sensory improvements was noticed in 4 lesions after 4 months of therapy. Within 2 months of therapy, 3 cases showed improved perception of heat sensation but 1 showed deterioration. Recovery of sensations did not correspond to other clinical parameters of improvement in all the cases. The utility of quantitative evaluation of thermal sensory perception in follow up of leprosy cases is discussed.

Inoculation leprosy developing after tattooing--a case report.

A case of Inoculation Leprosy following tattooing in a soldier is being reported. Escape of infection in one tattoo and occurrence of disease in another when tattooing was done simultaneously, is of interest. Possible mechanism for such occurrence is discussed.

Quantification of thermal sensory perception in leprosy (a preliminary report).

An instrument called 'Thermosense' was designed and developed for quantitative assessment of thermal sensory perception. Preliminary testing on 20 healthy adult males showed that 39 degrees C was perceived as hot in 19 individuals on the forearm and arm. The perception on the finger tips was less than forearms. In 5 cases of leprosy (BT 4, TT 1) testing showed detectable difference in thermal perception within the lesion, in the skin, in the vicinity of the lesion and the uninvolved skin.

CAN WE SATISFY OUR CLIENTS? INTROSPECTION.

Criticism of medical professionals is on the rise. The perception of the medical profession and the media, which educates the clientele, is widely different. The likely causes for dissatisfaction of the clientele and some possible solutions are presented.

Family physicians: importance and relevance.

Due to rapid advancement in medical technology and knowledge patients today prefer treatment from specialists, if they can afford it. Medical treatment has become a purchasable commodity, to be procured as and when required, based on cost and availability.This is unfortunate but true. Specialisation tends to divide the patients into'parts' and increases the cost of treatment. Moreover no single physician is in charge of the patient as a whole to maintain long term continuity and coordinate the treatments given by different specialists. Since long term dependence on 'family doctor' has reduced, trust deficit in the profession has started creeping in. It is essential to rejuvenate the concept of family doctors equipped with skills suitable for modern technology and practice, to restore the faith of patients in medical professionals. Family doctor can provide a 'single window clearance' for all healthcare needs of an individual. Exploitation of gullible patient can be prevented when the family doctor becomes the friend and guide for all treatments being given to the individual. Society should be educated on the benefits of getting the treatment through the family doctor. The family doctor then becomes the Authorised Medical Attendant (AMA), responsible for all treatments beings provided to the patients. The Medical Council of India (MCI) may consider incorporating this in code of medical ethics.

VDRL titres in early syphilis before and after treatment.

OBJECTIVE: To observe the pretreatment VDRL titres in different stages of early syphilis and evaluate the changes in VDRL titre following treatment using different treatment schedules. DESIGN: Retrospective study was carried out by analysing the records of cases of early syphilis treated between 1976 to 1981. SETTING: Armed Forces personnel treated at different service hospitals in India. SUBJECTS: Of 3183 cases of early syphilis treated with different regimens during this period, 1532 were fully followed-up for a period of 30 months. Records of these 1532 cases were analysed. MAIN OUTCOME MEASURES: Assessment of VDRL titres before treatment and during post treatment surveillance period of 30 months. Attainment of non-reactivity of VDRL test in various stages of early syphilis using different treatment schedules was evaluated. RESULTS: Relatively higher titres were observed in secondary syphilis. Following treatment it was observed that VDRL test was still reactive at the end of 6 months in 16.47% of primary, 27.56% of secondary and 18.95% of early latent cases; at the end of 12 months in 11.38% of primary, 17.25% of secondary and 15.79% of early latent cases while at 30 months reactivity was still observed in 6.60% of primary, 8.39% of secondary and 11.58% of early latent cases. CSF was examined in 1173 cases at 6 months, of which one case revealed VDRL reactivity while two cases showed reactivity amongst 1188 CSF examined at 30 months. There has been no significant difference with broad spectrum antibiotics and 2.4 MU benzathine penicillin. Results were better with 4.8 MU benzathine penicillin and procaine penicillin. CONCLUSION: VDRL test appears to be a reliable test for the follow-up of treated patients in early syphilis. Early treatment prevents development of seropositivity in seronegative syphilis while majority of seropositive cases attain seronegativity by 6 months. Higher doses of benzathine penicillin and procaine penicillin accelerate the speed of seroconversion.

Dermatitis Cruris Pustulosa et Atrophicans.

Fifteen male soldiers having dermatitis cruris pustulosa et atrophicans were studied clinically, bacteriologically, histopathologicafly and immunologically. Average age at detection was 26 years. Skin lesions were classically distributed on the legs. Staphylococcus aure was grown from the lesions. Histopathological findings were of eczematous pattern with polymorphic cellular infiltrate in the dermis. IgG and IgA levels in blood were increased.

Wars and sexually transmitted diseases in the Indian Army.

PIP: A large majority of the world's soldiers are young, away from home, of low rank, and of low educational level. Many consume large quantities of alcohol and other drugs to cope. This combination of factors leads many soldiers to have sex with prostitutes and other casual partners, placing them at high risk of contracting and transmitting STDs. The worldwide incidence of STD for the US Army in 1978 was 98 per 1000 soldiers. The authors reviewed the records of STD cases treated in the Indian armed forces during the period 1938-78 to find that there was a decline in STDs in the Indian Army from 5.22 per 1000 in 1895 to 2.12 per 1000 in 1978. There was, however, an increase in the incidence of STD during war in the Indian Army, albeit marginal compared to global figures. The incidence of STD in the Indian Armed Forces has been much lower than in any other country. Chancroid was the most common STD, affecting most commonly soldiers aged 21-30 years. Prostitutes remained the most common source of infection. Better education appears to decrease the incidence of infection, there was no homosexuality recorded, marital status had little impact upon the risk of contracting STD, prophylactic measures were taken by only 6% of individuals, and 5% of infected soldiers in 1965 and 7% in 1971 were repeat patients. 60% of the men contracted their STD while on leave just prior to entering the theater of war. The rapid expansion of armed forces which results in relaxed recruiting standards, individual separation from sources of moral influence, the lack of disciplinary and moral control by superiors, the uncertainty of survival, emotional strains, illiteracy, and the lack of adequate recreational facilities support the increased incidence of STD during war. Reasons for the comparatively low incidence of STD among Indian soldiers include good management and discipline, religious faith, social customs, fear of social stigmatization upon contracting STD, close surveillance by military police of soldiers' movements, limited alcohol and drug consumption, patriotic motivation to be as physically and mentally strong as possible for combat, regular medical check-ups, and racial factors.^ieng