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CorrespondenceTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 8, NO.4, 1995

Management of rhesus isoimmunization

I should like to take issue with some of thestatements made by Drs George and Andersonin their otherwise concise and clear articleon the management of rhesus (Rh) isoimmuni-zation.!

It is unlikely that bilirubin resulting from thehaemolytic process affecting the foetus reachesthe amniotic fluid through excretion by thefoetal kidneys. Indeed, the immature foetalliver, due to low levels of glucuronyl trans-ferase, is unable to conjugate bilirubin; andunconjugated bilirubin is insoluble in aqueoussolutions. The circulating unconjugated foetalbilirubin crosses the placenta, and ismetabolized and subsequently excreted by themother. It is highly probable that some ofthe bilirubin, during this process of transfer,crosses from the lumen of the umbilical andplacental vessels into the amniotic cavity.

Secondly, while it may theoretically be usefulto determine the blood group and zygosity ofthe partner, this information is of little practicalvalue, as in a number of cases the partner isnot the genitor. It may be wise to make it arule to consider the genitor unknown, and tomanage the Rh negative gravida as ifthe formercould be a carrier of the Rh antigen.

Thirdly, I object to the course of actionsuggested by George and Anderson when thepartner (again probably, but not necessarily,the genitor) is known to be heterozygous forthe Rh antigen. If the Rh negative woman isnot immunized, there is no indication to per-form a chorionic villus biopsy and determinethe Rh type of the foetus. If the woman isimmunized, the option of artificial inseminationwith the sperm of a Rh negative donor shouldbe discussed with both partners beforepregnancy. The same applies to the situationwhere the partner is homozygous for the Rhantigen.

22 May 1995 J. J. AmyDepartment of Gynaecology, Andrology

and ObstetricsAcademisch Ziekenhuis

Vrije Universiteit BrusselBrusselsBelgium

REFERENCE

GeorgeA, AndersonS.Newtrendsinthemanage-ment of rhesusisoimmunization.Natl Med J India1995;8:26-7.

The GATT· TRIPS agreement

I was pleased to read the informative andthought-provoking commentary by Drs George

and Begum on 'The' TRIPS agreement andpharmaceuticals'. 1 The fact that this communi-cation is the outcome of a well-researched studyby a doctor from the Railway Hospital andanother from a Primary Health Centre, is proofenough that there are still well-informed andgenuinely concerned physicians amongst ourmuch maligned practitioners of primary healthcare. However, I wish that this report had beenpublished as a full paper to avoid it being over-looked as an item under 'Correspondence'.

I wish that the Indian medical professiontook a greater interest in such issues which havemajor implications for the future of health carein developing countries. These are likely tobe dismissed by busy professionals as mattersof government concern. How many of usrecognize the importance of moves by ascientific organization such as the New YorkBotanical Garden to explore plant wealth intropical countries for western pharmaceuticalcompanies. The US pharmaceutical company,E. Merck has initiated a programme in CostaRica to obtain alcohol extracts of differentorganisms including obscure species of moths,wasps and mites for the same purpose. TheUnited States Government is reported to havefiled patent applications for some unusual celllines derived from the indigenous people ofPapua New Guinea and the Solomon Islands.By using their expertise, advanced technology,industrial capability and economic resourcesthe developed world is thus in a position toacquire a monopoly on the biodiversity ofdeveloping countries.

It should be nobody's case to deny appro-priate incentives, returns and rewards to thosewho contribute to innovative advances. Theconcern of persons like George and Begum,no doubt, is to safeguard the economic and,more importantly, the social interests of thedeveloping world. Those who talk of humanrights should first think of the consequencesof such international agreements on humansurvival. Such concerns have been expressedas early as 1964by the United Nations SecretaryGeneral in his 'Report on the Role of Patentsin the Transfer of Technology to DevelopingCountries' as well as by the World HealthOrganization.

I also urge that the scientific community inIndia should mitigate the possible adverseeffects of such agreements by paying muchmore attention to research and development,focusing on areas where we have inherentadvantages.

7 May 1995 P. N. TandonDepartment of Neurosurgery

All India Institute of Medical SciencesNew Delhi

REFERENCE

.1 George T, BegumZ. The TRIPS agreementandpharmaceuticals.Natl Med J India 1995;8:96-8.

Selection and management of thebrain dead donor

The article by Dr Strong on the selection andmanagement of the brain dead donor is timelyand aptly warns against 'ad hocism' in initiationof solid organ transplantation programmes. 1

There are certain problems peculiar to theIndian situation which are likely to come up inthe process of cadaveric transplantation and itwould be wise to anticipate them and think ofpossible solutions.

Starting in July 1994, we made an effort todocument brain death and support organ func-tion in all patients with severe head injuryadmitted to the Surgical Intensive Care Unit(SICU) of the K.E.M. Hospital, Bombay. Allthe clinical tests, as now laid down in theHuman Organs Transplant Rules, 1995, exceptthe apnoea test, were performed. The findingswere confirmed by a neurologist or a neuro-surgeon. Metabolic causes of reversible comawere ruled out. All patients were monitored athourly intervals for vital parameters (with acardioscope) and serial blood gases. They wereventilated on a pressure-cycled ventilatorand inotropic support was provided (withdopamine) at the earliest sign of hypotension.Liver function tests were performed in 6of them.

Using the above criteria, 8 patients withbrain death were identified from July 1994 toFebruary 1995. After admission to the SICU,the average time to cardiac arrest of thesepatients was 28 hours (range: 8 to 90 hours).Two of the patients had sudden cardiac arrestwithin 10 hours probably due to coning of thebrain. In 5 patients there was evidence ofbronchopneumonia and septicaemia which wasconfirmed at post-mortem. All these patientshad maintained cardiac function for morethan 24 hours. Liver enzymes were normal in2 patients and mildly raised in 4 others. Onepatient had diabetes insipidus.

Based on the experience of treating theseand similar patients in the past, I foreseesome practical problems for cadaveric trans-plantation which are likely to be faced by mostmajor institutions in this country. These are:

Development of sepsis. 5 of the abovepatients developed sepsis in the form ofbronchopneumonia and succumbed to it inspite of antibiotic cover. Such sepsis in thedonor could be a major impediment to trans-plantation. Aseptic precautions often take abackseat in our ICUs and nosocomial sepsis isextremely common. This is possibly due to theICUs being overloaded, understaffed as wellas lacking in isolation facilities.

A relative shortage of ventilators and leUbeds in our hospitals. In such a. situationmaintaining a brain dead patient for a longperiod of time creates problems especially

CORRESPONDENCE

when another deserving patient requiresventilatory support.

Problems in obtaining consent. 2 of theabove patients had no relatives; 2 had eithercolleagues or friends. It would be difficult toobtain consent. Surgeons involved in acadaveric kidney transplant programme havealready documented that in such a situation thedecision of organ donation often does not restwith one person but the entire family; theyhave to be spoken to repeatedly causing a delayof several hours.! Since this has to be doneby the treating physician who is not a part ofthe transplant team it needs a high degree ofmotivation. Such detailed communication withthe patients' relatives is alien to the prevalentculture of medical practice and, therefore, amajor attitudinal change is required.

Given the media coverage of the kidneytransplant rackets in major cities during the lastfew months, the very term 'transplantation' islikely to conjure up an image of shady anddangerous dealings by unscrupulous doctors inthe minds of the public. Changing such a publicperception is going to be a challenge in itself.The first step in this direction would be to breakthe silence within the medical profession andconduct open, public debates on these issues.Organizations of various specialty groups aswell as medical councils must take the lead. Inshort, we must restore the act of organ trans-plantation to where it really belongs; not as anexample of all that is unethical and commercialin our profession but as an example of the mar-vellous advance of modern medical science inwhich the dead can confer the gift of life to thesick.

1 May 1995 Sanjay NagralDepartment of Surgery

K.E.M. HospitalParel

BombayMaharashtra

REFERENCES

Strong RW. Selection and management of thebrain dead donor for liverand kidneytransplanta-tion. NaIl Med J India 1995;8:33-5.

2 Bakshi A, Nandi D, Guleria S. Cadaveric renaltransplants. Our experience with relatives. NollMed J India 1994;7:252.

Basal cell carcinoma of the scrotum

Skin cancer is the most common humanmalignancy and basal cell carcinoma (BCC)accounts for 65-75% of the malignant tumoursof the skin. As ultraviolet light is the mostcommon predisposing factor, 85% of all BCesoccur in the head and neck region.' However,BCCs can also occur in non-exposed areasincluding the unusual site of the scrotum andcomprise 5-7% of all scrotal carcinomas.t-'Only 26 cases of scrotal BCes have beenreported in the hterature.t-' We now reportanother case and review the literature.

A 64-year-old retired barber presented with

FIG 1. The basophilic epidermal cells formstrands and rounded cell masses occupyingupper and mid-dermis. The cells at themargin of the tumour form pallisades.Histology of the tumour is typical of anodulo-ulcerative basal cell carcinoma(H & E, x 1(0)

a 2-year history of left scrotal eruption. He wastreated with various topical corticosteroidsand antifungal drugs. The lesion graduallyincreased in size and became itchy. There wasno 'history of exposure to chemicals or indust-rial oils. Physical examination revealed a 1 cmnodular ulcer with peripheral erythema. Therewas no inguinal lymphadenopathy. The lesionwas excised with a 0.5 ern margin. Histologyrevealed BCC (Fig. 1) with the excised marginfree of tumour. There was no evidence ofrecurrence on follow up for 10 months.

Although irradiation, industrial oils, chronicirritation, and immunosuppression" have beensuggested as possible causes, the aetiology ofscrotal BCC is still unclear. The average ageof patients with scrotal BCC has been reportedto be 65 years (range: 42-82 years). 4The lesionspresent as ulcers or plaques" but other condi-tions such as extramammary Paget's disease,melanoma and Bowen's disease may mimicscrotal BCC.4

The natural history of BCC elsewhere is oneof chronic local extension and invasion. Itrarely metastasizes and the reported incidenceis only 0.0028% to 1.0%.! However, Nahasset al. described a 13% incidence of metastaticdisease in scrotal BCCs.4

Wide local excision is usually curative.Although radiotherapy has been used as thesole treatment modality in a few cases, it isgenerally. held to be ineffective primarytherapy.? Scrotal BCC has a better prognosisthan the more common squamous cell

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carcinoma. In metastatic scrotal BCC, combi-nation chemotherapy may prolong survival."

12 June 1995 W. S. HoW. W. K. King

W. Y. ChanA. K.C.Li

Departments of Surgery and Anatomicaland Cellular Pathology

Prince of Wales HospitalThe Chinese University of Hong Kong

ShatinHong Kong

REFERENCES

MillerSJ. Biologyof basalcellcarcinoma(Part I).JAm Aead DermaloI199I;24:1-13.

2 Kickman CJE, Dufresne M. An assessment ofcarcinomaof thescrotum.J UroI1967;98:108-1O.

3 Ray B, Whitmore WF Jr. Experience withcarcinomaofthe scrotum.J UroI1977;1l7:741-5.

4 Nahass GT, Blauvelt A, Leonardi CL, PenneysNS. Basal cell carcinomaof the scrotum. Reportof three cases and reviewof the literature. JAmAcad DermaloI1991;26:574-8.

5 ParysBT. Basalcellcarcinomaofthe scrotum-Arare clinicalentity. Br J Uroll991;68:434-5.

6 Miller SJ. Biologyof basal cell carcinoma (PartII). JAm Aead Dermaloll991;24:161-75.

7 Cieplinski W. Combination chemotherapy forthe treatment of metastaticbasalcellcarcinomaofthe scrotum: A case report. c/in Oneol 1984;10:267-72.

Resident doctors' strike at AllMS

The resident doctors' strike in February-March 1995 disrupted the health services ofthenation's premier medical institute, the All IndiaInstitute of Medical Sciences (AIIMS), for49 days. The agitating doctors were demandingunconditional reinstatement of a colleaguein the Department of Neurosurgery whoseservices had been terminated for his allegedprofessional incompetence. The administrationof the Institute had served the dismissal orderafter conducting an inquiry into the chargesagainst the resident. However, the ResidentDoctors' Association (RDA) maintained thatthe termination was arbitrary and Vindictive.Meanwhile, the administration managed to getits action endorsed by the faculty of the institute.We believe that this manoeuvre, instead ofresolving the crisis, aggravated it further. Itnot only prolonged the strike but unwittinglywidened the mistrust between the faculty andresidents. Each blamed the other for the dead-lock in negotiations and both stuck to their ownviews on the termination.

The strike was finally called off on 27 March1995following an order from the Union Ministerof State for Health and Family Welfare. Thefaculty, which had rejected a similar agreementearlier, found this order one-sided and weredisappointed. However, they had no option butto follow the government directive.

During this period, the strike remained astaple item for news, editorials or articles inthe regional and national press. The medical

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news magazine-Medical Pulse, publisheda prominent article entitled 'AIIMS: Strike orscandal'. By and large, the entire controversywas reduced to a series of competing allegationsand insinuations. Similarly, the discussionsin the meetings, of residents or faculty, wereconfined to 'terms' and 'technicalities' whichincluded the legality of the number of memosissued, the applicability of relevant service andconduct rules and the validity of proceduresadopted in the inquiry. All this, with anadequate dose of moralizing concerning thedeath and suffering of the patients.

I think it would be erroneous to view thisstrike in isolation. Unlike other strikes forpay hikes or accommodation, this was uniquebecause of its bearing on the academic medicalcommunity. It was the first major manifestationof the underlying malaise in Indian medicinethat has affected residents' confidence in theirteachers. The problem needs to be examinedcarefully and urgently in a broad social perspec-tive or else its resolution will remain elusive.

The AIIMS was established in 1956, with theaim of providing a model for patient care andmedical education. Is it not surprising that39 years later, there is a proposal for framingguidelines for quality control in residents' train-ing? Unless such quality audit is applied tothe teacher and the taught alike, a democraticinstitution cannot function. The central ques-tion is: Are the teachers willing to subject theirperformance and competence to audit? Theprevailing lack of accountability in the medicalprofession is not consistent with the social andeconomic changes that are now in progress inIndia. While this persists, audit in any form,as well as action taken against an individualwill remain contentious. The strike at AIIMSmay therefore be the first of a series of conflictson medical academic campuses.

28 May 1995 L. R. MurmuShashi Kant

Departments of Surgery andCommunity Medicine

All India Institute of Medical SciencesNew Delhi

Was it actually plague?

I was rather uncomfortable to read theeditorial by K. K. Datta! on the recent plagueepidemic. I am not an expert on the subjectand was not involved in investigating the cause

THE NATIONAL MEDICAL JOURNAL OF INDIA

of the outbreak; therefore I have no firm viewsone way or the other. However, following thereport of the Ramalingaswami Committee, allcontroversy related to whether it was plagueor some other disease should have ended. Butall the scientists with whom I have had an occa-sion to speak on this issue are convinced thatit was not plague and that the RamalingaswamiCommittee report is not reliable.

I am intrigued by the depth of feelings ofthe scientists. It seems there was a lack ofcommunication between the scientists, theRamalingaswami Committee, the team whichinvestigated the epidemic in the beginning andthe Ministry of Health, Government of India.

I suggest that an open discussion be heldat a public forum where all the scientists andadministrators involved with the 'plagueepidemic' are present. A senior journalist couldbe the moderator. The time and venue for thedebate must be well publicized so that anyonewilling to contribute to the information hassufficient notice. Some provision could bemade to facilitate the attendance of ~rsonsfrom out of town. Perhaps, everyone in Indiaand abroad may be encouraged to write to themoderator if they are unable to attend. Suchan effort is worth undertaking and would bemost rewarding from the national point of view.

24 May 1995 Ramesh KumarDepartment of Microbiology

All India Instituteof MedicalSciencesNewDelhi

REFERENCE

I DattaKK. Plague.NatlMed} India 1995;8:51-3.

Pitfalls in the way of today's physician

Practising medicine is not easy. There arenumerous perils and traps and no longer is thephysician placed on a pedestal by society. How-ever, unlike in the United States where thedoctor is increasingly regarded with suspicion,mostly due to the rampant commercializationof medicine in that country, the physician inIndia is still considered to be superior to allother professionals. A physician should becareful about the following:

Drugs and alcohol. It has been said that moremedical careers have been ruined by alcoholthan by any other cause.' It is very easy

VOL. 8, NO.4, 1995

to succumb to recreational drinking or drugs.This may progress to an addiction and resultin criminal negligence and impaired medicaljudgement.

Greed. Although it should be simpler for theestablished doctor to be honest, I have oftenfound that it is the leaders who are greedy,unmindful of the distress and harm they maycause poor patients. They may make falseclaims for services undertaken, do excessiveinvestigations or perform unnecessary opera-tions such as appendicectomy, tonsillectomy,cholecystectomy and hysterectomy.

According to a report." 70% of generalpractitioners in Bombay expect kickbacks. Aningenious system has been perfected wherebyconsultants give a certain percentage of theirfees to the referring general practitioners andthey in turn get their kickbacks from pathologylaboratories and expensive imaging centres.

Arrogance. Many doctors seem to be unmovedby human suffering and behave contemptuouslywith their patients and subordinates.! It isunderstandable if the sick patient is irritableand easily provoked by a seemingly minorrebuke by the doctor. The junior doctors areas stressed as their chief by the long workinghours and the unreasonable demands made onthem. Is it fair that they should bear the bruntof the boss's ill temper as well?

Family. Most doctors tend to neglect theirfamilies. Today's physician tends to take hisfamily for granted and this has led to a highincidence of divorce amongst doctor couples inthe West.

Recreation. The doctor can easily become anautomaton. There is constant pressure to takeon more and more patients, to be on variouscommittees and organizations, leaving little timefor relaxation. Fatigue often passes unnoticed,yet it insidiously undermines efficiency" till oneday the doctor may find himself in the middleof a full-fledged nervous crisis.

3 June 1995 Ravi MehrotraDepartment 'of Pathology

Motilal Nehru Medical CollegeAllahabad

Uttar Pradesh

REFERENCES

RawnsleyK. The national counsellingserviceforsickdoctors.Proc R Coli Phys Edinb 1991;21:4-7.

2 Pandya SK. Medicalcollegeschargingcapitationfees. Natl Med } India 1992;5:243-4.

3 KraybillDB, Good PP. Perils of professionalism.Ontario: Herald Press, 1962:51-78.

4 DouthwaiteAH. Pitfallsin medicine.8M} 1956;2:896-900.