Ijcp July 2013

Indexed with IndMED

ISSN 0971-0876

www.ijcpgroup.com

Volume 24, Number 2

July 2013, Pages 101-200

Peer Reviewed Journal

yy American Family Physician yy Alternative Medicine yy Anesthesiology yy Cardiology yy Dentistry

yy Dermatology yy Diabetology yy ENT

yy Gastroenterology

yy Obstetrics and Gynecology

an i c i ys ians

yy Ophthalmology

yy Orthopedics and Rheumatology

Phly Physic y l mi ami

yy Pediatrics

Fademy of F n ica Aca

yy Urology

yy Medifinance

er merican m A eA

yy Medilaw

ingurnal of th t a or d Jo

rp-reviewe o c In eer AP

Full text online: http://ebook.ijcpgroup.com/ijcp/

Single Copy Rs. 300/-

Online Submission

IJCP Group of Publications Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Padma Shri and Dr BC Roy National Awardee

Dr KK Aggarwal Group Editor-in-Chief Dr Veena Aggarwal MD, Group Executive Editor

Volume 24, Number 2, July 2013 from the desk of group editor-in-chief

105 What is Etiquette-based Medicine?

KK Aggarwal

community health

107 Sixty Percent of People do not Discuss their Sexual Behavior and Performance with the Doctor when they go for Consultation

KK Aggarwal

109 People on Facebook are more Health Aware than Nursing Students or People not on the Net

KK Aggarwal

American Family Physician

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj

110 Update on the Evaluation and Management of Functional Dyspepsia

115 Practice Guidelines 116 Photo Quiz

Cardiology Dr Praveen Chandra, Dr SK Parashar Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty ENT Dr Jasveer Singh Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dermatology Dr Hasmukh J Shroff Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan

Ryan A. Loyd, David A. McClellan

Alternative Medicine

118 Yoga: A Therapeutic Adjuvant

Jayashree Sen

Anesthesiology

122 The Urgency of Redifining Minimum Monitoring Standards in Anesthesia

LD Mishra, Ankit Agarwal

Cardiology

125 Echocardiographic Findings in Submassive Pulmonary Embolism

SR Mittal

Dentistry

130 Odontogenic Myxoma of Maxilla: Management and Follow-up of A Rare Case

Karuna Jindwani, Vilas Nevaskar, Deepak Agrawal

Dermatology

138 Accidental PUVA Burns Leading to Prurigo Nodularis:

Journal of Applied Medicine & Surgery Dr SM Rajendran, Dr Jayakar Thomas Asian Journal of Orthopedics Dr J Maheshwari Anand Gopal Bhatnagar Editorial Anchor Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

This journal is indexed in IndMED (http://indmed.nic.in) and full-text of articles are included in medIND databases (http://mednic.in) hosted by National Informatics Centre, New Delhi.

A Rare Complication of Phototherapy

Shyam Verma

diabetology

141 A Hospital-based Observational Study of Type 2 Diabetic Subjects from India

Mayur Patel, Ina M Patel, Yash M Patel, Suresh K Rathi

ENT

149 Kartagener`s Syndrome: A Case Report

Lakshmi Ponnathpur, Lakshmi Shantharam

GASTROENTEROLOGY

152 Synchronous Gastrointestinal Stromal Tumors: A Rare Case Report

Samarth Shukla, Sourya Acharya, DP Rajput, S Vagha

OBSTETRICS AND GYNECOLOGY Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

155 Effect of Rosiglitazone on Spontaneous and Clomiphene Citrateinduced Ovulation in Polycystic Ovary Syndrome

Sandhya Mittal, Anupama Goel, Ajay Mittal, Bal K Taneja, Praveen Gupta

160 Vulvar Elephantiasis of Filarial Origin: A Case Report

Rachan Chaudhary, Sudhir Rathi, Amit Maheshwari, Shipra Nigam

163 Infection Associated Hemophagocytic Lymphohistiocytosis:

Printed at IG Printers Pvt. Ltd., New Delhi E-mail: igprinter@rediffmail.com, printer_ig@yahoo.com

A Case Report

Rajani Dube, Subhranshu Sekhar Kar, Samarendra Mahapatro, Rajib Ray

166 Effect of Valethamate Bromide on the First Stage of Labor

© Copyright 2013 IJCP Publications Ltd. All rights reserved.

The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

Sreelatha S, Vedavathi Nayak, Nirmala, Satya, Renuka Ramiah

Ophthalmology

168 Ectoparasite Presenting with Common Eye Condition

SA Kareem, Kiran Madhusudhan, Nishant Thambe

Orthopedics and Rheumatology

Editorial Policies

171 Camurati-Engelmann Disease

The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

Atul Jadhav, Jaishree Ghanekar

Pediatrics

175 Retinoblastoma: A Curse to Childhood

Harpal Singh Jhagta, Prachi Jain, Manoj Gupta, Ashish Bajaj

Urology

179 Benign Prostatic Hyperplasia: Current and Future Therapeutics

Shailesh Yadav, Praveen Gupta, Manoj Goyal, Monika Bansal

Medifinance

183 Doctor’s Economic Lifecycle Medilaw

184 What is the Summary of the SC Judgment Regarding Termination of Pregnancy in a Mentally Retarded Woman? forthcoming conferences

187 Forthcoming Conferences Confederation of Medical Associations in Asia and Oceania

Note: Indian Journal of Clinical Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

188 Be Human Stop Child Abuse emedinews inspiration

189 Money is Yours but Resources belong to Society eMedi Quiz

190 Quiz Time

IJCP’s Editorial & Business Offices Delhi

Mumbai

Kolkata

Bangalore

Chennai

Hyderabad

Dr Veena Aggarwal 9811036687 E - 219, Greater Kailash, Part - I, New Delhi - 110 048 Cont.: 011-40587513 editorial@ijcp.com drveenaijcp@gmail.com Subscription Dinesh: 9891272006 subscribe@ijcp.com Ritu: 09831363901 ritu@ijcp.com

Mr. Nilesh Aggarwal 9818421222 Mr. Pravin Dhakne 8655611025, 24452066

Ritu Saigal Sr. BM 9831363901

H Chandrashekar GM Sales & Marketing 9845232974

Chitra Mohan Sr. BM 9841213823 40A, Ganapathypuram Main Road Radhanagar Chromepet Chennai - 600 044 Cont.: 22650144 chitra@ijcp.com

Venugopal GM Sales & Marketing 9849083558

Unit No: 210, 2nd Floor, Shreepal Complex Suren Road, Near Cine Magic Cinema Andheri (East) Mumbai - 400 093 nilesh.ijcp@gmail.com

Sr.: Senior; BM: Business Manager

7E, Merlin Jabakusum 28A, SN Roy Road Kolkata - 700 038 Cont.: 24452066 ritu@ijcp.com

Arora Business Centre, 111/1 & 111/2, Dickenson Road (Near Manipal Centre) Bangalore - 560 042 Cont.: 25586337 chandra@ijcp.com

H. No. 16-2-751/A/70 First Floor Karan Bagh Gaddiannaram Dil Sukh Nagar Hyderabad 500 059 Cont.: 65454254 venu@ijcp.com

from the desk of group editor-in-chief Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS National Vice President, Elect, IMA Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

What is Etiquette-based Medicine?

O

ur body consists of physique, mind, intellect, memory, ego and soul. We, therefore, have our physical profile, mental profile, ego profile and a soul profile. Our soul profile makes us calm, compassionate, caring, smiling with full of empathy. Our ego profile (controlled) on the other hand makes us behave like a well-dressed and self-disciplined gentleman.

Patients want us to live upto our soul profile and be compassionate with them and practice empathy and not sympathy.

To practice conscious-based medicine, one needs to control one’s desires and detach oneself from the results of action and from attachment to the patient and the worldly atmosphere.

The job of medical associations and the councils should be to educate medical graduates to become compassionate physicians and if that is not possible, they should at least inculcate etiquettes and habits to make them learn good behavior.

The new terminology for intellectual profile or skill-based profile is now called etiquette-based medicine, which prioritizes behavior over feeling, stresses practice and mastery over character development and puts professionalism and patient satisfaction at the center of the clinical counter and brings back some of the elements of the rituals that have always been important part of healing profession.

It is simpler to change behavior than attitude. Training of etiquette-based medicine complements with physicians becoming more humane. However, the aim should not be to make etiquette-based medicines a priority over compassionate based medicines.

The first step in etiquette-based medicine is to learn good manners and good bedside skills. It includes patientdoctor communication and details of explanations at admission and discharge or declaring deaths.

For example, when you are meeting a patient for the first time at the time of hospitalization, you may not be compassionate but at least you can follow the following: ÂÂ Acknowledge the patient and ask permission to enter the room and wait for an answer. ÂÂ Introduce yourself - shake hands and let the patient know your name. ÂÂ Sit down near the patient and smile. ÂÂ Explain in detail your role in the team. ÂÂ Explain about the time, duration of everything of your plan. ÂÂ And lastly, always thank the patient for giving you an opportunity to serve him.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

105

from the desk of group editor-in-chief Such a checklist is clear, efficient to teach, evaluate and is easy for anyone to practice. It does not address the way a doctor feels but at least it disciplines us how to behave.

Let our patients not start writing in the suggestion cards as under: ÂÂ My doctor was not with me during consultation ÂÂ My doctor never smiles. ÂÂ I have no idea to whom I was talking to ÂÂ My doctor did not look in my eyes even once ÂÂ My doctor was all the time receiving phone calls on mobiles ÂÂ My doctor’s concentration was on the computer screen.

(With excerpts from Dr MW Khan, MD, New MEJM 2008;358, 1988-89, May 8).

■■■■

106

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

community health

Sixty Percent of People do not Discuss their Sexual Behavior and Performance with the Doctor when they go for Consultation KK Aggarwal

Abstract On Doctor’s Day 2013 a survey was conducted to assess the perception of doctor-patient relationship among the people and the expectations of the patients from the doctors. Data was collected using a questionnaire came up with some interesting changing trends among the people with regard to doctor-patient relationship.

Keywords: Family physician, specialist, sexual history, etiquette based medicine, privacy, health insurance

A

survey of 452 people was conducted by Heart Care Foundation of India and eMedinewS on the occasion of Doctors Day 2013. The objective of the survey was to assess the perception of doctor-patient relationship among the people and the expectations of the patients from the doctors.

The survey included patients, social workers, RWAs, morning walkers, college students and government employees from NCR Delhi and consisted of middle to high socioeconomic strata. Data was collected using a questionnaire, which the survey participants were asked to answer. The data came up with some interesting changing trends among the people with regard to doctor-patient relationship.

New trend to directly go to specialists The survey revealed that only 42% had a family physician. When suffering from an illness, 52% of the people would directly opt to visit a specialist and not a family physician, which is not a good trend. The traditional concept of a ‘family physician’ that looked after all the health needs of a family regardless of his/ her specialization, is now changing.

Sexual preferences, choices and behaviors Eighty percent of the people want their doctors to ask about the sexual history in confidence. They feel

Padma Shri & Dr BC Roy National Awardee President Heart Care Foundation of India E-mail: emedinews@gmail.com

shy coming out with the history as most of the times patients are accompanied by the relations. The survey found that 60% of the patients have never opened out to their doctors and 80% of the doctors have never asked then about the sexual history. This brings them to seek help from sex quacks and advise from friends and neighborhood.

The survey found that people are sexually active even at elderly age. The proportion of man reporting no sex is 20% at age 51-60 and 87.5% at age above 75. In women, reporting no sex is 100% after the age of 70.

About 16.17% of men reported that they are facing erectile dysfunction and 17.64% are having premature ejaculation during sexual act.

The survey enlisted that the public wanted the following to be asked to them in isolation in person or through a document about the following: ÂÂ Are you sexually active ÂÂ Are you satisfied with your sexual life ÂÂ Are you sexually attracted to men, women or both ÂÂ Do you have multiple partners People want experienced doctors Sixty-five percent prefer senior doctors with white hair to treat them as they can provide better patient care than their younger fashionable counterparts with less clinical experience. Hundred percent of the people said that if their doctor cannot practice ‘compassion based medicine’ at least practice ‘etiquette-based medicine’.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

107

community health Sixty percent of the people put their faith in the capabilities of their doctor and not on their dress code.

Fifty-seven percent however check the credentials and qualifications of a doctor before visiting them for consultation. This is a new trend in the society.

When asked about the criteria of a good doctor 90% people said that for them availability and behavior of a doctor is more important than competency. “What is the use of a competent doctor if he is not available and is arrogant”: Was the common question asked by them?

When questioned about the etiquette based medicine, 84% people said that they would like their doctor to call them with their name; would like the doctor to introduce about his credentials and competency; would like to explain and reason out the plan and duration of treatment.

Patients want privacy Forty percent of the people did not want doctors to be their friends on Facebook. New International guidelines also warn doctors not to be connected with their patients on facebook. Eighty percent of the people wanted that their personal health information should not be leaked to any one without asking them including the spouse and their name should not be shouted outside the operation theatre or the intensive care unit (ICU).

Patients do not like smoking doctors Eighty-one percent people reported being disturbed when they saw their doctors smoking in public and would not like to be treated by a doctor who smoked in front of them.

Patients want doctors to write legibly

Patients want doctors to spend more time with them Forty-nine percent people reported being satisfied with less 15 minutes of a doctor’s time; 26% wanted their doctor to spend more than 15 minutes with them and the rest wanted time till they were satisfied. Fifty-four percent people said that their doctors never advised them about adult vaccination. This needs immediate attention. Fifty-five percent said that their blood pressure had never been checked in both arms. Fortynine percent people said that they would prefer to take a dietary advice from their doctor and not from a dietitian.

Patient wants second opinion from the same doctor Sixty percent people wanted to get a second opinion from their regular doctor if they are not satisfied.

Seventy-two percent people do not want doctors to treat them just on clinical grounds but prefer getting investigated first. When advised investigations, 57% would ask their doctor to suggest a lab, while the rest said that they would choose their own lab.

Patient etiquette Forty-six percent people said that they preferred to call their doctor directly to fix an appointment and not the secretary. When calling for an appointment, 53% would choose to call on a mobile number and not the landline, whether the call is to the doctor or the secretary.

Ignorance is still high ÂÂ Forty-seven percent persons did not have any health insurance.

Sixty-seven percent people felt that their doctors should have legible handwriting and favored an electronic prescription instead.

ÂÂ Forty-nine percent did not know that when they are hiring a room in a private hospital, the insurance covers only 1% of the sum amount insured for the bed.

Patients want affordable, quality and safe medical care

ÂÂ Fifty-two percent of the people do not know that error of judgment or difference of opinion is not an act of negligence on the part of the doctor.

Seventy-eight percent people felt that medical profession is becoming commercialized today and should be made more affordable for a common man.

Seventy-two percent people said that doctors should be transparent in their fee. Fifty-nine percent people felt that doctors’ charging less fee is not their concern. But, 41% were of the opinion that doctors should charge less as their profession is a noble one.

108

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

ÂÂ Forty-eight percent people were unaware of the fact that a doctor is supposed to possess only an average degree of skill and knowledge and not the maximum degree of skill and knowledge when treating a patient. ÂÂ Thirty percent of the people were unaware that creating violence in the hospital premises is an offence.

community health

People on Facebook are more Health Aware than Nursing Students or People not on the Net KK Aggarwal

Abstract In a survey of two hundred net savvy people, 500 nursing students and 400 general public aged 14-70 years attending the Perfect Health Mela 2012 it was seen that the level of health awareness was much higher in net savvy people compared to nursing students and general public.

Keywords: Net savvy, nursing, general public, cholesterol, trans fats, garlic, turmeric

N

ew Delhi, India: Two hundred net savvy people, 500 nursing students and 400 general public aged 14-70 years attending the Perfect Health Mela 2012 were interviewed and their level of health awareness was compared. The level of awareness was highest in the net savvy people. ÂÂ Eighty percent of the net savvy people, 67% of the nursing students and 64% of general public answered correctly that foods that are of plant in origin have no cholesterol.

and 90% of general public answered correctly that garlic is good for health. ÂÂ All the net savvy people, 85% of nursing students and 95% of the general public answered correctly that turmeric has anti-inflammatory properties. ÂÂ Seventy-three percent of net savvy people, 70% of the nursing students and 60% of the general public answered correctly that with advancement of age, one should eat less.

ÂÂ Seventy-four percent of the net savvy people, 63% of nursing students and 75% of general public answered correctly that trans fats are bad for health.

ÂÂ Seventy-three of net savvy people, 60% of the nursing students and 65% of general public answered correctly that foods, which are bitter in taste reduce diabetes.

ÂÂ Ninety-four percent of the net savvy people, 68% of nursing students and 45% of general public answered correctly that unsaturated fat is liquid at room temperature.

ÂÂ All net savvy people, 80% nursing students and 90% general public answered correctly that one should include all seven colors and 6 tastes in their food.

ÂÂ Seventy-five percent of net savvy people, 49% nursing students and 43% of the general public answered correctly that fat solid at room temperature is saturated fat. ÂÂ All the net savvy people, 95% of nursing students

ÂÂ All net savvy people, 90% of nursing students and 90% of general public answered correctly that death is reversible in the first 10 minutes of cardiac arrest.

The level of health awareness was found to be much higher in net savvy people compared to nursing students and general public.

Padma Shri & Dr BC Roy National Awardee President Heart Care Foundation of India E-mail: emedinews@gmail.com

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

109

American Family Physician

Update on the Evaluation and Management of Functional Dyspepsia RYAN A. LOYD, DAVID A. Mcclellan

Abstract Dyspepsia affects up to 40 percent of adults each year and is often diagnosed as functional (nonulcer) dyspepsia. The defining symptoms are postprandial fullness, early satiation, or epigastric pain or burning in the absence of causative structural disease.

These symptoms may coexist with symptoms of functional gastrointestinal disorders, such as gastroesophageal reflux and irritable bowel syndrome, as well as anxiety and depression. The history and physical examination can help identify other possible causes of the symptoms. Warning signs of serious disease, such as cancer, are unintended weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, and a family history of cancer. In these cases, more extensive laboratory investigation, imaging, and endoscopy should be considered as clinically indicated. During the initial evaluation, a test-and-treat strategy to identify and eradicate Helicobacter pylori infection is more effective than empiric treatment and more cost-effective than initial endoscopy. Eradication of H. pylori helps one out of 15 patients with functional dyspepsia diagnosed by endoscopy, but may not be cost-effective. Treatment options that may be beneficial for functional dyspepsia include histamine H2 blockers, proton pump inhibitors, and prokinetic agents. Although psychotropic medications and psychological interventions have no proven benefit in patients with functional dyspepsia, they are appropriate for treating common psychiatric comorbidities.

Keywords: Dyspepsia, gastroesophageal reflux, irritable bowel syndrome, Helicobacter pylori infection, histamine H2 blockers, proton pump inhibitors, prokinetic agents

D

yspepsia affects up to 40 percent of adults each year, and about 10 percent of those affected seek medical care.1 Most cases in patients who seek care are eventually diagnosed as functional dyspepsia.2 Functional (nonulcer) dyspepsia is defined as the presence of postprandial fullness, early satiation, or epigastric pain or burning in the absence of causative structural disease (Table 1).3,4

Recent guidelines distinguish dyspepsia from heartburn and gastroesophageal reflux symptoms, which often coincide with dyspepsia but are considered separate entities.5 Previous studies have used a variety of definitions for dyspepsia. As a result, further research is needed to better differentiate functional dyspepsia from other diseases of the gastrointestinal (GI) tract. To facilitate this research, the Rome III diagnostic criteria divide functional dyspepsia into two subcategories: epigastric pain syndrome (i.e., epigastric pain or burning) and postprandial distress syndrome (i.e., postprandial fullness or early satiation).3 RYAN A. LOYD, MD, is an assistant professor of family and community medicine, and director of global health for the Family Medicine Residency at the Texas A&M Health Science Center College of Medicine in Bryan, Tex. DAVID A. McCLELLAN, MD, is an assistant professor of family and community medicine, and director of the Family Medicine Residency at the Texas A&M Health Science Center College of Medicine.

Source: Adapted from Am Fam Physician. 2011;83(5):547-552.

110

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Table 1. Rome III Diagnostic Criteria for Functional Dyspepsia Presence of at least one of the following: Bothersome postprandial fullness Early satiation Epigastric pain Epigastric burning and No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms Note: Criteria must be fulfilled for the past three months, with symptom onset at least six months before diagnosis.

Information from references 3 and 4.

Pathophysiology There is no definitive pathophysiologic mechanism for functional dyspepsia, which suggests that it is a heterogeneous group of disorders. Patients with functional dyspepsia commonly have coexisting symptoms of irritable bowel syndrome or other functional GI disorders.6 In one 10-year follow-up study of patients with dyspepsia or irritable bowel syndrome, 40 percent of symptomatic patients switched subgroups over the study period.7

American Family Physician Several studies implicate gastric dysmotility in the pathophysiology of functional dyspepsia.8-12 Many patients experience motility-related symptoms, such as bloating, early satiation, nausea, and vomiting.

Studies have documented altered gastric motility (e.g., gastroparesis, gastric dysrhythmias, abnormal fundus accumulation, pyloric sphincter dysfunction) in up to 80 percent of patients with functional dyspepsia.8,9 However, the degree of dysmotility does not correlate with symptoms.8-12 Because many patients with functional dyspepsia have burning pain that is indistinguishable from ulcerrelated dyspepsia, the relationship between functional dyspepsia and acid secretion is unclear. One study demonstrated a lower pH level in the duodenum of patients with functional dyspepsia compared with those in the control group, although the pH level did not correlate with symptoms.13 The role of Helicobacter pylori infection in functional dyspepsia has also been investigated. Large population studies have shown an increased incidence of H. pylori infection in patients with functional dyspepsia; however, given the high incidence of both conditions in the general population and the minimal response to treatment, the significance of the association is unclear.1,14 In spite of this uncertainty, testing for and treating H. pylori infection have become integral to the diagnostic management of functional dyspepsia.

Diagnostic Approach Functional dyspepsia is a diagnosis of exclusion; therefore, physicians should focus on excluding serious or specifically treatable diseases, without spending too much time investigating symptoms. Dyspepsia has a broad and diverse differential diagnosis (Table 2),15-18 including functional dyspepsia, peptic ulcer disease, reflux esophagitis, and gastric or esophageal malignancy. Functional dyspepsia is the most prevalent diagnosis, making up 70 percent of dyspepsia cases.15 The physician should perform a detailed history and physical examination at the initial presentation, noting any findings that point to a diagnosis other than functional dyspepsia (e.g., right upper-quadrant pain with cholelithiasis, exercise association with coronary artery disease, radiation to the back with pancreatitis). Table 3 includes medications and other agents commonly associated with dyspepsia.19 Because the differential diagnosis is broad, the workup can range from empiric therapy to extensive laboratory and imaging studies. Figure 1 is an algorithm for the

Table 2. Differential Diagnosis of Dyspepsia Diagnostic category Functional (nonulcer) dyspepsia Peptic ulcer disease Reflux esophagitis Gastric or esophageal cancer Abdominal cancer, especially pancreatic cancer Biliary tract disease Carbohydrate malabsorption (lactose, sorbitol, fructose, mannitol) Gastroparesis Hepatoma Infiltrative diseases of the stomach (Crohn disease, sarcoidosis) Intestinal parasites (Giardia species, Strongyloides species) Ischemic bowel disease Medication effects (Table 3) Metabolic disturbances (hypercalcemia, hyperkalemia) Pancreatitis Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease)

Approximate prevalence* Up to 70 percent 15 to 25 percent 5 to 15 percent < 2 percent Rare Rare Rare Rare Rare Rare Rare Rare Rare Rare Rare Rare

*Based on the occurrence of the disorders in patients with dyspepsia who are evaluated with endoscopy.

Information from references 15 through 18.

Table 3. Agents Commonly Associated with Dyspepsia Acarbose

Metformin

Alcohol

Miglitol

Antibiotics, oral (e.g., erythromycin)

Nonsteroidal antiinflammatory drugs, including cyclooxygenase-2 inhibitors

Bisphosphonates Corticosteroids (e.g., prednisone)

Opiates

Herbs (e.g., garlic, ginkgo, saw palmetto, feverfew, chaste tree berry, white willow)

Potassium chloride

Iron

Theophylline

Orlistat

evaluation and treatment of patients with dyspepsia.5,19 History and physical examination alone have low sensitivity and specificity for predicting which patients with dyspepsia will have organic disease discovered on esophagogastroduodenoscopy.15,20 Because of this inaccuracy, the high incidence of normal endoscopic

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

111

American Family Physician Evaluation and management of dyspepsia Patient presents with uninvestigated dyspepsia

Exclude diagnoses with history and physical examination findings (see Table 2 for differential diagnosis)

Evaluate patient for serious risk factors: age > 55 years,5 unintended weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, family history of cancer

Risk factors present

No risk factors

Perform endoscopy

Positive for specific diagnosis: treat as indicated

Negative results Test for Helicobacter pylori infection, and treat if present* Trial of antisecretory therapy if patient is still symptomatic

No improvement

Improvement

Perform endoscopy

Continue treatment with periodic reevaluation

signs for serious disease, a test-and-treat strategy is effective and cheaper than initial endoscopy.21 Initial endoscopy has been shown to provide a small reduction in the risk of recurrent dyspepsia symptoms; however, physicians need to weigh the cost of endoscopy against patient preference for early reassurance and symptom reduction.21 The Cochrane review showed the testand-treat strategy to be slightly more effective than empiric acid suppressants, although the comparative cost-effectiveness of these strategies has not been established.21 Physicians can diagnose H. pylori infection with noninvasive tests, such as serologic, stool antigen, or urea breath tests. Serologic testing is the most common because of its wide availability and low cost, although urea breath testing is more accurate.22 In patients 55 years or younger, the American Gastroenterological Association (AGA) identifies several warning signs that should trigger an early, aggressive workup (e.g., unintended weight loss, progressive dysphagia, persistent vomiting, evidence of GI bleeding, family history of cancer).5 The AGA recommends proceeding directly to endoscopy in patients with warning signs and in those older than 55 years5; however, there has been debate about a lower cutoff age of 35 to 45 years in men.23 Although it is not addressed in the AGA guidelines, an initial complete blood count may be appropriate to screen for anemia. The AGA guidelines do not address laboratory testing and imaging; however, it is reasonable to consider these approaches in patients with negative esophagogastroduodenoscopy findings and warning signs, or if the treatment course is unsuccessful.

Treatment

Evaluate and treat comorbid conditions (e.g., stress, anxiety, depression) Consider judicious use of laboratory tests and imaging when clinically indicated *Physicians may prefer a trial of antisecretory therapy before testing for H. pylori infection, especially when the onset of dyspepsia is relatively recent (less than three to six months)

Figure 1. Algorithm for the evaluation and management of dyspepsia.

findings, and the very low incidence of malignancy, it is desirable to try empiric treatment before invasive and expensive diagnostic testing.

Several strategies have been suggested for initial management of uninvestigated dyspepsia, including a trial of acid suppressants, a test-and-treat approach (for H. pylori infection), and early endoscopy.

A Cochrane review found that in the absence of warning

112

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Treatment of functional dyspepsia can be frustrating for physicians and patients because few treatment options have proven effective. Patients will need continued reassurance and support from their physicians.

Treatment is generally aimed at one of the presumed underlying etiologies of functional dyspepsia.

Gastric Acid Suppression Gastric acid suppressants have been studied extensively in the treatment of functional dyspepsia. Although their benefit in patients with ulcer-related dyspepsia or gastroesophageal reflux disease is considerable, the benefit in patients with functional dyspepsia is less clear. Antacids, sucralfate, and misoprostol have been evaluated in limited studies without evidence of benefit.24 Bismuth salts showed some benefit compared with placebo in a meta-analysis;

American Family Physician however, the studies that showed benefit were not well designed and involved only patients with H. pylori infection, with intent to eradicate the infection.

Because of the questionable benefit and long-term risk of neurotoxicity, bismuth salts cannot be recommended as first-line agents for functional dyspepsia.24 Histamine H2 blockers are more promising agents for treating functional dyspepsia and have been evaluated in multiple trials. A meta-analysis concluded that H2 blockers significantly improve symptoms; however, there was evidence of some publication bias, and the effect may have been overestimated, especially in comparison with proton pump inhibitors.24 Studies of proton pump inhibitors have shown a statistically significant improvement in symptoms of functional dyspepsia compared with placebo. These studies were of better quality than those investigating H2 blockers, making it difficult to compare relative effectiveness.24 Given the small benefit of gastric acid suppressants and the commonly chronic nature of functional dyspepsia symptoms, physicians must consider the cost and longterm safety profile of the medication chosen for initial treatment.

Prokinetics Many patients with functional dyspepsia report predominant symptoms of bloating, early satiation, nausea, and vomiting. As a result, physicians have tried targeting treatment at improving GI motility. Multiple randomized controlled trials have demonstrated that prokinetic agents are effective in treating functional dyspepsia.24 However, the quality of these studies is questionable, and the effectiveness of the agents may have been overestimated. The trials showing effectiveness tended to be targeted at patients with symptoms suggestive of motility disorders, raising the question of their effectiveness in cases of isolated epigastric pain.

Also, most studies showing effectiveness used cisapride, which has since been removed from the U.S. market because of concerns about cardiac arrhythmias.24 One study has shown that domperidone is effective for functional dyspepsia.24 Domperidone is relatively safe, but has not been approved for use in the United States.

The only available prokinetic agents in the United States are metoclopramide and erythromycin, for which the evidence is sparse. Metoclopramide may cause tardive dyskinesia and parkinsonian symptoms in older persons, limiting its use.24 Erythromycin has some prokinetic effects and is used to treat gastroparesis. However, erythromycin has not been studied as a treatment for functional dyspepsia, so its effectiveness is unknown.

There is some initial evidence to suggest that herbal formulations containing peppermint improve functional dyspepsia symptoms, possibly through effects on the smooth muscle of the intestines.25,26 However, peppermint formulations available in the United States have not been well studied, and more research is needed.

H. pylori Eradication H. pylori eradication may be beneficial as an initial strategy for management of uninvestigated dyspepsia before endoscopy. Several meta-analyses have examined eradication therapy in patients with endoscopically confirmed functional dyspepsia.19 Although there have been some discrepancies between studies, the most recent meta-analysis showed a small but statistically significant improvement in functional dyspepsia symptoms with H. pylori eradication.27 The number needed to treat for one patient to have relief of symptoms is 15. It is not known whether this strategy is cost-effective.22,27

Psychotropic and Psychological Interventions Because of the high rate of coexisting depression and psychiatric illness in patients with refractory functional dyspepsia, many physicians prescribe antidepressants.

However, there are only limited studies with a lack of randomized controlled trials supporting this strategy.

A meta-analysis showed that tricyclic antidepressants significantly improved functional GI disorders, but the review did not isolate functional dyspepsia from other functional GI disorders, such as irritable bowel syndrome and heartburn.28 A small crossover study found that low-dose amitriptyline improved functional dyspepsia symptoms; however, it included only 14 patients and lasted only one month.29 A larger study of children with irritable bowel syndrome, functional abdominal pain, or functional dyspepsia showed no improvement with amitriptyline versus placebo.30 More trials are underway that may elucidate the use of tricyclic antidepressants in patients with functional dyspepsia.31 Four randomized controlled trials investigated the use of psychological interventions in patients with dyspepsia symptoms.32 Because each trial evaluated a different intervention (i.e., psychotherapy, psychodrama, cognitive behavior therapy, relaxation therapy, and hypnosis), no meta-analysis was possible. Additionally, because of the poor quality of these trials, there was insufficient evidence to recommend these interventions for treatment of dyspepsia. However, these methods can still be used to treat common psychiatric comorbidities.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

113

American Family Physician REFERENCES 1. McNamara DA, Buckley M, O’Morain CA. Nonulcer dyspepsia. Current concepts and management.

Gastroenterol Clin North Am. 2000;29(4):807-818.

2. McQuaid K. Dyspepsia. In: Feldman M, Friedman LS, Sleisenger MH. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 7th ed. Philadelphia, Pa.: Saunders; 2002:102-103.

3. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders [published correction appears in Gastroenterology. 2006;131(1):336]. Gastroenterology.

2006;130(5):1466-1479.

4. Drossman DA, Corazziari E, Delvaux M, et al. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, Va.: Degnon Associates; 2006. http://theromefoundation. org/assets/pdf/19_RomeIII_apA_885-898. pdf. Accessed June 15, 2010.

5. Talley NJ. American Gastroenterological Association medical position statement: evaluation of dyspepsia.

Gastroenterology. 2005;129(5):1753-1755.

6. Kaji M, Fujiwara Y, Shiba M, et al. Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life. J Gastroenterol Hepatol. 2010;25(6):1151-1156.

7. Ford AC, Forman D, Bailey AG, Axon AT, Moayyedi P. Fluctuation of gastrointestinal symptoms in the community: a 10-year longitudinal follow-up study.

Aliment Pharmacol Ther. 2008;28(8):1013-1020.

8. Sha W, Pasricha PJ, Chen JD. Correlations among electrogastrogram, gastric dysmotility, and duodenal dysmotility in patients with functional dyspepsia. J Clin Gastroenterol. 2009;43(8):716-722.

9. Sha W, Pasricha PJ, Chen JD. Rhythmic and spatial abnormalities of gastric slow waves in patients with functional dyspepsia. J Clin Gastroenterol. 2009;43(2): 123-129.

10. Mizushima T, Sawa K, Ochi K, et al. Gastrobiliary motility is not coordinated in patients with non-ulcer dyspepsia of normal gastric emptying time: simultaneous sonographic study. J Gastroenterol Hepatol. 2005;20(6):910-914.

11. Lin X, Levanon D, Chen JD. Impaired postprandial gastric slow waves in patients with functional dyspepsia. Dig Dis Sci. 1998;43(8):1678-1684.

12. Lin Z, Eaker EY, Sarosiek I, McCallum RW. Gastric myoelectrical activity and gastric emptying in patients with functional dyspepsia. Am J Gastroenterol.

1999;94(9):2384-2389.

13. Bratten J, Jones MP. Prolonged recording of duodenal acid exposure in patients with functional dyspepsia and controls using a radiotelemetry pH monitoring system.

J Clin Gastroenterol. 2009;43(6):527-533.

14. Armstrong D. Helicobacter pylori infection and dyspepsia.

Scand J Gastroenterol Suppl. 1996;215:38-47.

15. Value of the unaided clinical diagnosis in dyspeptic patients in primary care. Am J Gastroenterol. 2001;96(5):1417-1421.

114

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

16. Bazaldua OV, Schneider FD. Evaluation and management of dyspepsia. Am Fam Physician. 1999;60(6):1773-1784.

17. Talley NJ, Silverstein MD, Agréus L, Nyrén O, Sonnenberg A, Holtmann G. AGA technical review: evaluation of dyspepsia. American Gastroenterological Association.

Gastroenterology. 1998;114(3):582-595.

18. Fisher RS, Parkman HP. Management of nonulcer dyspepsia. N Engl J Med. 1998;339(19):1376-1381.

19. Dickerson LM, King DE. Evaluation and management of nonulcer dyspepsia. Am Fam Physician. 2004;70(1): 107-114.

20. Moayyedi P, Talley NJ, Fennerty MB, Vakil N. Can the clinical history distinguish between organic and functional dyspepsia? JAMA. 2006; 295(13):1566-1576.

21. Delaney B, Ford AC, Forman D, Moayyedi P, Qume M. Initial management strategies for dyspepsia. Cochrane Database Syst Rev. 2005;(4): CD001961.

22. Ables AZ, Simon I, Melton ER. Update on Helicobacter pylori treatment. Am Fam Physician. 2007;75(3):351-358.

23. Marmo R, Rotondano G, Piscopo R, et al. Combination of age and sex improves the ability to predict upper gastrointestinal malignancy in patients with uncomplicated dyspepsia: a prospective multicentre database study. Am J Gastroenterol. 2005;100(4):784-791.

24. Moayyedi P, Soo S, Deeks J, Delaney B, Innes M, Forman D. Pharmacological interventions for non-ulcer dyspepsia.

Cochrane Database Syst Rev. 2006;(4):CD001960.

25. Kligler B, Chaudhary S. Peppermint oil. Am Fam Physician. 2007;75(7):1027-1030.

26. Melzer J, Rösch W, Reichling J, Brignoli R, Saller R. Metaanalysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast). Aliment Pharmacol Ther. 2004;20(11-12):1279-1287.

27. Moayyedi P, Soo S, Deeks J, et al. Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006;(2):CD002096.

28. Jackson JL, O’Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a metaanalysis. Am J Med. 2000;108(1):65-72.

29. Mertz H, Fass R, Kodner A, Yan-Go F, Fullerton S, Mayer EA. Effect of amitriptyline on symptoms, sleep, and visceral perception in patients with functional dyspepsia.

Am J Gastroenterol. 1998;93(2):160-165.

30. Saps M, Youssef N, Miranda A, et al. Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional gastrointestinal disorders.

Gastroenterology. 2009;137(4):1261-1269.

31. Talley NJ, Herrick L, Locke GR. Antidepressants in functional dyspepsia. Expert Rev Gastroenterol Hepatol.

2010;4(1):5-8.

32. Soo S, Moayyedi P, Deeks J, Delaney B, Lewis M, Forman D. Psychological interventions for non-ulcer dyspepsia.

Cochrane Database Syst Rev. 2005;(2):CD002301.

American Family Physician

Practice Guidelines

AAP Reports on Diagnosis and Prevention of Iron Deficiency Anemia Iron is the most common single-nutrient deficiency among children in developing countries and is a common cause of anemia in industrialized nations.

Evidence shows that iron deficiency and iron deficiency anemia during infancy and childhood may have longlasting detrimental effects on neurodevelopment that may not be reversible.

Approximately 80 percent of the iron in newborn infants is accumulated during the third trimester of pregnancy; therefore, infants born prematurely may be iron deficient. Maternal conditions such as anemia, hypertension with intrauterine growth restriction, or diabetes mellitus can also result in low fetal iron stores.

Full-term healthy infants have sufficient iron for at least the first four months of life. Because human milk contains little iron, infants who are breastfed exclusively are at risk of iron deficiency after four months of age and should receive 1 mg of supplemental iron daily per kg of body weight. Supplementation should continue until iron-containing foods are introduced in the diet. Starting at four months of age, infants who are breastfed for more than one-half of their feedings should also receive 1 mg of supplemental iron daily per kg of body weight.

In formula-fed infants, iron needs can be met for the first 12 months of life by using formula that contains 12 mg of iron per dL and by introducing iron-containing foods after four to six months of age. Whole milk should not be given before 12 months of age.

Iron intake in infants between six and 12 months of age should be 11 mg per day. Liquid iron supplements are appropriate if iron needs are not being met.

Iron intake in children one to three years of age should be 7 mg per day. Liquid supplements are suitable in those who do not receive this intake. Chewable multivitamins can be used in children three years and older.

Iron intake in preterm infants should be at least 2 mg per day through 12 months of age. Preterm infants who are breastfed should receive 2 mg of supplemental iron per kg of body weight each day by one month of age, and supplementation should continue until the infant is weaned to iron-fortified formula or begins to eat foods that supply 2 mg of iron per kg of body weight.

Supplementation is not required in infants who have received an iron load from multiple transfusions of packed red blood cells.

Universal screening for anemia should be performed at 12 months of age, with measurement of hemoglobin levels and an assessment of risk factors associated with iron deficiency and iron deficiency anemia. Additional screening can be performed in children one to three years of age who have risk factors for iron deficiency or iron deficiency anemia.

Further evaluation is required in children with hemoglobin levels less than 11 g per dL (110 g per L) at 12 months of age. If the child is at high dietary risk of iron deficiency, testing should be performed because of potential adverse effects on neurodevelopmental outcomes. Additional screening tests should include measurement of serum ferritin and C-reactive protein levels, or measurement of reticulocyte hemoglobin concentration.

Children with mild anemia (hemoglobin level of 10 to 11 g per dL [100 to 110 g per L]) who can be monitored closely can be diagnosed by documenting an increase of 1 g per dL in plasma hemoglobin concentration after one month of iron-replacement therapy.

Source: Adapted from Am Fam Physician. 2011;83(5):624.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

115

American Family Physician

Photo Quiz

Ulcer on Lower Lip of Deployed Serviceman A 46-year-old serviceman deployed to Iraq presented with a papule on his lower lip that had developed over four weeks. Two days after the patient nicked his lip with a razor, a small, red, tender bump appeared.

Over the next few weeks, the bump became firmer and slowly enlarged.

Although the patient had received multiple insect bites in the previous weeks, he did not recall any on his lips.

He had no fever or chills. He had used smokeless tobacco for 20 years and had moderate sun exposure as a child and adult. Physical examination revealed an indurated, 4-mm papule with a dry central ulcer (see accompanying figure). There was no regional lymphadenopathy, and the patient was otherwise healthy.

A. Arthropod envenomation necrosis.

B. Cutaneous leishmaniasis.

Question

C. Ecthyma.

Based on the patientâ&#x20AC;&#x2122;s history and physical examination, which one of the following is the most likely diagnosis?

D. Ecthyma gangrenosum.

E. Squamous cell carcinoma.

See the following page for discussion.

Source: Adapted from Am Fam Physician. 2011;83(5):601-602.

116

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

American Family Physician Leishmaniasis is caused by intracellular parasites that gain entry during an arthropod bite. The disease can manifest as primary local lesions, delayed mucocutaneous lesions, or visceral leishmaniasis.

The classic description of leishmaniasis is a nonhealing ulcer with a rolled border. Because of this patient’s travel history, leishmaniasis must be carefully considered,5 especially if there is no response to initial therapy.

Summary Table Condition

Characteristics

Arthropod envenomation necrosis

Large, painful, rapidly developing ulcers surrounded by erythema; may develop central eschar

Cutaneous leishmaniasis

A polymorphic eruption, but classically described as a nonhealing ulcer with a rolled border at the site of an arthropod bite

Ecthyma

Begins as a vesicle or vesicopustule, then develops hemorrhagic crust

Ecthyma gangrenosum

Papule with hemorrhagic crust resembling ecthyma; deep tissue Gram stain and culture can confirm diagnosis, if needed

Squamous cell carcinoma

Slowly progressive, scaly papule on sun-exposed areas of skin

Ecthyma gangrenosum is a pseudomonal infection leading to a papule with hemorrhagic crust similar to ecthyma. It results from hematogenous spread of Pseudomonas, which is not suggested by the patient’s history or examination. Ecthyma gangrenosum usually occurs in persons who are immunosuppressed or gravely ill.3 When ecthyma gangrenosum is suspected, biopsy with deep tissue Gram stain and culture can be used for diagnosis.

Discussion The answer is C: ecthyma.

Ecthyma is a cutaneous bacterial infection that extends into the dermis. It usually occurs on disrupted skin,1 beginning as a vesicle or vesicopustule, then developing a hemorrhagic crust.2 Ecthyma is classically associated with group A streptococci, but staphylococci may also be present. Because the infection extends into the dermis, scarring may result. Ecthyma is treated using systemic antibiotics with good gram-positive coverage.3 Arthropod envenomation from several types of stinging insects can quickly cause large, painful ulcers that are surrounded by erythema. Central eschar may develop.

However, it is unlikely that a sting on the patient’s lip would go unnoticed. Insect bites and stings with or without envenomation can also serve as portals for infection, including ecthyma.4

Squamous cell carcinoma often occurs on sun-exposed skin. It presents as a slowly progressive, scaly papule.

The quick progression of the patient’s lesion and the history of trauma to his lip are more consistent with an infectious process than squamous cell carcinoma.

References 1. Wasserzug O, Valinsky L, Klement E, et al. A cluster of ecthyma outbreaks caused by a single clone of invasive and highly infective Streptococcus pyogenes. Clin Infect Dis. 2009;48(9):1213-1219.

2. Bolognia J, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. St. Louis, Mo.: Mosby; 2008.

3. James WD, Berger TG, Elston DM, Odom RB, eds.

Andrew’s Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2006.

4. Hochedez P, Canestri A, Lecso M, Valin N, Bricaire F, Caumes E. Skin and soft tissue infections in returning travelers. Am J Trop Med Hyg. 2009;80(3):431-434.

5. AlSamarai AM, AlObaidi HS. Cutaneous leishmaniasis in Iraq. J Infect Dev Ctries. 2009;3(2):123-129.

■■■■

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

117

Alternative Medicine

Yoga: A Therapeutic Adjuvant JAYASHREE SEN

Abstract Illness occurs when the total balance of perfect health is deranged. Yoga with asanas relax and tone the muscles as well as massage the internal organs. Thus, inner harmony is restored and health on all levels improves. The aim of Yoga is to maintain a balance between the psychopathological and spiritual aspects. Yoga, fundamentally different from conventional medical treatment, is considered a therapeutic adjuvant.

Keywords: Yoga, asanas, meditation, lifestyle modification Yoga-sthah kuru karmani sanyugam tyaktva dhananjay siddhy-asiddhyoh samo bhutva samatvam yoga ucyate

—Bhagavad Gita 2.48

A. C. Bhaktivedanta Swami Prabhupada translates it as “Be steadfast in Yoga (Yoga sthan, O Arjuna, perform your duty (kuru karmani), Abandon all attachment (sanyugam) to success or failure (siddhy-asiddhyoh), such evenness of mind (samatvam) is called Yoga.” The literal meaning of the sanskrit word yoga is ‘Yoke’, a Root Yuj, which means, to attach, to join or to unite. According to Patanjali, the “Father of Yoga”, “Yoga controls the activities of the mind” “Yogah Chitha Vritti Nirodhah” and “each individual is a composite of prakritti (matter) and purursha (spirit).”

popularity worldwide along with the increasing use of alternative medicine, has a spiritual aspect too and has percolated as mind-body medicine in different medical conditons as therapeutic measures.

In 1918 at Versova near Mumbai in India, the first practical application of yoga for treatment of disease started. Then in 1920, Swami Kuvalyananda established Kaivalyadham, the Yoga Institute in Lonavala.

Method

Subsequently, the Swami Vivekananda Yoga Research Institute near Bangalore (SVYASA), made yoga therapy an accepted and wide spread one.

In 1999 the National Institutes of Health created the National Centre of Complementary and Alternative Medicine (NCCAM). One of the major branches of complementary and alternative medicine is yoga with mind-body intervention.

Yoga is commonly defined as joining together of the mind, body and spirit. Yoga, whose growth is gaining

Associate Professor Dept. of Anesthesiology Gold Field Institute of Medical Sciences Chhainsa, Faridabad E-mail: jayashree_sen@rediffmail.com

118

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Research on the psychophysiological effects of yoga practice began with Kuvalyananda’s work in the 1920s.

Research on therapeutic applications of yoga and meditation began more recently.

The practice of yoga, includes physical postures and exercises, regulation of breathing, deep relaxation, meditation and yoga lifestyle modification involving dietary and psychospiritual techniques. The techniques are capable of enhancing both physical and mental health.

The psychopathological development of yoga practice is the basis of therapeutic effect. So, the improvement on disease process through yogic practice can be described as its positive ‘side effects’.

Gharote (1987) has stated that “the therapeutic aspect of yoga does not feature in any of the traditional systems of self help except in the yoga sutras of Patanjali, where we come across the word vyadhi meaning ‘disease’ in the list of disturbing factors of mind those are obstacles to liberation... although yoga therapy was not a developed branch of yogic discipline as such, we do get a glimpse of the therapeutic effects of the practices in some of the Hatha yoga literature such as the Hatha

Alternative Medicine yoga pradipika. However, advice is given here within the context of practice; that is how to deal with the complaints that arise from faulty practice”.

ÂÂ

Asanas: Which includes a mild form of exercise to enhance flexibility and circulation. It involves stretches and different postures engaging the neck, shoulders, chest, midsection, pelvis and spine and improve the strength, tone and efficiency of the concerned muscles.

ÂÂ

Controlled breathing: Practiced along with the asanas, regulates the flow of prana and slows breathing techniques.

ÂÂ

A short period of deep relaxation or meditation, which calms the mind and emotions and creates a profound sense of relaxation.

The psychosomatic component of yoga technique is relatively new than the spiritual component.

Bagchi and Wenger, in their yoga research study wrote, “physiologically yogic meditation represents deep relaxation of the autonomic nervous system without drowsiness or sleep and a type of cerebral activity without highly accelerated electrophysiological manifestation but probably with more or less insensibility to some outside stimuli for a short or long time.” It was observed that isometric exercise and stretching brings a generalized ‘relaxation response’ in the hypothalamic-pituitary axis and in the autonomic nervous system.

Result Yoga practices have been shown to be beneficial as a therapeutic adjuvant in the treatment of a wide variety of psychological and medical conditions such as depression, anxiety, post-traumatic stress disorder (psychopathological), hypertension, heart disease (cardiovascular), bronchial asthma, chronic obstructive pulmonary (COPD) (respiratory), diabetes (endocrinal), musculoskeletal, chronic pain, balance problembecause yoga has been found to be effective in reducing autonomic arousal and in counteracting the factors, which are known to affect stress disorders.

Discussion Yoga practice can vary from gentle peaceful Hatha yoga to strenuous active ‘power’ form called Ashtanga. The activities depend on the physical ability and personal preference. Patanjali’s Ashtanga Yoga has eight aspects as: ÂÂ

Yama or moral code

ÂÂ

Niyama or nonattachment

ÂÂ

Asana or posture

ÂÂ

Pranayama or regulation of breathing

ÂÂ

Pratyahara or control of senses

ÂÂ

Dharana or concentration

ÂÂ

Dhyana or meditation

ÂÂ

Samadhi or contemplation

Hatha yoga, is the most common type of yoga practiced in the United States too. ‘Ha’ means the sun and ‘Tha’ means the moon. Hatha yoga brings a balance between the sun and the moon and prepares the body for therapeutic benefits. Hatha yoga combines three elements:

A comprehensive yoga program thus can have a beneficiary effect on respiratory health as well as general health.

In the cases of respiratory diseases the first yoga is Pranayama. ‘Pranayama’, translated from sanskrit into english means ‘Expanding vital force’. Pranayama is the breathing process, which splits into three partspuraka, rechaka and kumbhaka. This is the complete breathing cycle, which controls the motion of inhalation, exhalation and the retention of vital energy.

Psychophysiological function of yoga has led to psychophysical and spiritual well-being. It connects the physical and psychological health, in other words, general and religious health with spiritual well-being where ‘healing’ is explained as a religious liberation.

Clinical Implication Yoga techniques are associated with ÂÂ

Reductions of basal cortisol and catecholamine secretion.

ÂÂ

Decrease in sympathetic activity, with a corresponding increase in parasympathetic activity.

ÂÂ

Tone down maladaptive nervous system arousal and can be a helpful practice for patients with posttraumatic stress disorder (PTSD).

ÂÂ

Reductions in consumption.

ÂÂ

Effects on cognitive activity and cerebral neurophysiology with release of serotonin, the ‘feel good factor.

metabolic

rate

and

oxygen

Yoga strengthens the immune system. So, shortness of breath, hay fever, allergies and chronic infections are less likely with yoga practice. Respiratory system diseases like sinus problems, asthma are also improved with yoga.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

119

Alternative Medicine Yoga counteracts insulin resistance, which is a risk factor for cardiovascular disease, diabetes, and stroke.

2. Gharote ML. Analytical survey of researches in yoga.

Yoga Mimamsa 1991;29:53-68.

Yoga is a natural cure for lowering the levels of lowdensity lipoprotein (LDL) cholesterol and triglycerides and increasing high-density lipoprotein (HDL) cholesterol. An average decrease in total cholesterol of over 25% was found in one study.

4. Ananthanarayanan TV, Srinivasan TM. Asana based exercises for the management of low-back pain. J Int Assoc Yoga Ther 1993;4:6-15.

Yoga lowers blood pressure naturally. In a study, over 75% of participants practicing yoga were found to have significantly lowered blood pressure.

Yoga facilitates weight loss. A study for 12 months, showed reductions in body weight from 1.5% and 13.6% in the participants.

Yoga (Hatha yoga) is beneficial in preventing and managing stress-related chronic health problems, including low back pain. In a survey of 3,000 people receiving yoga for health ailments (back pain in 1,142 [38%] participants), 98% claimed that yoga benefited them.

Many major mental illnesses such as obsessivecompulsive disorder, anxiety disorder are associated with low levels of gamma-aminobutyric acid (GABA) brain’s primary inhibitory neurotransmitter. One of the functions of GABA is to inhibit the firing of neurons in the brain. Yoga can increase brain GABA levels and optimizes the symptoms of panic, anxiety, obsession, depression, which helps in an individual’s ability to calm down, relax and sleep. (A study in 2007 by Boston University and McLean Hospital).

Conclusion The yoga is thus an adjuvant in both preventive and curative therapy and an approach towards a highyielding and relatively low-risk improvement to overall health. Anand (1991) has stated, “The ultimate aim of medical sciences is the attainment of optimum physical and mental health for the individual. The ultimate aim of yogic practices is also the same, viz. physical and mental well-being.

Daily practice of a complete yoga can restore one’s natural balance and harmony, bringing positive good health, which is comprised of - physical, mental and spiritual factors.

3. Willoughby, D. 2000;55:39-46.

Yoga

therapy.

Yoga

International

5. Balkrishna V, Sanghvi LD, Rana K, Doongaji DR, Vahia NS. The comparison of psychophysiological therapy with drug therapy. Indian J Psychiatr 1977;19:87-91.

6. Behera D, Jindal SK. Effect of yogic exercises on bronchial asthma. Lung India 1990;8: 187-9.

7. Bhole MV, Karambelkar PV. Effect of yogic treatment on blood picture in asthma patients. Yoga Mimamsa 197l;14:1-6.

8. Damodaran A, Malathi A, Patil N, Shah N, Suryavansihi, Marathe S. Therapeutic potential of yoga practices in modifying cardiovascular risk profile in middle aged men and women. J Assoc Physicians India 2002;50(5):633-40.

9. Chaudhary AK, Bhatnagar HN, Bhatnagar LK, Chaudhary K. Comparative study of the effect of drugs and relaxation exercise (yoga shavasan) in hypertension.

J Assoc Physicians India 1988;36(12):721-3.

10. Dash M, Telles S. Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. Indian J Physiol Pharmacol 2001;45(3):355-60.

11. Datey KK, Deshmukh SN, Dalvi CP, Vinekar SL. “Shavasan”: A yogic exercise in the management of hypertension. Angiology 1969;20(6):325-33.

12. Khalsa SB. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol 2004;48(3):269-85.

13. Bhole MV. Effect of yogic treatment on various lung functions of asthma patients - A pilot study. Yoga Mimamsa 1982;20:43-50.

14. Bhole MV. Treatment of bronchial asthma by yogic methods - A report. Yoga Mimamsa 1967;9:33-41.

15. Bhaskaracharyulu C, Sitarama Raju P, Girija Kumari D, et al. The effect of yoga on lipoprotein profile in diabetics.

J Diabetic Assoc India 1986;26:120-4.

16. Alien KS, Steinkohl RP. Yoga in a geriatric mental clinic.

Activ Adapt Aging 1987;9:61-8.

17. Benson H. The Relaxation Response. Morrow: New York, NY, 1975.

18. Behera D. Yoga therapy in chronic bronchitis. J Assoc Physicians India 1998;46(2):207-8.

Suggested reading

19. Bera TK, Gore MM, Kulkarni DD, Bhogal RS, Oak JP. Residential and non-residential yoga training on health related physical fitness of obese patients. Yoga Mimamsa 2002;34:166-87.

1. Bhole MV, Gharote ML. Effect of yogic treatment on breath-holding time in asthmatics. J Res Indian Med Yoga Homeopathy 1978;13:1-4.

20. Bhagwat JM, Soman AM, Bhole MV. Yogic treatment of bronchial asthma - A medical report. Yoga Mimamsa 1981;20:1-12.

120

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Alternative Medicine 21. Cohen L, Warneke C, Fouladi RT, Rodriguez MA, Chaoul-Reich A. Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer 2004;100(10):2253-60.

22. Bernardi et al., 2001,2002; Bowman et al., 1997; Khanam et al., 1996:Raghuraj et al., 1998; Selvamurthy et al., 1998 23. Telles S, Singh N, Joshi M, Balkrishna A. Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study.

BMC Psychiatry 2010;10:18.

24. Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, et al. Alterations in brain and immune function produced by mindfulness meditation.

Psychosom Med 2003;65(4):564-70.

25. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract 2002;51(12):1049-55.

26. Singh V, Wisniewski A, Britton J, Tattersfield A. Effect of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma. Lancet 1990;335(8702):1381-3.

27. Divekar MV, Bhat M, Mulla A. Effect of yoga therapy in diabetes and obesity. J Diabetic Assoc India 1978;18:75-8.

28. Khare KC, Rai S. Study of lipid profile in post myocardial infarction subjects following yogic life style intervention.

Indian Practitioner 2002;55:369-73.

29. Aivazyan TA. Psychological relaxation therapy in essential hypertension: Efficacy and its predictors. Yoga Mimamsa l990;29:27-39.

30. Latha, Kaliappan KV. Yoga, pranayama, thermal biofeedback techniques in the management of stress and high blood pressure. J Indian Psychol 1991;9:36-46.

31. Lakshmikanthan C, Alagesan R, Thanikachalam S, Ramamurthi B, Elangovan D, Viswanathan TR, et al. Long term effects of yoga on hypertension and/or coronary artery disease. J Assoc Physicians India 1979;27(12): 1055-8.

32. Flynn MA, McNeil DA, Maloff B, Mutasingwa D, Wu M, Ford C, et al. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations. Obes Rev 2006;7 Suppl 1:7-66.

33. Telles S, Naveen VK, Balkrishna A, Kumar S. Short term health impact of a yoga and diet change program on obesity. Med Sci Monit 2010;16(1):CR35-40.

34. Gharote ML. An evaluation of the effects of yogic treatment on obesity: a report Yoga Mimamsa 1977;9:13-37.

35. Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Puyallup, Wash: Future Medicine Publications; 1993.

36. Shannahoff-Khalsa DS, Beckett LR. Clinical case report: efficacy of yogic techniques in the treatment of obsessive compulsive disorders. Int J Neurosci 1996;85(1-2):1-17.

37. http://www.bu.edu/phpbin/news/releases/display. php?id=1343 on July10, 2008.

38. Cooper S, Oborne J, Newton S, Harrison V, Thompson Coon J, Lewis S, et al. Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial. Thorax 2003;58(8):674-9.

■■■■

Yoga Passes Secularism Test in US A California judge ruled that the Yoga practice, which originated in India is now a '’distinctly American cultural phenomenon,’' while dismissing complaints from some parents that teaching it to school children amounted to ''an unconstitutional promotion of Eastern religions.''

Judge John Mayer agreed that yoga ''at its roots is religious,'' but pronounced that the kind introduced by a school district near San Diego, which was the subject of the litigation, passed the test of secularism.

"A reasonable student would not objectively perceive that Encinitas School District yoga does advance or promote religion," he said.

School authorities said in court, that they had removed all religious elements from what was taught to the students, including the use of the word Namaste and substituting Sanskrit name of asanas with English ones.

For instance, Padmasana, usually called lotus pose in English, became ''criss cross apple sauce'' in Americanese to appeal to children.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

121

Anesthesiology

The Urgency of Redifining Minimum Monitoring Standards in Anesthesia LD Mishra*, Ankit Agarwal**

Abstract Anesthesiology is an intense discipline, which entails unexpected, often life threatening complications, requiring immediate recognition and prompt intervention. It is essential to have uniform standards of monitoring irrespective of location, duration and type of anesthesia. The Indian Society of Anesthesiologists (ISA) in 1998 started preparing guidelines suited for indian conditions and presented these in 1999. The 1999 ISA guidelines have outlived and there is an urgent need to update the currently applicable guidelines. These guidelines of ISA are under revision since April 2007. Keeping in view of developments in the field, medically complex patients, training methods of present day trainees and CPA needs, updated guidelines should include additional monitoring techniques and precautions.

Keywords: Anesthesiology, standard of monitoring, guidelines, ECG monitor, defibrillator, pulse oxymetry

I

t has been almost a decade since minimum monitoring standards for anesthesiologists in India came into force. In this decade, medicine and its practice has changed a lot. With changing trends in medicine, there is an urgent need for revision in guidelines for anesthesiologists too. The practice of anesthesiology is not a wait and watch approach. It is indeed an intense discipline which entails unexpected, often life threatening complications, requiring immediate recognition and prompt intervention.

Most perioperative complications are preventable, if properly monitored. Executing at least a core monitoring standard is important for patient safety as well as for anesthetistâ&#x20AC;&#x2122;s safety. It is essential to have uniform standards of monitoring irrespective of location, duration and type of anesthesia.1

The first worldwide attempt to establish monitoring standards was by the American Society of Anesthesiologists (ASA) in the year 1986.2 Thereafter, the World Federation of Society of Anesthesiologists (WFSA), in 1992 endorsed these recommendations of ASA with few changes. Subsequently, the ASA (and also the WFSA) has been updating its guidelines every few years.

There was an impending need for preparing and following such guidelines in India too. But lack of *Head, Dept. of Anesthesiology Division of Neuroanesthesiology **Dept. of Anesthesiology Banaras Hindu University, Varanasi, Uttar Pradesh

122

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

availability of infrastructure and the cost involved had been a hindrance. The Indian Society of Anesthesiologists (ISA) took lead in 1998 and started preparing guidelines suited for Indian conditions and presented these in 1999 w.e.f. 31/12, mostly based on 1992 WFSA guidelines.3 These were adopted as National Monitoring Standards being applicable to anesthesia practice in the entire country.

Details of 1999 ISA Guidelines for Minimum Monitoring Standards A hospital in an Indian setup cannot boast of the luxury of meeting all standards set internationally.

To comply with the vital standards and to have others whenever possible, these standards were divided into: i) Prerequisites, ii) basic standards and iii) desirable standards.

Prerequisites These are the facilities whose availability should be a must to every anesthetist, and must be ensured before starting any anesthetic procedure, whether elective or emergency. The prerequisites imply to, not just the material availability of certain equipments, but also to the anesthetist, the medical fraternity involved and the management of the organization responsible.

Physician A medically qualified anesthesiologist only can administer anesthesia.

Anesthesiology Facilities and Equipments All resuscitation equipments must be available in operating room (OR) area. Availability of resuscitation equipments, uninterrupted oxygen supply, anesthesia machine and other equipments should be confirmed and checked before starting procedure. There should be a reliable suction and an uninterrupted light source.

Personnel and Workload Adequate number of anesthetists must be available as per workload. Each anesthesiologist should be assisted with a fully dedicated personnel/technician. Sharing of manpower, may sometimes, in the event of an untoward emergency, be disastrous.

Anesthesia team is responsible for transport of patient to recovery room (RR) unit and availability for later consultation, if needed. Transport of patients must not be leftover to other staff, as the anesthetist, who was with the patient throughout the procedure best knows about conditions such as drugs administered, possible interactions and thus can most efficiently manage an emergency.

Records Keeping Details of each anesthesia procedure must be entered into patient’s medical record with outcome/ complications, if any.

be equipped with failure warning facility. Pulse oxymetry, should be used in every procedure.

In addition major procedures will require noninvasive BP (NIBP), oxygen analyser, airway pressure alarm, respiratory volume monitor, capnography, NM monitor, etc.

The urgent need of updated guidelines The 1999 ISA guidelines have outlived, as many, even very basic monitorings have been left out. Thus, there is an urgent need to update the currently applicable guidelines.

These guidelines of ISA are under revision since April 2007. Now, India is emerging as an economically sound country, and more sophisticated surgeries and other treatments are being undertaken. Keeping in view of developments in the field, medically complex patients, training methods of present day trainees and CPA needs, addition in these guidelines is needed. Thus, updated guidelines should include following additional monitoring techniques and precautions: ÂÂ

An anesthesiologist should start a case only when prerequisites and basic monitoring facilities are available and functional.

ÂÂ

ECG, NIBP, SaO2 (with PR and waveform) and core temperature monitoring should be a must for every case.

ÂÂ

Most standards from desirable should now be shifted to ‘Basic monitoring standards.’

ÂÂ

All machines and equipments should have O2 failure warning facility.4

ÂÂ

Anesthetic specific vaporizer should be available.

ÂÂ

There should be availability of central gas supply and suction.

ÂÂ

Availability of a flexible fiberoptic bronchoscope would ease difficult airways and to a large extent will reduce complications.5

ÂÂ

Access to modern equipments as fiberoptic laryngoscopes and C-LMAs would greatly increase patient safety, at the same time easing the anesthetist. These must be labeled as desirable.

ÂÂ

In place of a routine defibrillator, an automated external defibrillator (AED) would be beneficial as it can automatically sense rhythm and act accordingly.

ÂÂ

Ready availability of portable ultrasound machine, Doppler, etc. with the anesthetist, providing point

Professional Organization Membership ‘Appropriate anesthesia forums’ must be active with regular organizational and scientific meetings to keep up-to-date with recent advances in this field. All anesthesiologits must attend regular CMEs, updates and conferences (local, state, national and international).

Basic Standards This includes requirements that are essential in all situations. These include: Often undermined, preanesthetic evaluation and adherence to a proxy autoconfiguration (PAC) protocol. Pulse, precordial stethoscope, BP and temperature monitoring should be routinely done. The skin color, pulse and blood pressure (BP) should be noted every five minutes.

In addition, an ECG monitor with a defibrillator capable of displaying rate and wave pattern should be available.

Desirable Standards Each operation theater (OT) should have at least one anesthesia machine with an anesthetic specific vaporizer, and all equipments should

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

123

Anesthesiology of care facility would ease and make procedures as central venous catheterization safer.

Major procedures will also require oxygen analyzer, airway pressure alarm, respiratory volume monitor, capnography, NM monitor, etc.6 Airway pressure ± EtCO2 monitor should be a must for laparoscopic surgeries.

Provision, maintenance, calibration and renewal of equipments should be an institutional responsibility.7 Another important aspect to be incorporated in the proposed guidelines will be the duration of monitoring a surgical patient by the anesthesiogist. The monitoring should be started well before starting the induction of anesthesia and continued until full recovery from anesthesia and into the recovery room without interruption. A brief interruption is acceptable only if RR is adjacent to OR, or else the monitoring should be continued until the patient is being transferred to the RR.

Additional Points to be Included in Final Proposals Anesthesiologists must give sufficient time and information to his reliever if handover is required and this should not be taken lightly. If called for a life saving procedure in an adjacent room, it is the individual decision whether to leave patient unattended or not. If he/she decides to leave; the surgeons must agree and stop surgery until return. Finally, an informed and alert anesthesiologist is the best monitor, provided guidelines too are followed.

References 1. Evron S, Ezri T. Organizational prerequisites for anesthesia outside the operating room. Curr Opin Anaesthesiol 2009;22(4):514-8.

2. Pierce EC Jr. ASA monitoring guidelines, their origin and development. ASA Newsletter 2002;66:22-3.

3. Anaesthesia monitoring standards recommended for India. Anaesthesia Monitoring Standard. Indian Society of Anaesthesiology.

4. Guidelines on monitoring in anaesthesia. The Hong Kong College of Anaesthesiologista. 1992 October.

Suggested Recommendations Regarding Recovery Room Care The recovery units must be located close to OTs with a dedicated patient transport system and staff. It must be binding to the anesthesiologist to accompany the patient to RR and provide adequate details to the staff, before leaving. He/she must not leave patients until they stabilize and all vital observations are noted.

5. Charles H. Kates DDS. Airway management/guidelines J Oral Maxillofac Surg 2003;61:18a-19.

6. Adekanye O, Dugani S, Wilkes AR, Srinivas K, Hodzovic I. AAGBI guidelines on the use of neuromuscular blockade monitoring. Anaesthesia 2009;64(8):923-4.

7. Patient Monitoring Guidelines to the Practice of Anesthesia-2008. Canadian Anesthesiologist’s Society.

■■■■

CPAP Reverses White matter Changes in Sleep Apnea The use of continuous positive airway pressure (CPAP) correlates with improvement in white matter deficits seen in patients with obstructive sleep apnea (OSA), suggesting that the damage seen in these patients is reversible.

(Source: Medscape)

Malignant Melanoma Risk 4-fold Higher in Parkinson’s A new study suggests that patients with Parkinson’s disease (PD) have about a 4-fold increased risk for development of malignant melanoma, underscoring the importance of dermatologic screening in PD, the researchers say. (Source: Medscape)

Post-Traumatic Stress Disorder Post traumatic stress disorder affects 23% of patients with paralysis within first year as per a meta-analysis published in PloS One.

124

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

cardiology

Echocardiographic Findings in Submassive Pulmonary Embolism SR Mittal

Abstract Echocardiography provides important clues for diagnosis of submassive pulmonary embolism in a high-risk patient.

Disproportionate right ventricular dilatation and dysfunction with apical sparing in the setting of mild-to-moderate pulmonary artery hypertension should raise suspicion. Absence of any regional wall motion abnormality of left ventricle is an important negative finding.

Keywords: Echocardiography, pulmonary embolism, right ventricle

E

chocardiographic findings in a case of pulmonary embolism depend on: Cardiorespiratory status prior to embolism and size of embolus-massive, submassive, small.

Massive emboli usually present as sudden death. Small emboli present as chronic pulmonary hypertension.

In a case of submassive pulmonary embolism in a case with normal cardiorespiratory system, echocardiography reveals following findings.

Normal size of pulmonary artery (Fig. 1) inspite of pulmonary artery hypertension. This occurs because in acute embolism, pulmonary artery does not have time to dilate.

Pulsed Doppler evaluation of pulmonary artery flow shows acceleration time <100 m-sec (Fig. 2) and midsystolic reduction in flow (Fig. 2) suggestive of pulmonary artery hypertension.1

Figure 1. Short-axis view at the level of aortic root showing normal-sized pulmonary artery.

Dilatation of right atrium and right ventricle (RV) due to RV dysfunction (Fig. 3).2 Normal size of left ventricle (LV) with no regional wall motion abnormality of LV (Fig. 4).2

Ex-Senior Professor and Head Dept. of Cardiology Jawaharlal Nehru Medical College, Ajmer, Rajasthan Address for correspondence Dr SR Mittal XI/101, Brahampuri Ajmer - 305 001, Rajasthan E-mail: sarweshwar_mittal@reddifmail.com

Figure 2. Pulsed Doppler evaluation of pulmonary artery flow showing acceleration time <100 m-sec and midsystolic reduction in flow.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

125

cardiology

Figure 3. Apical four chamber view showing dilatation of right atrium and right ventricle.

Figure 6. M-mode of lateral tricuspid annulus showing systolic excursion <18 mm.

Figure 4. End-diastolic (ED) and end-systolic (ES) frames of short-axis view showing normal size and contractility of LV.

Figure 7. Tissue Doppler imaging of medial tricuspid annulus showing Aa velocity more than Ea velocity and MPI >0.3.

Figure 5. End-diastolic (ED) and end-systolic (ES) frames of apical four chamber view showing hypokinesia of proximal and mid-portion of RV free wall (double arrow) with normal contractility of RV apex (single arrow).

Figure 8. Tissue Doppler imaging of medial mitral annulus showing Aa velocity more than Ea velocity.

126

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

cardiology

Figure 9. Pulsed Doppler evaluation of tricuspid regurgitation jet showing calculated pulmonary artery systolic pressure <60 mmHg.

Figure 10. Apical four chamber view showing increased right atrial volume and shifting of interatrial septum to left.

Hypokinesia of proximal and mid part of free wall of RV with sparing (normal contractility) of RV apex (McConnell sign) (Fig. 5).1

Tricuspid regurgitation with calculated pulmonary artery systolic pressure of <60 mmHg (Fig. 9).2 Dilatation of right atrium due to increased right atrial pressure (Fig. 10).2 Shifting of interatrial septum to left due to raised right atrial pressure (Fig. 10).2

Impairment of overall RV systolic function: Lateral tricuspid annulus systolic excursion (TAPSE) <18 mm (Fig. 6).2 Impaired relaxation (Aa > Ea) and decreased contractility (myocardial performance index [MPI] >0.3) of RV on tissue Doppler imaging of medial and lateral tricuspid annulus (Fig. 7).

Decreased filling of LV as evidenced from decreased Ea velocity in tissue Doppler imaging of medial and lateral mitral annulus (Fig. 8).2

References 1. Forfia PR, Wiegers SE. Echocardiographic findings in acute and chronic respiratory disease. In: The Practice of Clinical Echocardiography. 3rd edition, Otto CM (Ed.), Saunders: Philadelphia 2007:p.848-76.

2. Armstrong WF, Ryan T. Echocardiographic in systemic disease and clinical problem solving. In: Fergenbaum’s Echocardiography. 7th edition, Armstrong WF, Ryan T (Ed.), Wolters Kluwer, Philadelphia 2010:p.741-74.

■■■■

Natural Foods and not Supplements Prevent Heart Disease One should take seasonal and locally grown natural food and vegetables grown out of organic farms. Eat less, dinner lighter then lunch, eat natural and in moderation- are few of the mantras.

Eating food supplements can be harmful. According to the American Heart Association (AHA), supplementation with beta carotene and vitamin E, either alone or in combination with each other or other antioxidant vitamins does not prevent heart disease.

High dose vitamin E supplementation (400 IU/day) may be associated with an increase in all-cause mortality.

Supplementation with vitamin C does not prevent a second heart attack. Beta carotene supplementation may be dangerous and should be discouraged. Vitamin E supplementation may be of benefit for only secondary prevention of heart patients with chronic renal failure who are undergoing hemodialysis.

The AHA concluded that current data do not justify the use of antioxidant supplements for the prevention or treatment of cardiovascular disease risk. The above recommendations apply to supplementation only. Diets that are rich in natural antioxidants are associated with lower cardiovascular mortality.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

127

Padma Shri & Dr BC Roy National Awardee

Dr SM Rajendran

Dentistry

Odontogenic Myxoma of Maxilla: Management and Follow-up of A Rare Case Karuna Jindwani*, Vilas Nevaskar**, Deepak Agrawal†

Abstract Odontogenic myxoma is a slow growing benign, locally malignant tumor, notorious for recurrence. It represents a broadspectrum of lesions of uncertain histogenesis with a characteristic histologic appearance. We report a rare case of odontogenic myxoma in a 10-year-old male patient and present the respective strategy for the management of a huge myxoma of right-side of maxilla via an intraoral approach after a brief review of its clinical and radiological features.

Keywords: Odontogenic myxoma, resection, intraoral approach

O

dontogenic myxomas (OMs) are benign tumors derived from the primitive mesenchymal structures of a developing tooth including the dental follicle, dental papilla or periodontal ligament.1 World Health Organization (WHO) defines OM as a benign, locally invasive neoplasm characterized by rounded and angular cells lying in an abundant mucoid stroma that replaces the cancellous bone and expands the cortex.2 It is an uncommon lesion and is unusual for a bone other than maxilla or mandible to be the site of origin of a true OM.3 The evidence for its odontogenic origin arises from its almost exclusive location in the tooth bearing areas of the jaws, its occasional association with missing or unerupted teeth and occasional presence of odontogenic epithelium.4 There are only a few reports on the relative frequency and incidence of OM in the available literature. However, in Asia, Europe and America relative frequencies between 0.5 and 17.7% have been reported.5 This tumor may present at any age but is most frequently discovered in the 2nd to 4th decades and occur more frequently in the mandible than in maxilla with marked female prediclection.6

*Senior Resident Dept. of Dentistry, SS Medical College and SGM Hospital, Rewa, Madhya Pradesh **Professor and Head †Associate Professor Dept. of Oral Surgery, Government College of Dentistry, Indore, Madhya Pradesh Address for correspondence Dr Karuna Jindwani Behind Vidya Bhawan Near HPO, Rewa - 486 001, Madhya Pradesh E-mail: jindwanikaruna@yahoo.co.in

130

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Clinical presentation involves a slow growing painless, site-aggressive mass causing marked asymmetry of face.

Pain and paresthesia are uncommon, thus the lesion can reach considerable size before the patient becomes aware of its presence and seeks treatment.7 Enlargement of the mass commonly leads to cortical expansion and even perforation. Maxillary myxomas often extend into the sinus.8 Loosening and displacement of the teeth are likely to occur in time, but root resorption is less frequently seen.9 Radiologically, the appearance may vary from a unilocular radiolucency to multilocular lesion with well-defined or diffuse margins with fine, bony trabeculae within its interior structure expressing a ‘honey-combed’, ‘soap bubble’ or ‘tennis racket’ appearance. This typical appearance can not be observed in all patients with OM.1,4,6,10 Histologically, the tumor is noncapsulated which promotes infiltration into the adjacent medullary bone.11 OM in maxilla is less frequent but behaves more aggressively than that of the mandible.

The treatment of choice for this infiltrative lesion varies from simple enucleation, curettage and excision (0.5 mm from apparent normal bony margin) and resection (1 cm from apparent normal bony margin) to more aggressive resection with disarticulation, excision of tumor with dentoalveolar segment and preservation of the mandibular lower border and maxillectomy.12 When associated with teeth, their removal is usually necessary.

We present a rare case of OM of maxilla in a 10-yearold male patient including the management and long asymptomatic 2-year follow-up of the patient.

Dentistry CASE REPORT In March 2009, a 10-year-old male patient was referred to the Dept. of Oral and Maxillofacial Surgery, Government College of Dentistry, Indore, MP for the evaluation and management of a painless swelling on right side of the face. The physical examination showed a well-developed child in no acute distress. His medical history revealed a gradual increase in the swelling on right half of the face in a span of approximately two years to the present size of approximately 3 inches diameter from a small pea-sized growth. However, he noticed rapid increment in its size in the last five months. He consulted many private clinics and institutions but was finally referred to our department for the management.

The medical history, family history and a review of systems of the patients were noncontributory.

Figure 1. Frontal veiw.

A nontender, bony hard swelling of the right maxilla was seen on extraoral examination extending from right corner of the mouth anteriorly till the tragus of the right ear posteriorly. Superiorly, the swelling extended from right infraorbital margin and rested inferiorly till the body of mandible measuring approximately 4 x 3 inches (Figs. 1 and 2). The intraoral examination of the maxillary arch revealed a nontender, bony hard expansile lesion extending from upper right lateral incisor till maxillary tuberosity, thereby obliterating the right buccal vestibule. All the associated teeth in the mixed dentition stage showed a low-degree of morbidity. The tumorous growth was soft and shiny involving the expansion of both buccal and palatal cortical plates (Fig. 3). The alveolar bone in the area appeared soft on palpation. However, the entire mucosa overlying the area was intact.

Figure 2. Lateral view.

Computed tomography (CT) showed the evidence of lytic destruction of maxilla causing expansion of right maxilla with erosion of alveolar bone (Fig. 4) and disclosed its extension into the sinus and zygomatic buttress. The left nasal and orbital cavities were intact.

Three dimensional reconstruction confirmed the extent of the tumor (Fig. 5).

The patients blood type was determined and crossmatched for 1 unit of whole blood. On admission to the hospital for the surgery, a routine physical examination, laboratory tests (complete blood count and urinalysis) and radiographs of the chest and limbs showed no abnormalities.

The differential diagnosis included odontogenic keratocyst, ameloblastoma, odontogenic myxoma, central giant cell granuloma and osteosarcoma.

Fine needle aspiration was performed to rule out odontogenic cyst and the result was negative.

Figure 3. Intraoral view showing buccal and palatal cortical plate expansion.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

131

Dentistry

Figure 4. Computed tomography showing the extent of growth.

Figure 5. Three-dimensional reconstruction depicting the lytic lesion.

Figure 7. Operated site after en bloc resection.

resection of the tumor was planned. The surgical management involved a solo intraoral approach to the massive growth under general anaesthesia by way of left nasal endotracheal intubation. Vertical releasing and gingival crevicular incisions helped us to raise a full thickness mucoperiosteal flap for approaching the tumorous mass. The partial en block excision of the maxilla was done with a margin of normal tissue.

The specimen was removed completely in one piece with all associated teeth embedded in the mass (Fig. 6).

The operated site was irrigated with copious amounts of saline and betadine solution (Fig. 7) and packed with an iodoform gauze before partial closure. The resected specimen was sent for histopathological analysis, which confirmed it to be an OM. The postoperative course of the patient and early healing of the wound were uncomplicated (Figs. 8a 8b). The patient was discharged on the seventh postoperative day. The wound was irrigated and the iodoform gauze dressing changed regularly during the first four weeks after surgery. Impressions were taken of maxillary arch and a partial acrylic denture was constructed to protect the healing surgical site from repeated exposures during meals. The dressing was removed and the defect treated with simple irrigation.

Figure 6. Specimen of growth.

Thereafter, an incisional biopsy was performed under local anesthesia and submitted for histopathological examination. The material submitted revealed the lesion to be an OM. Based on the incisional biopsy report, progressive nature of the lesion and cortical expansion, radical

134

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

The patient was regularly seen in the our department for six months (Figs. 9a and 9b) on a monthly basis and then every third month. The patient has been followed for two years since the surgical resection of tumor (Figs. 10a and 10b). Radiographic and clinical examination confirm that the healing phase was uneventful with no evidence of recurrence. Periodical evaluation and surgical reconstruction of the edentulous region is to be planned for complete rehabilitation of the patient.

Dentistry

Figure 8a. Immediate postoperative view.

Figure 8b. Immediate postoperative intraoral view.

Figure 9a. Postoperative view after six months.

Figure 9b. Postoperative intraoral view after six months.

Figure 10a. Postoperative view after two years.

Figure 10b. Postoperative intraoral view after two years.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

135

Dentistry DISCUSSION Odontogenic myxoma (OM) is a rare benign neoplasm derived from embryonic mesenchymal tissue associated with odontogenesis. The prevalence of this lesion is principally quoted between 0.04% and 3.7%.13 In Asia, Europe and America, relative frequencies between 0.5% and 17.7% have been reported.5,14 There was lack of uniformity in the most common age group studies of OM, but the previous studies by Noffke et al, refer the incidence of OM in an age group of 11-70 years.15 However, it is rarely seen in patients younger than 10 years of age and older than 50.5,16 The mandible appears to be more frequently affected than maxilla in most of the studies.6,7 However, Zimmermann and Dahlin17 reported in their study that OM could be found in both jaws with an equal frequency. Odontogenic maxillary myxoma were first mentioned in the literature by Thoma and Goldman in 1947.18 A marked female predilection has been reported in several studies.6,7 The male patient presented in this report approached our department at the age of 10 years involving right side of the maxilla with a previous history of swelling for the last two years. This is usually rare and differs from the prevalence reported in the literature.

OM is commonly reported as a slow growing tumor that is generally symptomless, although some patients present with progressive pain in lesions involving surrounding structures with eventful neurological disturbances.19 Our case presented with a painless swelling without signs of paresthesia in the mentioned area which is almost in conformity with the reported literature.

These tumors usually show variable radiographic features ranging from small unilocular lesions to large multilocular lesions. Varying radiographic descriptions reported in literature are ‘honey comb’, ‘soap bubble’, ‘tennis racket’ ‘Wispy’ and ‘spider-web’ appearance.1,4,6,10 CT in the present case presented with a multilocular osteolytic expansile lesion in the right maxilla involving the right maxillary sinus and zygomatic buttress region.

The aggressive nature of OM is well-documented in the literature. It is now well-established that for the management of OM a surgical approach is the treatment of choice.11,12,20 It is also generally agreed upon that the radiation therapy is of no value in the management of these tumors as OM is not radiosensitive.7,12,17 The nonencapsulated nature and infiltrative growth pattern is responsible for high rate of recurrence when conservative modes like enucleation and curettage

136

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

are performed.5,11,21 Hence, radical treatment of block resection is advised over conservative therapy by most authors.9,11,13 In agreement with the available literature, the tumor was completely removed by en bloc resection and no recurrence was reported even after two years of the surgery. Prognosis in the present case after excision was excellent in this two year follow-up period.

Postoperatively, patients should be closely follow-up for the period of 2-year in which the recurrence is most likely.22 However, CS Columbo and Y Boivin in their study recommended a minimum of five years of surveillance to confirm that the lesion healed,23 and periodical clinical and radiographic followed-up should be maintained indefinitely irrespectively of treatment modality applied to treat OM.11,23 CONCLUSION A rare case of OM in a 10-year-old boy is presented in this report, which illustrates the resective strategy for the treatment of a huge maxillary OM via an intraoral approach. A close follow-up of the patient was maintained for two years to confirm an uneventful healing in the present case. Hence, it is summarized that with adequate surgical excision, long-term survival without recurrence can be anticipated. However, one should be cautious in drawing general conclusions on the basis of a single case.

REFEReNCES 1. Halfpenny W, Verey A, Bardsley V. Myxoma of the mandibular condyle. A case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90(3):348-53.

2. Kramer IRH, Pindborg JJ, Shear M. Histological Typing of Odontogenic Tumours. 2nd edition, Springer Verlag: Berlin 1992:p.23.

3. Shafer WG. Cysts, neoplasms, and allied conditions of odontogenic origin. Semin Roentgenol 1971;6(4):403-13.

4. Stout AP. Myxoma, the tumor of primitive mesenchyme.

Ann Surg 1948;127(4):706-19.

5. Simon EN, Merkx MA, Vuhahula E, Ngassapa D, Stoelinga PJ. Odontogenic myxoma: a clinicopathological study of 33 cases. Int J Oral Maxillofac Surg 2004;33(4):333-7.

6. Kaffe I, Naor H, Buchner A. Clinical and radiological features of odontogenic myxoma of the jaws.

Dentomaxillofac Radiol 1997;26(5):299-303.

7. Farman AG, Nortje CJ, Wood RE. Oral and Maxillofacial Diagnostic Imaging. Mosby: St Louis 1993:p.257-60.

8. Brannon RB. Central odontogenic fibroma, myxoma (odontogenic myxoma, fibromyxoma), and central odontogenic granular cell tumor. Oral Maxillofac Surg Clin North Am 2004;16(3):359-74.

Dentistry 9. Peltola J, Magnusson B, Happonen RP, Borrman H. Odontogenic myxoma - a radiographic study of 21 tumours. Br J Oral Maxillofac Surg 1994;32(5):298-302.

10. Regizi JA, Sciubba JJ, Jordan RC (Eds.). Oral Pathology: Clinical - Pathologic Correlations. 4th edition, WB Saunders Company Ltd: Philadelphia 2003:p.278-9.

11. Lo Muzio L, Nocini P, Favia G, Procaccini M, Mignogna MD. Odontogenic myxoma of the jaws: a clinical, radiologic, immunohistochemical, and ultrastructural study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82(4):426-33.

12. Reddy SP, Naag A, Kashyap B. Odontogenic myxoma: Report of two cases. Natl J Maxillofac Surg 2010;1(2): 183-6.

13. Slootweg PJ, Wittkampf AR. Myxoma of the jaws. An analysis of 15 cases. J Maxillofac Surg 1986;14(1):46-52.

14. Lu Y, Xuan M, Takata T, Wang C, He Z, Zhou Z, et al.

Odontogenic tumors. A demographic study of 759 cases in a Chinese population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86(6):707-14.

15. Noffke CE, Raubenheimer EJ, Chabikuli NJ, Bouckaert MM. Odontogenic myxoma: review of the literature and report of 30 cases from South Africa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104(1):101-9.

16. King TJ 3rd, Lewis J, Orvidas L, Kademani D. Pediatric maxillary odontogenic myxoma: a report of 2 cases and review of management. J Oral Maxillofac Surg 2008;66(5):1057-62.

17. Zimmerman DC, Dahlin DC. Myxomatous tumors of the jaws. Oral Surg Oral Med Oral Pathol 1958;11(10):1069-80.

18. Reichart PA, Philipsen HP. Odontogenic Tumors and Allied Lesions. Quintessence Publishing Co Ltd: Illinosis; 2004.

19. Hernández Vallejo G, Cohn C, García Peñín A, Martínez Lara S, Llanes Menéndez F, Montalvo Moreno JJ. Myxoma of the jaws. Report of three cases. Med Oral 2001;6(2): 106-13.

20. Thoma KH, Goldman HM. Central myxoma of the jaw.

Am J Orthod Oral Surg 1947;33:532-40.

21. Leiser Y, Abu-El-Naaj I, Peled M. Odontogenic myxoma - a case series and review of the surgical management. J Craniomaxillofac Surg 2009;37(4):206-9.

22. Moshiri S, Oda D, Worthington P, Myall R. Odontogenic myxoma: histochemical and ultrastructural study. J Oral Pathol Med 1992;21(9):401-3.

23. Colombo CS, Boivin Y. Myxoma of the jaws. Oral Surg Oral Med Oral Pathol 1966;21(4):431-6.

■■■■

New Report Concludes that Dental Implants can Save Costs and Improve Quality-of-life A report published as the lead article in the International Journal of Oral & Maxillofacial Implants shows that dental implants offer a cost-effective alternative to traditional treatments for tooth replacement.

The report, which is also cited on PubMed, the US National Library of Medicine located at the National Institutes of Health, is based on a systematic review of all available studies published in English between 2000 and 2010 relating to the cost-effectiveness of various tooth-replacement options. In total, 14 studies on long-term costs were included in the final review, which yielded the following conclusions.

MTA Beat CaOH in a Direct Dental Pulp Capping Trial Mineral trioxide aggregate (MTA) fails less often when used for direct pulp capping than calcium hydroxide (CaOH), according to a new study published in a clinical supplement to the Journal of Dental Research. In the study, 24.6% of pulp caps made with CaOH failed within two years compared with only 13.6% of those made with MTA. (Source: Medscape)

ADA/AAOS Look at Joint Implant Infections after Dental Care The first evidence-based clinical practice guideline to be codeveloped by a both the American Academy of Orthopedic Surgeons (AAOS) and the American Dental Association (ADA) suggest that prophylactic antibiotics might not always be needed for routine dental procedures in patients with joint implants, that the jury is still out on the usefulness of topical antibiotics during dental procedures, and that patients with joint implants should be particularly careful about oral hygiene. The recommendations from the AAOS/ADA working group were published in the April 17 issue of the Journal of Bone and Joint Surgery. (Source: Medscape)

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

137

Dermatology

Accidental PUVA Burns Leading to Prurigo Nodularis: A Rare Complication of Phototherapy Shyam Verma

Abstract Medical treatment function vitiligo aims to restore color to use depigmented patches. Psoralen photochemotherapy (PUVA) may be used if there is extensive vitiligo. Possible long-term adverse effects of PUVA therapy include accelerated skin aging with wrinkle formation, telangiectasias, lentigines, elastosis, xerosis and pigmentary changes. Accidental burns during photochemotherapy have been reported though nodular prurigo has never been reported. Vitiliginous skin is more rone to burns.

Keywords: Vitiligo, PUVA burns, prurigo nodularis, hyperkeratotic nodules, itching Case Report A 50-year-old woman presented with severely pruritic nodules (PN) and plaques on her legs and breasts. She developed vitiligo at the age of 18 years for which she was treated unsuccessfully with many drugs. In 1991, she was treated with home psoralen + ultraviolet-A radiation (PUVA) therapy using 20 mg of oral methoxsalen. The light source used was a set of 4 tube lights of 100 W emitting UVA between 315-350 nm wave length and she exposed the areas for 3 minutes three times a week.

There was marked improvement in the vitiligo on her legs in about five months with total clearing of the lesions on the face except the lips. Around this time, she accidentally fell asleep during her PUVA session and woke up after 60 minutes with blistering burns on her breasts and legs, which took a month to heal.

During the healing stage, she started developing thickened skin, nodules and plaques on her legs and breasts, which were intensely itchy.

She was given emollients, topical steroids, antihistamines, individually and in combination but with little benefit. Many nodules coalesced to form scaly plaques. Her homoeopath husband then started treating her with some homoeopathic medication, which apparently caused resolution of lesions for many years only to reappear in 2004. Several physicians and

Consultant Dermatologist, Vadodara Gujarat

138

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

dermatologists diagnosed her condition as psoriasis and post burn keloids. She was prescribed oral steroids by a private practitioner for a few months, which was later stopped as she developed diabetes. She now has excruciating itching, which has severely affected her quality-of-life.

On examination, she had vitiligo on her breasts and lower extremities showing perifollicular pigmentation.

Her legs were studded with thick, horny, hyperkeratotic nodules with a rough surface, many of them coalescing to form plaques on the anterior aspect (Fig. 1).

She had severely pruritic erythematous nodules on the breasts (Fig. 2). Her skin was otherwise normal.

She was diabetic, hypothyroid and took metformin and thyroxine daily. Her blood work up and serum chemistry was normal except an IgE of 700 IU/ml with no history, signs or symptoms of atopy like chronic itching, eczema, allergic rhinitis or asthma.

A skin biopsy taken from the nodule showed a superficial perivascular lymphocytic infiltrate with moderate irregular epidermal hyperplasia. The papillary dermis was thickened with papillomatosis and showed thickened bundles of collagen in vertical array. The capillaries in papillary dermis were increased in number and thick walled. The granular layer was thickened and stratum corneum showed marked compact orthokeratosis. One of the sections showed abundant deposit of amyloid in papillary dermis. The histological diagnosis was prurigo nodularis (PN) with lichen amyloidosis (Fig. 3). We started her on gabapentin 900 mg daily with topical halobetasol and petrolatum with about 20% relief in itching reported in 30 days.

Dermatology Discussion

Figure 1. Multiple coalescing erythematous excoriated nodules on both legs.

Figure 2. Erythematous nodules on vitiliginous skin of breast.

Figure 3. Massive hyperortho-keratosis associated with hyper-granulosis and acanthotic epidermis with masses of amyloid in papillary dermis (H&E 40x).

We report a case of PN occurring in the sites of PUVA burns in a patient of vitiligo. Oral PUVA side effects include short-term and long-term. Short-term adverse effects include erythema, swelling, dry skin, pruritus, axillary freckling, increased recurrence of herpes simplex virus and rarely, phototoxic blisters.

Possible long-term adverse effects include accelerated skin aging with wrinkle formation, telangiectasias, lentigines, elastosis, xerosis and pigmentary changes.

High cumulative PUVA exposure is associated with a dose-related increase in the risk of nonmelanoma skin cancer, particularly genital and cutaneous squamous cell carcinoma in Caucasians only. However, nodular prurigo has never been reported.

Accidental burns during photochemotherapy have also been reported, which includes self-treatment as seen in this patient. Bothersome pruritus following burns per se is a known phenomenon though there is a paucity of long-term prospective studies documenting the course and magnitude of this phenomenon. Burns are known inducers of neuropathic itch. A study by Van Loey et al documented itching at 3, 12 and 24 month post burns and recorded mild-to-severe itching in 87%, 70% and 67% of patients. However, this appears to be the first case of PN developing in a case of accidental PUVA burns.

We propose the following logical sequence. Vitiliginous skin is more prone to burns. The accidental PUVA burns due to gross overdose initiated the itch in this patient, who also had atopic diathesis indicated by a high serum IgE. Itching is known to induce hyperplastic cutaneous response and this probably would have led to development of PN in this patient. There is a report of a bomb blast injury causing PN-like lesions. The diagnosis of PN is based upon family and personal history, typical clinical presentation and distribution of the lesions along the cleavage lines (Langerâ&#x20AC;&#x2122;s lines) of skin and was confirmed by histopathology. The amyloid deposit seen in some sections could be due to the chronic scratching of PN. Highly characteristic for PN is the presence of thick compact orthohyperkeratosis; the hairy palm sign (folliculosebaceous units in nonvolar skin in conjunction with a thick and compact cornified layer, like that of volar skin), irregular epidermal hyperplasia or pseudoepitheliomatous hyperplasia, focal parakeratosis, hypergranulosis, fibrosis of the papillary dermis

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

139

Dermatology with vertically arranged collagen fibers, increased number of fibroblasts and capillaries, a superficial, perivascular and/or interstitial inflammatory infiltrate of lymphocytes, macrophages and to a lesser extent, eosinophils and neutrophils. Histological analysis of lesional and nonlesional skin in PN has demonstrated a reduced density of nerve endings, findings suggesting a cutaneous neuropathy. Interestingly, the itch induced by burns, which would have played a major role in development of PN is also neuropathic in origin. The rationale of using gabapentin is that it has been tried with varying success in burns-induced itching as well as in PN. We believe, we are reporting the first case in dermatological literature of accidental PUVA burns developing PN.

Suggested Reading 1. Abdel Naser MB, et al. Clin Exp Dermatol 2004;29(4): 380-2.

2. Murase JE, et al. Int J Dermatol 2005;44(12):1016-21.

3. Herr H, et al. Burns 2007;33):372-5.

4. Sulliman MT, et al. Burns 2005;31(8):1063.

5. Goutos I, et al. J Burn Care Res 2009;30(2):221-8.

6. Van Loey NE, et al. Br J Dermatol 2008;158(1):95-100.

7. Ghosh SK, et al. Clin Exp Dermatol 2009;34(7):e471-2.

8. Weigelt N, et al. J Cutan Pathol 2010;37(5):578-86.

9. Schuhknecht B, et al. Br J Dermatol 2011;165(1):85-91.

10. Gencoglan G, et al. Dermatol Ther 2010;23(2):194-8.

11. Ahuja RB, et al. Burns 2011;37(2):203-7.

■■■■

Very Potent Steroids Most Effective Against Chronic Scalp Psoriasis Very potent steroids in topical solution may be the most effective first-line treatment of chronic plaque psoriasis of the scalp, according to a new meta-analysis published online June 24 in the British Journal of Dermatology.

Those options include the very potent steroid clobetasol propionate, followed by the potent steroid betamethasone dipropionate, then the vitamin D3 analogue calcipotriol. Also, calcipotriol combined with a potent steroid may be more effective than a potent steroid alone. (Source: Medscape)

Psoriasis Patients should be Screened for Type 2 Diabetes Patients with psoriasis are at increased risk of type 2 diabetes, especially those with psoriatic arthritis, a new meta-analysis confirms. (Source: Medscape)

Eczema: Antibiotic Exposure in Infancy may up Risk Antibiotic exposure in the first year of life, but not prenatally, may predispose children and young adults to eczema, according to a systematic review and meta-analysis published online June 20 in the British Journal of Dermatology. (Source: Medscape)

Methotrexate Effective as Adjuvant for Treating Pemphigus Vulgaris Methotrexate allows discontinuation of steroids in many patients with pemphigus vulgaris, a retrospective study suggests. (Source: Medscape)

Malignant Melanoma Risk 4-fold Higher in Parkinson's A new study suggests that patients with Parkinson's disease (PD) have about a 4-fold increased risk for development of malignant melanoma, underscoring the importance of dermatologic screening in PD, the researchers say. (Source: Medscape)

140

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

diabetology

A Hospital-based Observational Study of Type 2 Diabetic Subjects from India MAYUR PATEL*, INA M PATEL*, YASH M PATEL*, SURESH K RATHI**

Abstract Aim: The aim of this study was to describe the profile of the subjects with type 2 diabetes mellitus (T2DM) to obtain a clear picture from Western India, that would help in management of diabetes. Methods: An observational study was conducted with newly diagnosed 622 type 2 diabetic subjects attending Dept. of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre (Swasthya), Ahmedabad during the period from August 2006 to January 31, 2009. Subjects completed an interviewer-administered comprehensive questionnaire, which included variables such as sociodemographic presenting symptoms, risk profile (hypertension, obesity, dyslipidemia and glycemic status), family history of diabetes, physical activity and behavioral profile. Blood pressure, body mass index (BMI), glycosylated hemoglobin (HbA1C) and fasting lipid profile were measured. Descriptive and bivariate analyses were carried out using SPSS version 11.5. Results: A total of 622 T2DM cases with mean age (years) 47.7 ± 10.9 were studied. Of these, 384 (62%) were male. The majority of T2DM subjects were obese (68%) and 67% had positive family history of diabetes. Renal dysfunctions and vision impairment were found in 10% (62/622) and 9% (57/622), respectively in T2DM subjects. The mean HbA1C level was 9.02% ± 1.67 and good glycemic control (HbA1C level <7%) was achieved only in 7.4% T2DM subjects. The Chi-square (χ2) analysis showed that higher BMI (≥25 kg/m2) is significantly associated with hypertension among T2DM subjects (p < 0.01). There were statistically significant differences between male and female study subjects with respect to mean age, BMI, waist and hip circumference and mean low-density lipoprotein (LDL) level (p < 0.05). Conclusions: The present study revealed that obesity, family history of diabetes, dyslipidemia, uncontrolled glycemic status, sedentary lifestyles and hypertension were more prevalent in T2DM subjects. Hence, the overall risk profile was very poor and needs improvement. The characterization of this risk profile will contribute in defining more effective and specific strategies for screening and controlling T2DM in Western India.

Keywords: Type 2 diabetes mellitus, obesity, polyuria, glycemic status, dyslipidemia, India

T

blindness, kidney failure and neuropathy. T2DM is also associated with 4-fold increase risk of cardiovascular events and risk factor for doubling the risk of cardiovascular death.5-7

*All India Institute of Diabetes and Research, Narainpura, Ahmedabad, Gujarat **SBKS Medical Institute and Research Centre, Piparia, Vadodara, Gujarat Address for correspondence Dr Suresh Kumar Rathi F-102, Aalekh Complex, 8, Amravati Society, Near Yash Complex Gotri Road, Vadodara, Gujarat - 390 021 E-mail: rathisj@yahoo.com

The prevalence of T2DM has been rising worldwide and globally more than 180 million people are suffering from it. In particular, developing countries are facing an epidemic of T2DM.8,9 The major global burden comes from India and China, where more than 75% of diabetic subjects will live in 2025.4 India, like many other developing countries, has witnessed a rapid epidemiological transition in the last two decades. Coupled with this, there has been a dramatic improvement of the Indian economy in terms of per capita income. These dramatic changes have had a great impact on urbanization and lifestyle of the Indians and as a result diabetes mellitus has become the main public health problem. It is amenable to change through early recognition at the individual level and surveillance at the population level. Studies showed that India is facing 3-fold rise of prevalence of diabetes in urban (from 5% to 15%) as well as in rural (2% to 6%) areas.10,11 India

ype 2 diabetes mellitus (T2DM) is a chronic, debilitating disease characterized by insulin resistance, impaired insulin secretion and hyperglycemia. It is the most prevalent metabolic condition and one amongst major health and socioeconomic problems worldwide.1-3 It represents more than 90% of total prevalence of diabetes in the world4 and is responsible for 9% of the global mortality corresponding to four million deaths per year. Since, the onset is insidious, there is an average delay of 3-5 years in diagnosis. By the time, the condition is diagnosed, minimal changes responsible for micro- and macrovascular complications are already present. This issue is further compounded by untreated diabetes because of ignorance or inaccessibility to treatment.

Untreated diabetes may result in limb amputation,

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

141

diabetology had the largest number of the diabetic subjects with 31.7 million cases of T2DM in India.3,12 This is further compounded by the epidemic of obesity and increase in the cost of diabetes management by 2-folds.13 Therefore, prevention is also important from monetary point of view. Misra et al reported that increasing awareness of risk factors and how to prevent them should be emphasized in the population.14 Apart from this, the lifestyle modifications (physical exercise, diet control, etc.) are appropriate measures in prevention of diabetes. Furthermore, to control and prevent T2DM epidemic, it must be approached in an appropriate, socioeconomically and culturally relevant manner but very little data are available from western part of India to support this and for prevention of diabetes it is also vital to know the profile of diabetics.

To describe the profile of type 2 diabetic subjects from Western India.

METHODS A hospital-based observational study was conducted during August 2006 to January 2009 in Ahmedabad district of Gujarat State. Ahmedabad is the largest district of Gujarat with an approximate population of 5 million. The city is famous for medical tourism because of its wide network of cost-effective tertiary care hospitals catering the population of not only from Gujarat but also from neighboring states and even from abroad.

To be included in this study, subjects had to be newly diagnosed cases of diabetes mellitus (diagnosed within last 6 months), attending the Dept. of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre (Swasthya) during the study period for first time and willing to participate in the study. A sample size of 660 was decided so as to study at least 20% of newly diagnosed cases, based on the data review of the Dept. of Diabetology, which revealed that at least 100 subjects (newly diagnosed) presented every month, hence during the study period there would be 3,000 subjects. The calculated minimum sample size was inflated by 10% to account for anticipated dropouts.

After satisfying the case definition and obtaining informed consent (written consent from literate subjects and a verbally informed consent from illiterate subjects), 709 subjects were enrolled through simple random sampling method. After explaining the details of the study, a comprehensive case history was recorded on a semi-structured, close-ended proforma.

142

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

The basic data on age, sex, education, occupation, smoking and tobacco chewing status, alcohol consumption, diet and physical activity were collected from all the subjects. All subjects were also interviewed regarding history of hypertension and other comorbid conditions and a general physical examination was done.

All anthropometric measurements were recorded using standardized procedures. These subjects also underwent various clinical tests like urinalysis (first morning urine sample for evaluation of microalbuminuria), blood tests for complete hemogram, plasma glucose, glycosylated hemoglobin (HbA1C), renal function tests and lipid levels. The blood samples were collected after ensuring 12 hours of overnight fasting. Total cholesterol (TC), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) levels were estimated in serum. Low-density lipoprotein cholesterol (LDL-C) was calculated using the Friedewald formula (LDL-C [mg/dl] = Non-HDL-C - TG/5).15 For analysis, the current smokers and ex-smokers were categorized in the ‘ever smoker’ group. Similarly, the current tobacco chewer and ex-tobacco chewer were categorized in the ‘ever tobacco chewer’ group.

Ever smoker and ever tobacco chewer groups were considered as tobacco user. Current alcohol users were defined as subjects who had consumed alcohol at least once in last 1-month period. The main occupational level was divided into three categories: Low (e.g., skilled workers, household workers and retired); medium (e.g., desk jobs) and high (e.g., professionals and businessmen). Physical activity was categorized as sedentary (sitting, standing and driving for most of the day, cooking, light cleaning, light yard work, slow walking and other major activities involve sitting); moderate (an occupation that includes lifting, lots of walking or other activities that keep you moving for several hours qualifies as moderately active) and heavy (heavy manual labor, a very active lifestyle, dancer or very active sports played for several hours almost daily, an elite athlete in training or an extremely active lifestyle - both at work and at play and sport or activity lasting for several hours, almost daily). Blood pressure (BP) was recorded, after the subjects had rested for at least five minutes. Two readings were taken five minutes apart and mean of two was considered as the BP. Hypertension was diagnosed based on drug treatment for hypertension or if the BP was >130/80 mmHg according to Joint National Committee-7 (JNC-7) criteria.16,17 The diagnosis of diabetes mellitus was done using criteria established by the American Diabetes Association.18 Either a fasting plasma glucose (FPG) level

diabetology >7.0 mmol/l or ≥126 mg/dl after a minimum 12-hour fast, or 2-hour post glucose level (oral glucose tolerance test [OGTT]) >11.1 mmol/l or ≥200 mg/dl on more than one occasion, with symptoms of diabetes.

In the absence of information from medical records, self-reported cases were confirmed by establishing the criteria of regular treatment with antidiabetic drugs or by performing a 2-hour OGTT. Impaired glucose tolerance (IGT) was defined as FPG level of 100 mg/dl (5.6 mmol/l) but <126 mg/dl (7.0 mmol/l) or 2-hour OGTT of ≥140 mg/dl (7.8 mmol/l) but <200 mg/dl (11.1 mmol/l). National Cholesterol Education Program (NCEP) guidelines were used for definition of dyslipidemia19 as presence of ≥1 abnormal serum lipid concentration like hypercholesterolemia, high LDL-C, hypertriglyceridemia and low HDL-C. Body mass index (BMI) values were defined according to the recommendations of Indian Council of Medical Research (ICMR) for Indians. A study subject was considered to be obese if BMI was ≥25 kg/m2, overweight when BMI was 23-24.9 kg/m2.20 The criteria for glycemic status were <7% (good control), 7-8% (suboptimal control), 8-9% (inadequate control) and >9% (uncontrolled).21

Table 1. Sociodemographic Characteristics of the Type 2 Diabetic Subjects from India Characteristics Age (years) (mean ± SD)

Number (n = 622)

Percentages (%)*

47.70 ± 10.94

Upto 40

164

27

41-48

170

27

49-55

150

24

>55

138

22

Male

384

62

Female

238

38

Never married

22

4

Ever married

600

96

521

84

Sex

Marital status

Religion Hinduism Islam

51

8

Christianity

19

3

Others

31

5

The study protocol was approved by the Institutional Review Board (IRB) of All India Institute of Diabetes and Research.

Education Nil

03

1

Statistical Analysis

Primary school

18

3

Data were entered in Excel sheet and cleaned, validated and analyzed using SPSS version 11.5. Quantitative variables were summarized using mean and standard deviation while categorical variables were tabulated using frequencies and percentages. Student t-test was used to test the significance of differences between mean values of two continuous variables. Chi-square (x2) test was carried out to test the difference between two or more groups. The probability (p) level of < 0.05 was considered significant.

Secondary school

105

17

College

420

67

Professionals (CA, MBBS, etc.)

76

12

Low

281

45

Medium

112

18

High

229

37

RESULTS A sample of 709 diabetic subjects was enrolled. Of 709 study subjects, 622 had T2DM. Hence, further analysis was performed on 622 T2DM subjects.

Sociodemographic: Sociodemographic characteristics of the study sample are shown in Table 1. Eightyfour percent (521/622) of the subjects were Hindus and almost all study subjects were literate. The sample comprised of 384 males and 238 females.

Type 2 diabetics were evenly distributed in the study sample in four quartiles of age with mean age 47.70

Occupation level

*All percentages rounded to whole numbers.

± 10.94 years. Around a third of the study sample had high level of occupation (37%).

Presenting complaints/symptoms: The study subjects had classic diabetic symptoms such as nocturia 44% (273/622), polyuria 31% (192/622) and polydypsia 23% (145/622). However, 9% (57/622) study subjects presented with vision impairment (Table 2).

Behavioral profile: Our findings showed that 28% (173/622) subjects had some form of habits; 9% (56/622) subjects were smoker, 20% (121/622) subjects were chewing tobacco and 8% (51/622) subjects were

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

143

diabetology Table 2. Presenting Symptoms of Type 2 Diabetic Subjects from India Characteristics Nocturia (Yes)

(n = 622) 273

Percentages (%)* 44

Polyuria (Yes)

192

31

Polydipsia (Yes)

Table 3. Profile of Clinical and Other Associated Factors of Type 2 Diabetic Subjects from India Characteristics

Number (n = 622)

HbA1C (mean ± SD)

9.02 ± 1.67

Percentages (%)*

145

23

Glycemic status

Vision impairment (Yes)

5

79

<7% (good control)

46

7

Itching of private parts (Yes)

50

8

Tingling (Yes)

136

22

7-8% (suboptimal control)

159

26

Weight loss (Yes)

165

27

8-9% (inadequate control)

163

26

Weakness (Yes)

365

59

>9% ( uncontrolled)

254

41

Leg pain (Yes)

155

25

Burning micturition (Yes)

68

11

417

67

Skin complaint (Yes)

59

10

Numbness (Yes)

39

6

Underweight (<18.5 kg/m2)

11

1

H/O impotence (Yes)

28

5

Normal (18.5-22.9 kg/m2)

99

16

Overweight (23.0-24.9 kg/m2)

92

15

420

68

62

10

487

78

289

47

Acute

446

72

Subacute

145

23

Insidious

31

5

Sedentary

525

84

Moderate

89

14

Heavy

8

1

Diet control

103

17

Other diabetic treatments

219

35

56

9

*All percentages rounded to whole numbers.

Family history of diabetes Present BMI group

Obese (≥25.0

kg/m2)

consuming alcohol. A large number of study subjects (84%) reported sedentary lifestyle (Table 3).

Microalbuminuria

Risk profile: Very few study subjects (7%) had good glycemic control (HbA1C <7%). Two-thirds of the study population had positive family history for diabetes. Our findings showed a mean BMI of 27.06 ± 4.57. According to BMI, only 16% of the studied sample was of normal weight; the majority was either over weight (23.0-24.9 kg/m2) or obese (BMI ≥ 25 kg/m2).

Microalbuminuria was found in 10% (62/622) T2DM subjects. Dyslipidemia and hypertension among T2DM was 78% and 47%, respectively (Table 3). There were statistically significant differences between male and female study subjects with respect to mean age (male = 46.93 ± 11.11, female = 48.95 ± 10.53), mean BMI (male = 26.47 ± 4.34, female = 28.02 ± 4.78), mean waist circumference (male = 93.12 ± 10.47, female = 88.96 ± 9.53), mean hip circumference (male = 98.46 ± 8.83, female = 101.69 ± 12.52) and mean LDL level (male = 119.20 ± 31.23, female = 127.73 ± 38.15) at p < 0.05 (Table 4). BMI was significantly associated with hypertension among T2DM subjects (p < 0.001) (Table 5).

Dyslipidemia

DISCUSSION Diabetes mellitus is a major public health problem worldwide. Its prevalence is on the rise in many parts of the developing world and India is no exception.

Individuals with T2DM are considered as high priority as they are potential candidates for rapid evaluation to

144

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Lipid Hypertension Present Mode of onset

Physical activity

(excluding diet) (Yes) Smoking (Yes) Years of tobacco smoking (mean ± SD) Tobacco chewing (Yes) Years of tobacco chewing (mean ± SD) Alcohol (Yes) Years of alcohol drinking (mean ± SD)

11.46 ± 9.27 121

20

12.37 ± 8.61 51 9.68 ± 7.64

*All percentages rounded to whole numbers.

8

diabetology Table 4. Study Population Characteristics, Clinical and Laboratory Findings by Sex among Type 2 Diabetic Subjects from India Characteristics

Mean ± SD

Table 5. Factors Associated with Hypertension among T2DM Subjects from India Factors

P value

Hypertension Yes

No

Male

Female

Age

46.93 ± 11.11

48.95 ± 10.53

0.026

Upto 40

67

97

BMI

26.47 ± 4.34

28.02 ± 4.78

0.000

41-48

73

97

93.12 ± 10.47

88.96 ± 9.53

0.000

49-55

74

76

>55

75

63

≥25 kg/m2

222

198

<25 kg/m2

67

135

Sedentary

246

279

Moderate to heavy

43

54

Dyslipidemia

220

267

Normal

69

66

Positive

205

212

Negative

84

121

<7% (good control)

24

22

7-8% (suboptimal control)

65

94

8-9% (inadequate control)

86

77

>9% (uncontrolled)

114

140

Waist circumference (cm)

HIP circumference (cm) 98.46 ± 8.83 101.69 ± 12.52

0.000

SBP (mmHg)

128.30 ± 16.43

129.60 ± 17.54

0.354

DBP (mmHg)

84.87 ± 9.13

83.41 ± 9.19

0.054

9.07 ± 1.74

8.93 ± 1.55

0.333

194.82 ± 39.24

201.00 ± 46.98

0.079

HDL (mg/dl)

41.17 ± 5.28

40.91 ± 6.10

0.575

LDL (mg/dl)

119.20 ± 31.23

127.73 ± 38.15

0.003

Triglycerides (mg/dl)

182.49 ± 123.31

169.87 ± 140.23 0.242

Lipid profile Cholesterol (mg/dl)

VLDL (mg/dl)

36.04 ± 18.46

32.03 ± 12.62

P value

6.86

0.076

21.25

0.000

0.21

0.659

1.4

0.242

3.7

0.054

5.449

0.142

Age (years)

Blood pressure

HBA1C

X2

0.004

BMI

Physical activity

Lipid profile

Family history (diabetes)

Glycemic status

prevent and halt the progression of the complications.

This study presents observational data from large number of subjects with diabetes attending Dept. of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre, Ahmedabad.

To the best of our knowledge, no such type of profiles has been reported from Western India. Nonetheless, literature regarding prevalence of diabetes is available from South and North India.22-26 Our main motivation for this analysis was to obtain the risk profile so that we can prevent or decrease the burden of T2DM in Western India.

This study found that T2DM is a major burden in Western India, which is consistent with a study

by Simon.4 Our study population had a negligible proportion of illiterate T2DM subjects. This finding was expected given that our sample was drawn from a tertiary care hospital located in an urban area. Many factors like family history of diabetes mellitus, age,

overweight/obesity, hypertension and lack of physical exercise have already been identified.27 In the present study, most subjects with T2DM were found to be obese. This complements various studies.28-31 Obesity was also associated with family history of diabetes in Indian population.32 Dyslipidemia and hypertension were also related with family history of diabetes through BMI.30,33 This study also identified BMI as predictor for hypertension among T2DM subjects and the role of BMI has been previously described.27 Our study could not demonstrate significant association between physical activity, dyslipidemia and controlled

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

145

diabetology glycemic status with hypertension among T2DM subjects. However, age and family history of diabetes are marginally significant.

Although diet control is the cornerstone in the management of T2DM but only 17% of the studied sample was on diet therapy. Achieving good glycemic control in diabetes subjects has proven a real challenge to the healthcare providers. It has been documented in studies that self care among T2DM subjects improved glycemic control and reduced complications.34,35 In this study, only 7% subjects had good glycemic control, which is different from various studies such as a Swedish survey, which found that 34% of type 2 diabetic subjects had good glycemic control,36 study

by Al-Maskari et al, which found that 38% T2DM of subjects had good glycemic control37 and study by AlKaabi et al, which reported 31% of subjects had good glycemic control.21 The possible explanation may be that our study sample consisted of newly- diagnosed T2DM subjects drawn from a tertiary care hospital and nonadherence to interventions may have contributed to uncontrolled glycemic status38 and these subjects may have had T2DM since many years as evident from the complications such as renal dysfunction in 9% and vision impairment in 10% subjects of T2DM. Limitations Several potential limitations should be considered in interpreting the results of this study. First, the study is limited by cross-sectional design so temporality (cause-and-effect relationships) cannot be established but it can provide a clear snapshot of the current situation and may help in developing improvement in management and in designing future studies to explore further. Second, this is a hospital-based study from a urban set up, which may not be representative and applicable to general population. However, this could provide a reasonably precise and reliable estimate of risk profile of T2DM in Western India. Lastly, we tried our level best to include newly diagnosed subjects but we are not sure that all subjects were newly diagnosed because we have relied on the subjects.

Conclusion and Recommendation The present study is directed at providing the profile of the T2DM subjects from Western India as an impetus for further exploration of the sociocultural and subjectrelated factors affecting the outcomes of T2DM care that in turn will lead to redefining of the diabetes control

146

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

and preventive strategies. The present study revealed that obesity, family history of diabetes, dyslipidemia, uncontrolled glycemic status, sedentary lifestyles and hypertension were highly prevalent in T2DM subjects.

Hence, the overall risk profile was very poor. The findings of this study also provide an early indication for development of complications of T2DM. Based on our findings, we recommend that appropriate management of T2DM subject requires a number of steps. ÂÂ

Uncontrolled glycemic status, dyslipidemia and vision impairment should be taken care by conducting early screening for complications, frequent check-ups and follow-ups.

ÂÂ

Lifestyle modification interventions like control of body weight through diet and exercise should be emphasized for prevention of T2DM.

ÂÂ

Early approach for prevention of onset and progression of diabetic complications can be achieved with reduction in HbA1C level.

Acknowledgment The authors would like to express their sincere thanks to all the subjects who participated in the study and Dr BD Mankad for his expert opinion. We would also like to thank Drs Prakash J Shah and WQ Shaikh for reviewing the manuscript. It is uncourteous if authors would not thank Mr Diwakar Sharma for statistical assistance. The study was supported by All India Institute of Diabetes and Research, Ahmedabad, Gujarat, India.

REFERENCES 1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27(5):1047-53.

2. Aguilar-Salinas CA, Reyes-Rodríguez E, OrdóñezSánchez ML, Torres MA, Ramírez-Jiménez S, DomínguezLópez A, et al. Early-onset type 2 diabetes: metabolic and genetic characterization in the mexican population. J Clin Endocrinol Metab 2001;86(1):220-6.

3. Mudaliar S. New frontiers in the management of type 2 diabetes. Indian J Med Res 2007;125(3):275-96.

4. Simon D. Epidemiological features of type 2 diabetes. Rev Prat 2010;60(4):469-73.

5. Delavari A, Alikhani S, Nili S, Birjandi RH, Birjandi F. Quality of care of diabetes mellitus type II patients in Iran.

Arch Iran Med 2009;12(5):492-5.

6. Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ 1998;316(7134):823-8.

diabetology 7. Tzoulaki I, Molokhia M, Curcin V, Little MP, Millett CJ, Ng A, et al. Risk of cardiovascular disease and all cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: retrospective cohort study using UK general practice research database. BMJ 2009;339:b4731.

19. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285(19):2486-97.

8. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications.

Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15(7):539-53.

20. Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al; Concensus Group. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009;57:163-70.

9. Zimmet P. The burden of type 2 diabetes: are we doing enough? Diabetes Metab 2003;29(4 Pt 2):6S9-18.

10. Ebrahim S, Kinra S, Bowen L, Andersen E, Ben-Shlomo Y, Lyngdoh T, et al. The effect of rural-to-urban migration on obesity and diabetes in India: a cross-sectional study.

PLoS Med 2010;7(4):e1000268.

11. Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, et al. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India-the Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia 2006;49(6):1175-8.

12. Deepa M, Pradeepa R, Rema M, Mohan A, Deepa R, Shanthirani S, et al. The Chennai Urban Rural Epidemiology Study (CURES) - study design and methodology (urban component) (CURES-I). J Assoc Physicians India 2003;51:863-70.

13. Ramachandran A, Ramachandran S, Snehalatha C, Augustine C, Murugesan N, Viswanathan V, et al.

Increasing expenditure on health care incurred by diabetic subjects in a developing country: a study from India. Diabetes Care 2007;30(2):252-6.

14. Misra A, Khurana L. The metabolic syndrome in South Asians: epidemiology, determinants, and prevention.

Metab Syndr Relat Disord 2009;7(6):497-514.

15. Chen Y, Zhang X, Pan B, Jin X, Yao H, Chen B, et al.

A modified formula for calculating low-density lipoprotein cholesterol values. Lipids Health Dis 2010;9:52.

16. Reddy KS, Prabhakaran D, Chaturvedi V, Jeemon P, Thankappan KR, Ramakrishnan L, et al. Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations. Bull World Health Organ 2006;84(6):461-9.

17. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-72.

18. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2006;29 Suppl 1:S43-8.

21. Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B, Parkar H, Nagelkerke N. Assessment of dietary practice among diabetic patients in the United arab emirates. Rev Diabet Stud 2008;5(2):110-5.

22. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al; Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44(9):1094-101.

23. Kutty VR, Soman CR, Joseph A, Pisharody R, Vijaya kumar K. Type 2 diabetes in southern Kerala: variation in prevalence among geographic divisions within a region. Natl Med J India 2000;13(6):287-92.

24. Ramachandran A, Jali MV, Mohan V, Snehalatha C, Viswanathan M. High prevalence of diabetes in an urban population in south India. BMJ 1988;297(6648):587-90.

25. Ramachandran A, Snehalatha C, Latha E, Vijay V, Viswanathan M. Rising prevalence of NIDDM in an urban population in India. Diabetologia 1997b;40(2): 232-7.

26. Misra A, Pandey RM, Devi JR, Sharma R, Vikram NK, Khanna N. High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India. Int J Obes Relat Metab Disord 2001;25(11):1722-9.

27. van Tilburg J, van Haeften TW, Pearson P, Wijmenga C. Defining the genetic contribution of type 2 diabetes mellitus. J Med Genet 2001;38(9):569-78.

28. Mayer-Davis EJ, Costacou T. Obesity and sedentary lifestyle: modifiable risk factors for prevention of type 2 diabetes. Curr Diab Rep 2001;1(2):170-6.

29. Lieberman LS. Dietary, evolutionary, and modernizing influences on the prevalence of type 2 diabetes. Annu Rev Nutr 2003;23:345-77.

30. Bener A, Al-Suwaidi J, Al-Jaber K, Al-Marri S, Elbagi IE. Epidemiology of hypertension and its associated risk factors in the Qatari population. J Hum Hypertens 2004;18(7):529-30.

31. Musaiger AO, Al-Mannai MA. Social and lifestyle factors associated with diabetes in the adult Bahraini population.

J Biosoc Sci 2002;34(2):277-81.

32. Habib SS, Aslam M. Lipids and lipoprotein(a) concentrations in Pakistani patients with type 2 diabetes mellitus. Diabetes Obes Metab 2004;6(5):338-43.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

147

diabetology 33. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Cosegregation of obesity with familial aggregation of type 2 diabetes mellitus. Diabetes Obes Metab 2000;2(3):149-54.

34. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V; Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49(2):289-97.

35. Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S.

The relationship between knowledge of recent HbA1c values and diabetes care understanding and selfmanagement. Diabetes Care 2005;28(4):816-22.

36. Holmström IM, Rosenqvist U. Misunderstandings about illness and treatment among patients with type 2 diabetes.

J Adv Nurs 2005;49(2):146-54.

37. Al-Maskari F, El-Sadig M. Prevalence of risk factors for diabetic foot complications. BMC Fam Pract 2007;8:59.

38. Kim N, Agostini JV, Justice AC. Refill adherence to oral hypoglycemic agents and glycemic control in veterans.

Ann Pharmacother 2010;44(5):800-8.

■■■■

ADA: Time since Diabetes Dx Key in Adherence Newly diagnosed type 2 diabetes patients are less likely to follow their medication regimen than those with longer-standing disease, and those who take more pills are more likely to be adherent than those on fewer medications, a study found. (Source: Medpage Today)

Type 2 Diabetics can Reduce Weight by WAIT Program A short-term lifestyle modification program for overweight diabetic patients can lead to long-term benefits. In a study conducted by Dr Osama Hamdy at the Joslin Clinic in Boston, patients who had a mean A1C of 7.6% at baseline were able to lower their A1C to 6.6% after 12 weeks of the intensive program and remained at 7% after three years. The name of the program is Why WAIT (Weight Achievement and Intensive Treatment) and it has been incorporated into regular practice at the clinic. The researchers enrolled 141 patients with diabetes in the study - 127 with type 2 diabetes and 14 patients with type 1 diabetes. Average patient age was 53 and mean time from diagnosis was about 9.5 years. The study included 91 women. The average baseline weight of the participants was 240 pounds. Six of the patients dropped out of the study before completing the study period.

The rest had at least two years of follow-up, including 105 followed for 2.5 years and 70 patients with three years of follow-up.

The program included diet, exercise and weight-neutral or weight-negative medications. The diet was low in glycemic index, high in fiber, and low in saturated fat. Patients were put on a structured strength and cardiovascular exercise program that gradually increased activity. For the first four sessions, patients were encouraged to exercise 20-40 minutes four days a week; during the next four the exercise prescription was increased to 40-45 minutes five days a week; and in the final four sessions patients were told to exercise 50-60 minutes six days a week.

The patients also attended weekly teaching and behavioral support sessions. At the 12-week program’s end, participants were instructed to follow the same plan on their own.

Intensive lifestyle changes can be successful and sustainable. ÂÂ

Average weight loss after 12 weeks of the study was 24.1 pounds.

ÂÂ

Weight loss averaged 18.2 pounds at one year; 18.8 pounds at two years and 17.2 pounds at both 2.5 years and at 3 years.

ÂÂ

HbA1C fell from 7.6% to 6.6% after 12 weeks and was 7% after one year, 6.9% at two years, 7% at 2.5 years and 7% at three years.

ÂÂ

About 82% of patients achieved the goal of 7% after 12 weeks, but that declined to 47% at two years, 43% at 2.5 years and 40% at three years.

148

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

ENT

Kartagener`s Syndrome: A Case Report Lakshmi Ponnathpur*, Lakshmi Shantharam**

Abstract Kartagener`s syndrome, a rare autosomal recessive disorder is a type of primary ciliary dyskinesia (PCD) associated situs inversus, bronchiectasis, sinusitis and male infertility. We present a case of a 12-year-old boy who came with features of bilateral glue ear, recurrent sinusitis, adenotonsillitis, obstructive sleep apnea and situ inversus. He was diagnosed to have Kartagener`s syndrome and was treated with bilateral grommet insertion, bilateral antral lavage and adenotonsillectomy to alleviate his symptoms.

Keywords: Kartagener`s syndrome, situs inversus, primary ciliary dyskinesia Case report A 12-year-old boy presented with history of recurrent nasal discharge, nasal obstruction and poor hearing since six months. The nasal discharge was thick, mucoid type. He also gave history of frequent sore throat, snoring and disturbed sleep at night. On examination, he was a normally built and nourished boy with delayed secondary sexual characteristics. On ENT examination, he had bilateral glue ear kind of picture with conductive hearing loss. He was a mouth breather with adenoid facies and had thick mucopus in both middle meati without any polyps. Examination of throat revealed huge tonsils compromising the oropharyngeal space. A diagnosis of obstructive sleep apnea secondary to chronic adenotonsillitis and chronic sinusitis and bilateral serous otitis media was made.

Chest X-ray revealed dextrocardia and right-sided fundal gas shadow suggesting situs inversus (Fig. 1).

X-ray of paranasal sinuses revealed bilateral haziness of maxillary sinuses. There was no evidence of bronchitis on chest X-ray. On further questioning, the child was known to have a heart on right side of chest and he also had features of hypogonadism. With all these clinical and radiological findings a diagnosis of Kartagener`s syndrome was made.

To alleviate his suffering and to improve his qualityof-life, adenotonsillectomy, bilateral antral lavage and bilateral grommet insertion was done. His post-op period was uneventful. He was greatly relieved of

Hematological investigations such as complete hemogram, bleeding time, clotting time, prothrombin time and activated partial thromboplastin time (APTT) and platelet count were done as preoperative work-up.

Pure tone audiometry showed mild conductive deafness and impedance audiometry showed bilateral B type tympanogram with absent reflexes, which suggested bilateral glue ear. *Senior Consultant Sagar Hospitals and Skin, Cosmetic and ENT Care Center, Jayanagar, Bangalore Honorary Consultant, Indira Gandhi Institute of Child Health, Bangalore **Junior Consultant, Skin, Cosmetic and ENT Care Center, Jayanagar, Bangalore Address for correspondence Dr Lakshmi Ponnathpur 742, Bhagyashree, 18th Main, 37th F Cross, 4th T Block Jayanagar, Bangalore - 560 041, Karnataka E-,mail: ponnathpurlakshmi@gmail.com

Figure 1. Chest X-ray showing dextrocardia and situs inversus.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

149

ENT his nasal obstruction and snoring. His hearing also improved. Parents were adviced to consult a genetic counselor. However, he was lost to follow-up as he was an NRI patient.

Discussion

Figure 2. Intraoperative picture - the ECG leads put on right side due to dextrocardia.

Figure 3. Adenoids and tonsils after excision.

Figure 4. Ear with grommet in situ.

150

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Kartagener`s syndrome is a triad of situs inversus, chronic sinusitis and bronchiectasis.1 It is a rare autosomal recessive disorder occurring in 1:15,000 live births.2 There is difficulty in clearing mucous secreted from the respiratory tract. It also affects the motility of spermatozoa resulting in male infertility. Patient can present to the otorhinolaryngologist with nasal obstruction, rhinorrhea and deafness. Nasal polyps as a result of allergy is more common in cystic fibrosis.3 Otitis media with effusion is the most common otolaryngeal problem in primary ciliary dyskinesia (PCD), but may stabilize by adolescence.4 Dextrocardia may be detected in routine general examination of patient or during pre-anesthetic check-up. Finding of dextrocardia on general examination or on X-ray points to a possible diagnosis of Kartagener`s syndrome.

Radiology in the form of chest X-ray not only shows dextrocardia but also reveals situs inversus by showing right-sided fundal gas shadow. As our patient did not have any pulmonary changes, CT scan of chest and spirometric assessments were not done.

Medical management consists of controlling the infections and antibiotic prophylaxis. Special consideration is required at the time of anesthesia. Care should be taken to avoid nasal tubes and airways. Strict aseptic precautions should be followed.5 Electron microscopy of nasal or bronchial biopsy can reveal defective ciliary structure. There will be defect in the dynein arm of chromosomes. Mutations in the DNA H 5 and DNA 11 have been confirmed.6 Genetic testing is available in specialized laboratories.

Primary epithelial cell culture can be done for both gene testing and electron microscopy.7 Transmission electron microscopy remains the most definitive method of establishing the diagnosis of PCD, as exact structural changes can be visualized. Ciliary beat frequency and ciliary beat pattern analysis by high speed videophotography, electron microscopy of ciliary ultrastructure and measurement of ciliary disorientation are recommended wherever facilities exist.8-10 Gene testing and electron microscopy are out of reach for most patients of PCD. Treatment is tailormade according to the needs of the patient; majority of patients enjoy a normal or near normal life.4

ENT Conclusion Kartagener`s syndrome is a rare condition, occasionally picked up by the otorhinolaryngologist. It may prove challenging if high index of suspicion is not made.

Thorough clinical evaluation, adequate investigations, simple surgical treatments in the form of FESS, Bilateral antral washout, adenotonsillectomy, grommet insertion, etc. go a long way in alleviating the patient`s symptoms, reducing the morbidity and improving the quality-of-life.

Ackowledgments We would like to thank Senior Anesthesiologist Dr PM Chandrashekar for his involvement in the surgery and Sagar Hospitals, Bangalore where the patient was operated.

References 1. Afzelius BA, Stenram U. Prevalence and genetics of immotile-cilia syndrome and left-handedness. Int J Dev Biol 2006;50(6):571-3.

2. Bush A, Cole P, Hariri M, Mackay I, Phillips G, O’Callaghan C, et al. Primary ciliary dyskinesia: diagnosis and standards of care. Eur Respir J 1998;12(4):982-8.

3. Marsden D. Nasal polyposis in children. Southern Med J1978;71(8):911-3.

4. Bush A, Chodhari R, Collins N, Copeland F, Hall P, Harcourt J, et al. Primary ciliary dyskinesia: current state of the art. Arch Dis Child 2007;92(12):1136-40.

5. Ho AM, Friedland MJ. Kartagener’s syndrome: anesthetic considerations. Anesthesiology 1992;77(2):386-8.

6. Geremek M, Witt M. Primary ciliary dyskinesia: genes, candidate genes and chromosomal regions. J Appl Genet 2004;45(3):347-61.

7. Jorissen M, Willems T, Van der Schueren B, Verbeken E, De Boeck K. Ultrastructural expression of primary ciliary dyskinesia after ciliogenesis in culture. Acta Otorhinolaryngol Belg 2000;54(3):343-56.

8. Afzelius BA. Cilia-related 2004;204(4):470-7.

diseases.

J

Pathol

9. Stannard W, Rutman A, Wallis C, O’Callaghan C. Central microtubular agenesis causing primary ciliary dyskinesia.

Am J Respir Crit Care Med 2004;169(5):634-7.

10. Teknos TN, Metson R, Chasse T, Balercia G, Dickersin GR. New developments in the diagnosis of Kartagener’s syndrome. Otolaryngol Head Neck Surg 1997;116(1): 68-74.

■■■■

Surgery May Hike Survival in Tonsil Cancer Tonsillectomy followed by radiation therapy led to better survival in patients with early-stage tonsil cancer compared with radiation alone, a retrospective analysis suggested. Overall survival at 5 years was 83.2% (95% CI 76.8 to 88) for patients who underwent surgery before radiation compared with 63.6% (95% CI 54.5 to 71.4, p < 0.001) among those who had only a tonsillar biopsy prior to radiation, according to Michael A. Holliday, MD, and colleagues from Georgetown University in Washington, DC. In addition, 5-year disease-specific survival rates were 89.6% (95% CI 84.1 to 93.3) and 76% (95% CI 67.8 to 82.2, p < 0.001), respectively, the researchers reported in the April JAMA Otolaryngology–Head & Neck Surgery.

Despite this apparent survival advantage, the researchers pointed out that their analysis was probably influenced by selection bias, and should not be considered definitive.

“Whether to treat patients with early-stage tonsil cancer using surgery or [radiation therapy] remains controversial, and with the advent of new procedures to address the primary tumor, the debate is far from settled,” they stated.

Current guidelines suggest that either surgery or radiation is appropriate for early tonsil cancer.

Tumor margins may remain positive when a diagnostic procedure such as a needle biopsy is done, but tonsillectomy requires delay in potentially curative radiation while the wound heals. Therefore, to see if a combined approach would be superior, Holliday’s team analyzed data from the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program, identifying 524 patients diagnosed with stage T1 or T2 tonsil cancer in the years 1988 to 2006.

T1 tumors were smaller than 2 cm, and T2 tumors were 2-4 cm. All cases were squamous or epithelial cell cancers, and 61% were stage T2. A total of 54% of patients had surgery plus radiation, while the remainder had only radiotherapy. In a univariate analysis, factors influencing overall and disease-specific survival were older age, having had surgery, and being diagnosed after 2004. In multivariate analyses, those factors remained significantly associated with death from tonsil cancer. (Source: Medpage)

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

151

GASTROENTEROLOGY

Synchronous Gastrointestinal Stromal Tumors: A Rare Case Report SAMARTH SHUKLA*, SOURYA ACHARYA**, DP RAJPUT†, S VAGHA‡

Abstract Gastrointestinal stromal tumors (GISTs) are a subset of GI mesenchymal tumors showing neural, smooth muscle, epitheloid types of varying differentiation accounting for approximately 80% of GI mesenchymal tumors. Over 90% of GISTs occur in adults over 40 years, the most common location being stomach (50-60%) and small intestine (30-40%). We report a case of a 70-year-old man who presented with diffuse dull pain in the abdomen, a gradual loss of appetite and weight since last eight months. He was investigated and a diagnosis suggestive of GI stromal tumor-NOS type with synchronous multicentric origin having an indeterminate malignant potential was made.

Keywords: Gastrointestinal stromal tumors, synchronous multicentric origin, indeterminate malignant potential, mesenchymal tumors, pluripotent mesenchymal stem cells

G

astrointestinal stromal tumors (GISTs) may originate from the esophagus to the rectum, but can also occur the mesentery and omentum.

According to Kindblom (1998), the actual cell of origin of GISTs is a pluripotential mesenchymal stem cell programmed to differentiate into the interstitial cell of Cajal.1

The incidence of GIST is estimated to be approximately 10-20 per million people, per year. The possibility of their turning malignant is 20-30%.2 Over 90% of GISTs occur in adults over 40 years, the most common location being stomach (50-60%) and small intestine (30-40%).

Outside the gastrointestinal (GI) tract, the tumors are known as extra-GISTs (EGISTs).3 Multicentric GIST’s are rare in elderly age group and if found are dubbed as metastatic, though synchronous arising tumors have been reported as well.

Case History A 70-year-old man presented with diffuse dull pain in the abdomen, a gradual loss of appetite and weight since

last eight months. There was a history of hematemesis since last five days.

Clinical examination revealed two irregular, palpable, nonpulsatile, masses in the upper abdomen over the umbilical and left hypochondrium-epigastrium region, respectively.

Laboratory investigations revealed anemia with hemoglobin (Hb) = 8.2 g/dl; total and differential leukocyte counts were within normal limits.

Biochemistry revealed plasma glucose within normal parameters, liver and kidney function tests were normal. GI endoscopy revealed mucosal ulceration at the body of the stomach. Ultrasound examination showed hyperechoic areas in the body of stomach (greater curvature), mesentery of the small intestine.

The patient underwent exploratory laparotomy and perioperatively, two large growths, one in the cecum and the other from the mesentery, and a small protruding polypoid growth at greater curvature at the body of the stomach were excised and subjected for histopathological examination.

Pathological Findings

*Associate Professor, Dept. of Pathology **Associate Professor, Dept. of Medicine †Assistant Professor, Dept. of Medicine ‡Professor and Head, Dept. of Pathology Address for correspondence Dr Samarth Shukla Associate Professor, Dept. of Pathology JN Medical College, DMIMS University, Sawangi (Meghe), Wardha, Maharashtra E-mail: samarthshukla@hotmail.com

152

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Gross Findings The resected segment consisted of ileum attached by a stalk to the mesenteric tumor mass along with the stomach and cecum (Fig. 1). The solitary solid tumor in the mesentry was of size 8 × 6 × 5 cm, the growth in the

GASTROENTEROLOGY findings of a predominant stromal cellularity with the stromal cells forming fascicles, the cells appeared elongated (spindle) with moderate cytoplasm and hyperchromatic nucleus, with inconspicuous nucleoli, the mitotic figures were only modestly elevated (< 5/50 HPF). Immunohistochemistry: CD 34+, CD 117+ Actin, desmin and S-100 were negative.

Based on gross-examination, histopathology and immunohistochemistry, a diagnosis suggestive of GIST– NOS (not otherwise specified) type with synchronous multicentric origin having an indeterminate malignant potential was made.

Discussion

Figure 1. Gross specimen cut section: Small intestine with mesenteric mass and cecum.

Gastrointestinal stromal tumors (GISTs) are a subset of GI mesenchymal tumors showing neural, smooth muscle, epitheloid types of varying differentiation.

With the advent of immunohistochemical staining techniques and ultrastructural evaluation, GISTs now are recognized as a distinct group of mesenchymal tumors. In the present classification, GISTs account for approximately 80% of GI mesenchymal tumors.4 GISTs are KIT-expressing and KIT (tyrosine kinase receptor - CD 117)-signaling driven mesenchymal tumors. It has nowadays been recognized that GISTs arise from multipotential mesenchymal stem cells.5

Differential Diagnosis Differential diagnoses for GIST’s include neural tumors (schwannoma) and smooth muscle tumors (leiomyoma), besides carcinoids and fibrotic lesions.

GIST themselves can have a mixed neural component or a pure neural component as in GI autonomic neural tumors (GNAT).

Figure 2. Polypoid growth in the stomach.

stomach was present as an ulcer in the mucosa jutting out through the gastric serosa as a polypoid growth of 5 × 3 × 1.5 cm (Fig. 2). The cecal mass measured 7 × 4 × 3 cm. External surface of the mesenteric as well as cecal mass was partially capsulated (pseudo capsule) and smooth. Cut surface of all masses was tan gray in color, firm in consistency.

Histological Findings The histopathology sections from the gastric, as well as the cecum and mesenteric tumor showed similar

Considering the diagnostic issues, the pathologists find it convenient to mention terms such gastrointestinal mesenchymal tumors-negative for smooth muscle cell and or neural differentiation schwannomas. Some authors specifically use the term ‘GIST’ to refer only to those mesenchymal tumors that express CD 117.6 In contrast, true leiomyomas and leiomyosarcomas typically express desmin and actin but not CD 34 and CD 117, Schwannomas typically express S 100 but not CD 117.7

Multiple Sporadic Malignant GIST A multicentric appearance is restricted to familial GISTs, pediatric forms or distinct syndromes such as type 1 neurofibromatosis or Carney’s syndrome with germline mutations of proto-oncogene tyrosine protein

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

153

GASTROENTEROLOGY kinase Kit (KIT) or platelet-derived growth factor receptor-a (PDGFR-a).

Beyond these situations any sort of multiplicity seen in GIST are dubbed as metatstatic growths from a single primary GIST. But, whether these multiple GIST’s in an adult patient are synchronously arising GIST’s or a metastatic behavior is debatable and extensive clonal studies have to be further carried out. This paradigm has been recently challenged by two articles, which suggested the existence of sporadic multiple primary GISTs in adult patients.6,8 The present case deals with a 65 years old with GIST’s present at multiple sites in the GI tract. Whether, this was a single tumor, which underwent metastasis or was it a synchronously arising GIST in an individual without any obvious genetic syndromes is again a matter of dilemma. The finding of GIST patients with tumor multiplicity suggests that, in these subjects, GIST precursors pluripotent mesenchymal stem cells are primed towards tumorigenic conversion.

This may recall the phenomenon of ‘field cancerization,’ reported for the mucosa of the upper respiratory tract.9

Behavior and Prognosis All tumors with size above 10 cm and a mitotic rate of >10/50 HPF are to be labeled as malignant while those with mitotic rate <5/50 HPF and tumor size <5 cm are considered benign. Those tumors fall in between 5-10 cm and a mitotic rate of 5-10/50 HPF are termed intermediates. The risk category was assessed according to the 2002 NIH classification.

Management Radiation therapy has not been proven effective in the management of GISTs, and only 5% of tumors respond to doxorubicin-based chemotherapy. Initial studies with imatinib mesylate, a competitive inhibitor of tyrosine kinases showed very encouraging results, with 54% of patients exhibiting at least a partial response.10 Most common indications for surgery include bleeding and obstruction.

References 1. Kindblom LG, Remotti HE, Aldenborg F, Meis-Kindblom JM. Gastrointestinal pacemaker cell tumor (GIPACT): gastrointestinal stromal tumors show phenotypic characteristics of the interstitial cells of Cajal. Am J Pathol 1998;152(5):1259-69.

2. Kim KM, Kang DW, Moon WS, Park JB, Park CK, Sohn JH, et al; Gastrointestinal Stromal Tumor Committee; Korean Gastrointestinal Pathology Study Group. Gastrointestinal stromal tumors in Koreans: it’s incidence and the clinical, pathologic and immunohistochemical findings. J Korean Med Sci 2005;20(6):977-84.

3. Miettinen M, Lasota J. Gastrointestinal stromal tumors definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis.

Virchows Arch 2001;438(1):1-12.

4. Nishida T, Hirota S. Biological and clinical review of stromal tumors in the gastrointestinal tract. Histol Histopathol 2000;15(4):1293-301.

5. Joensuu H. Gastrointestinal stromal tumor (GIST). Ann Oncol 2006;17 Suppl 10:x280-6.

6. Haller F, Schulten HJ, Armbrust T, Langer C, Gunawan B, Füzesi L. Multicentric sporadic gastrointestinal stromal tumors (GISTs) of the stomach with distinct clonal origin: differential diagnosis to familial and syndromal GIST variants and peritoneal metastasis. Am J Surg Pathol 2007;31(6):933-7.

7. Miettinen M, Virolainen M, Maarit-Sarlomo-Rikala.

Gastrointestinal stromal tumors - value of CD34 antigen in their identification and separation from true leiomyomas and schwannomas. Am J Surg Pathol 1995;19(2):207-16.

8. Kang DY, Park CK, Choi JS, Jin SY, Kim HJ, Joo M, et al. Multiple gastrointestinal stromal tumors: Clinicopathologic and genetic analysis of 12 patients. Am J Surg Pathol 2007;31(2):224-32.

9. Ha PK, Califano JA. The molecular biology of mucosal field cancerization of the head and neck. Crit Rev Oral Biol Med 2003;14(5):363-9.

10. Plaat BE, Hollema H, Molenaar WM, Torn Broers GH, Pijpe J, Mastik MF, et al. Soft tissue leiomyosarcomas and malignant gastrointestinal stromal tumors: differences in clinical outcome and expression of multidrug resistance proteins. J Clin Oncol 2000 ;18(18):3211-20.

■■■■

154

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

OBSTETRICS AND GYNECOLOGY

Effect of Rosiglitazone on Spontaneous and Clomiphene Citrate-induced Ovulation in Polycystic Ovary Syndrome Sandhya Mittal*, Anupama Goel*, Ajay Mittal**, Bal K Taneja†, Praveen Gupta**

Abstract Objective: The aim of this study was to evaluate the effect of rosiglitazone on spontaneous and clomiphene-induced cycle in polycystic ovary syndrome (PCOS) women. Methods: A randomized controlled trial was carried out on 30 women of PCOS divided into two groups of 15 each. Group I women received rosiglitazone and Group II women received both rosiglitazone and clomiphene citrate for three months. Main outcome measures: Primary outcome measures were improvement in body mass index (BMI), Hirsutism scoring and ovulation rate. Secondary outcome measures included conception rate and changes in hormonal profile. Results: Overall 20 of 30 (66.67%) women ovulated successfully. Ovulation occurred in nine of 15 women (60.00%) in Group I as compared to 11 of 15 (73.33%) in Group II (p value 0.6). Out of 30, total 53.33% became pregnant, 40% from Group I and 66.67% from Group II (p value 0.14). No significant improvement in follicle-stimulating hormone (FSH) and Hirsutism score was observed. Mean BMI of patient improved significantly and fasting insulin declined but not statistically significant. The hormonal profile showed improvement in both the groups, with decline in luteinizing hormone (LH), LH/FSH ratio and testosterone. Conclusion: Thus rosiglitazone, a wonderful insulin sensitizer, plays a significant role alone as well as in adjunct with clomiphene citrate in PCOS women.

Keywords: Polycystic ovary syndrome, anovulatory infertility, rosiglitazone, clomiphene citrate, insulin resistance

P

olycystic ovary syndrome (PCOS) is one of the most common endocrinopathies affecting approximately 5-10% of women of reproductive age1 and is the most common cause of female anovulatory infertility.2 PCOS is a heterogeneous disorder characterized by any two of the following three features: ÂÂ

Oligo-ovulation or anovulation

ÂÂ

Clinical or biochemical signs of hyperandrogenism

ÂÂ

Polycystic ovaries (either 12 or more follicles measuring 2-9 mm in diameter or an ovarian volume of <10 cm3).3

These women have hyperandrogenism, and inappropriate gonadotropin secretion and approximately 44% of them are obese and 60% display insulin *Assistant Professor Dept. of Obstetrics and Gynecology **Associate Professor Dept. of Medicine †Professor Dept. of Obstetrics and Gynecology

MMIMSR, Mullana (Ambala), Haryana Address for correspondence Dr Sandhya Mittal 344/5, Urban Estate, Kurukshetra, Haryana - 136 118 E-mail: sandhya81969@yahoo.com

resistance.4 Insulin resistance is an intrinsic, virtually universal feature of PCOS and is independent of obesity as evidence by the presence of insulin resistance even in lean women with PCOS.4 Correction of hyperinsulinemia enhances spontaneous ovulation or alternatively the responsiveness to ovulation inducing agents such as clomiphene citrate.

Hyperinsulinemia is due to point mutation of insulin receptors gene5 and is known to be associated with increased cardiovascular risk and development of diabetes mellitus.6 Because of the link between insulin resistance and PCOS, metformin either alone or in combination with clomiphene citrate is now the most widely used insulin sensitizer.7-9 On the other hand rosiglitazone, another insulin sensitizer, a member of the thiozolidinediones family has been shown to be effective in type II diabetics and has been in trial for PCOS.10 No significant change in lipid profile including total cholesterol, low-density lipoprotein (LDL) high-density lipoprotein (HDL) and triglycerides was observed after treatment with rosiglitazone.10-12 Kaul and Diamond on their metaanalysis on 42 clinical trials found that the data showing the increased risk for myocardial infarction and death

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

155

OBSTETRICS AND GYNECOLOGY from cardiovascular disease for diabetic patients taking rosiglitazone are inconclusive.13 Further in patients with nonalcoholic steatohepatitis, rosiglitazone improves steatosis and transaminase level.14 Our study was to evaluate the effect of rosiglitazone on ovulation and conception in spontaneous as well as clomiphene-induced cycles.

Methods A randomized controlled trial was conducted on 30 subjects who received the diagnosis of PCOS-based on clinical features and laboratory findings. Written informed consent was obtained from all the women and the Departmental Ethical Committee approved the study. All the subjects were of reproductive age and desired to be pregnant. By systemic random sampling subjects were randomly put into two treatment groups.

Subjects in Group I (n = 15) received rosiglitazone 4 mg b.i.d. from day 1 of cycle for three months continuously.

Group II (n = 15) women received rosiglitazone 4 mg b.i.d. from Day 1 of cycle and clomiphene citrate 50 mg o.d. added on Days 2-6 of cycle for a maximum of three months.

The patients with secondary amenorrhea were given progesterone for withdrawal bleeding followed by the administration of the drugs as per our protocol in both the groups.

Inclusion Criteria All subjects have confirmed PCOS either on USG or hormonal assay and were in good health with no major medical illness. Other causes of infertility including local, uterine or adnexal were ruled out by performing per speculum examination, bimanual vaginal examination and hysterosalpingography. Male factor of infertility was ruled out by doing husband semen analysis, performed within one year of participation in the study and sperm concentration at least 20 millions/ ml was required.15

Exclusion Criteria Subjects were excluded from the study if they had hyperprolactinemia, congenital adrenal hyperplasia, thyroid diseases or other cause of amenorrhea including premature ovarian failure. Clinically suspected Cushing syndrome and androgen secreting neoplasm were also excluded from the study.

Fasting blood sugar and insulin level were done by using enzymatic methods and serum luteininzing

156

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

hormone (LH), follicle-stimulating hormone (FSH) by immunoradiometric assay on 2nd or 3rd day of first menstrual cycle.16 Serum testosterone was estimated by radioimmunoassay.17 Body mass index (BMI) was calculated by BMI equation and Hirsutism scoring was done by Ferriman-Gallwey scale.18,19 Assessment of the ovulatory rate was done by transvaginal sonography from the 10th day of the menstrual cycle. All the tests were repeated in last treatment cycle to find out the effect of treatment.

Primary outcome measures were improvement in clinical picture of PCOS including changes in BMI and Hirsutism scoring as well as ovulation rate. Secondary outcome measures included conception rate and changes in hormonal profile like serum LH, LH/FSH ratio, fasting blood sugar and fasting insulin level as well as serum testosterone. Data for all subjects before and after treatment was statistically analyzed using paired students (t) test and Chi-square test and Z-test was used for comparison of outcome. The level of statistical significance was set at p < 0.05. P value ∞ denotes highly significant.

Results All the women were in reproductive age group between 20-35 years of age. Out of 30, 20 women had primary and 10 had secondary infertility and were equally distributed in both the groups. Out of five patients of secondary infertility in Group I only one patient was para 1 and rest four had previous abortions. In Group II two patients were primipara and rest three had previous abortions (Table 1). The overall compliance was good.

We found a significant effect of rosiglitazone on clinical features. Six patients who had normal menstruation before treatment remained unchanged after treatment.

Out of 12 patients who had oligomenorrhea, seven resumed normal cycles with rosiglitazone. Nine patients who presented with amenorrhea, five developed oligomenorrhea and four resumed normal menstruation after treatment. Among the three patients who presented with polymenorrhea, all resumed normal cycles. No significant improvement in acne was observed (Table 2).

Table 1. Shows Age and History of Abortions in the Two Groups Parameter

Group I (n = 15)

Group II (n = 15)

P value

Age

22.53 ± 8.14

24.73 ± 3.419

0.32

Previous abortions

4 (26.67%)

3 (0.20%)

0.66

OBSTETRICS AND GYNECOLOGY Table 2. Effect of Rosiglitazone on Clinical Features and Laboratory Parameters Parameters

Before treatment (Mean ± SD range)

After treatment (Mean ± SD range)

Z value

P value

yy Oligomenorrhea

12 (40%)

10 (34.48%)

0.66

yy Amenorrhea

9 (30%)

0 (0%)

0.001

yy Polymenorrhea

3 (10%)

0 (0%)

0.08

yy Normal

6 (20%)

20 (66.66%)

0.0006

Acne

14 (46.67%)

8 (27.58%)

0.12

BMI

25.9 ± 5.3

23.5 ± 4.9

5.15

∞

Hirsutism score

15.9 ± 6.3

14.1 ± 5.1

1.27

0.1020

LH (mIU/ml)

13.67 ± 6.2

9.4 ± 4.3

7.2

∞

FSH (mIU/ml)

7.15 ± 8.9

9.9 ± 12.2

0.20

0.4207

LH/FSH ratio (mIU/ml)

2.0 ± 0.9

1.2 ± 0.65

5.7

∞

Menstrual pattern

Testosterone (ng/dl)

0.78 ± 0.2

0.66 ± 0.16

1.85

0.0322

FBS (mg/dl)

86.0 ± 10.0

85.16 ± 8.54

0.41

0.3409

Fasting insulin level (mg/dl)

8.85 ± 6.8

7.84 ± 5.0

0.02

0.4920

Table 3. Ovulation Rate and Conception Rate Group I (n = 15) Ovulation rate

Group II (n = 15)

Conception rate

Ovulation rate

Conception rate

First cycle

2 (13.33%)

0

5 (33.33%)

4 (26.67%)

Second cycle

3 (20.00%)

2 (13.33%)

4 (26.67%)

4 (26.67%)

Third cycle

4 (26.67%)

4 (26.67%)

2 (13.33%)

2 (13.33%)

Total

9 (60.00%)

6 (40.00%)

11 (73.33%)

10 (66.67%)

p value of ovulation was 0.6 and of pregnancy was 0.14.

Mean BMI of patient improved highly significantly from 25.9 ± 5.3 to 23.5 ± 4.9 (p value ∞) after treatment.

No significant change in Hirsutism score was observed.

It was 15.9 ± 6.3 before and 14.1 ± 5.1 after treatment with rosiglitazone (Table 2).

Overall 20 of 30 (66.67%) women ovulated successfully.

Ovulation occurred in nine of 15 women (60.00%) in Group I as compared to 11 of 15 (73.33%) in Group II (p value 0.6). Out of 30, 16 women (53.33%) became pregnant. Pregnancy rate was 40% and 66.67% in Group I and II, respectively (p value 0.14) (Table 3).

Among the six pregnancies in Group I, one landed in missed abortion. Rest five had successful pregnancy outcome, one delivered by cesarean section and four vaginally. Out of 10 conceptions in Group II, two had missed abortion, one had twin pregnancy who was delivered by cesarean section and rest seven delivered at term vaginally. The hormonal profile showed improvement in both the groups after treatment with

rosiglitazone with decline in LH, LH/FSH ratio, which was statistically highly significant. There was decrease in LH hormone from 13.67 ± 6.2 to 9.4 ± 4.3 (p value ∞) and LH/FSH ratio from 2.0 ± 0.9 to 1.2 ± 0.65 (p value ∞).

No significant difference in FSH level was noted. Level of serum testosterone had decreased after treatment but difference was not statistically significant. Fasting insulin level improved from 8.8 5 ± 6.8 to 7.84 ± 5.1 (p value 0.4920) while fasting blood sugar (FBS) did not show any significant change (Table 2).

Discussion PCOS is a very common disorder and is the most common cause of chronic anovulation and menstrual irregularity in infertile women. In current infertility practice, ovarian surgery for PCOS is not frequently recommended because of the risk of scar tissue formation that can profoundly impair tubal function

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

157

OBSTETRICS AND GYNECOLOGY thereby creating a new, very serious fertility problem that the woman did not previously has.

Clomiphene is the traditional first-choice treatment for induction of ovulation in PCOS women. Though it leads to ovulation induction in 90% cases, the number of pregnancies achieved is much lower than expected.10 Combining clomiphene with one of the wonderful new insulin sensitizing drugs, metformin or rosiglitazone may convert these patients to a responsive one.

The ovulation rate in our study was 60% in women who received rosiglitazone alone and 73.33% with combination (p value 0.6) while Ghazeeri et al11 had found a comparatively lower ovulation rate i.e., 33% and 77%, respectively. These findings support the fact that hyperinsulinemia impedes ovulation and decreasing insulin resistance facilitates ovulation spontaneously as well as by induction with clomiphene.20,10 There is a significant difference in conception rate in both the groups (40% in Group I vs 66.67% in Group II) with overall rate being 53.33%. Our results are higher than the results reported by Ghalaut et al10 and Ghazeeri et al.11 Regularity in the menstrual cycle was observed after treatment with rosiglitazone. Another randomized controlled trial21 studied the use of rosiglitazone in combination with clomiphene citrate and reported improvement in menstrual regularity. (92% with combination therapy vs 68% with rosiglitazone).

Similar results were also reported by other authors.10,12 Rosiglitazone therapy resulted in highly significant improvement in weight and BMI (p value ∞) while other authors11,4 reported no improvement in weight and BMI after treatment with rosiglitazone. No significant change in Hirsutism score was observed in our study, which was comparable to another study.10 We had observed a highly significant decrease in LH hormone and LH/FSH ratio in both groups (p value ∞) with no change in FSH levels after treatment with rosiglitazone. Similar results were reported by other authors.10,11 While Sepilian et al4 did not find any significant change in LH levels and Shobokshi et al21 had found a significant decrease in FSH level.

The level of serum testosterone had decreased in both the groups after treatment but statistically nonsignificant with p value 0.032. Our results were similar to another study.21 Serum testosterone level decreased after treatment due to raised level of sex hormone-binding globulin (SHBG).12 While no significant decrease was noted in level of serum testosterone by Ghalaut10 and Ghazeeri et al.11

158

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

In present study, fasting insulin declined from 8.85 ± 6.8 to 7.84 ± 5.0 after rosiglitazone (p value 0.492). Belli et al12 has also reported similar results. Unlike other study,4 we did not find any significant change in FBS level after treatment with rosiglitazone. Our findings were consistent with other studies.10,11,17,20 Conclusion Combing clomiphene with one of the wonderful new insulin sensitizing drug rosiglitazone may convert the resistant women to a responsive one. Rosiglitazone is well-tolerated with minimum side effects but should be discontinued when pregnancy occurs due to its teratogenicity.

References 1. Moll E, Korevaar JC, Bossuyt PM, van der Veen F. Does adding metformin to clomifene citrate lead to higher pregnancy rates in a subset of women with polycystic ovary syndrome? Hum Reprod 2008;23(8):1830-4.

2. Barbieri RL. Clomiphene versus metformin for ovulation induction in polycystic ovary syndrome: the winner is ....

J Clin Endocrinol Metab 2007;92(9):3399-401.

3. Shokeir T, El-Kannishy G. Rosiglitazone as treatment for clomiphene citrate-resistant polycystic ovary syndrome: factors associated with clinical response. J Womens Health (Larchmt) 2008;17(9):1445-52.

4. Sepilian V, Nagamani M. Effects of rosiglitazone in obese women with polycystic ovary syndrome and severe insulin resistance. J Clin Endocrinol Metab 2005;90(1): 60-5.

5. Hershlag A, Peterson CM. Endocrine disorders. In: Novak’s Gynaecology. 13th edition, Rebecca DR, Paula AH, Eli YA (Eds.), Williams and Lippincott Wilkins: Philadelphia 2002:p876-9.

6. Lord JM, Flight IHK, Norman RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev 2003;(3):CD003053.

7. Nestler JE. Should patients with polycystic ovarian syndrome be treated with metformin?: an enthusiastic endorsement. Hum Reprod 2002;17(8):1950-3.

8. Glueck CJ, Papanna R, Wang P, Goldenberg N, SieveSmith L. Incidence and treatment of metabolic syndrome in newly referred women with confirmed polycystic ovarian syndrome. Metabolism 2003;52(7):908-15.

9. Practice Committee of the American Society for Reproductive Medicine. Use of insulin sensitizing agents in the treatment of polycystic ovary syndrome. Fertil Steril 2004;82 Suppl 1:S181-3.

10. Ghalaut VS, Sharma D, Dahiya K, Dora A, Dahiya P. Rosiglitazone: Effect of clomiphene citrate induced

OBSTETRICS AND GYNECOLOGY ovulation in polycystic ovary syndrome. J Obstet Gynecol India 2008;58(1):53-6.

11. Ghazeeri G, Kutteh WH, Bryer-Ash M, Haas D, Ke RW. Effect of rosiglitazone on spontaneous and clomiphene citrate-induced ovulation in women with polycystic ovary syndrome. Fertil Steril 2003;79(3):562-6.

12. Belli SH, Graffigna MN, Oneto A, Otero P, Schurman L, Levalle OA. Effect of rosiglitazone on insulin resistance, growth factors, and reproductive disturbances in women with polycystic ovary syndrome. Fertil Steril 2004;81(3):624-9.

13. Kaul S, Diamond GA. Rosiglitazone and cardiovascular risk. Curr Atheroscler Rep 2008;10(5):398-404.

14. Ratziu V, Giral P, Jacqueminet S, Charlotte F, HartemannHeurtier A, Serfaty L, et al; LIDO Study Group.

Rosiglitazone for nonalcoholic steatohepatitis: one-year results of the randomized placebo-controlled Fatty Liver Improvement with Rosiglitazone Therapy (FLIRT) Trial.

Gastroenterology 2008;135(1):100-10.

15. Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA,et al; Cooperative Multicenter Reproductive Medicine Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007;356(6):551-66.

16. Woodhead JS, Addison GM, Hales CN. Radioimmunoassay and saturation analysis.

The immunoradiometric assay and related techniques. Br Med Bull 1974;30(1):44-9.

17. Abraham GE, Manlimos FS, Garza R. Radioimmunoassay of steroids. In: Handbook of Radioimmunoassay. Marcel Dekker: New York 1977:p.597-620.

18. Ferriman d, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab 1961;21:14407.

19. Wild RA, Vesely S, Beebe L, Whitsett T, Owen W. Ferriman Gallwey self-scoring I: performance assessment in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005;90(7):4112-4.

20. Rouzi AA, Ardawi MS. A randomized controlled trial of the efficacy of rosiglitazone and clomiphene citrate versus metformin and clomiphene citrate in women with clomiphene citrate-resistant polycystic ovary syndrome.

Fertil Steril 2006;85(2):428-35.

21. Shobokshi A, Shaarawy M. Correction of insulin resistance and hyperandrogenism in polycystic ovary syndrome by combined rosiglitazone and clomiphene citrate therapy. J Soc Gynecol Investig 2003;10(2):99-104.

■■■■

Woman given Wrong Blood in Hospital, Dies A 25-year-old woman died after being given blood of a wrong group in KC General Hospital. Malleswaram resident Rajeshwari breathed her last in Victoria Hospital early on Thursday. Police booked cases against physician, nurse and two other employees of the government-run KC General Hospital. Her blood group was O positive, but she was given B positive blood, causing grave complications.

Comments ÂÂ

MCI 7.18 In the case of running of a nursing home by a physician and employing assistants to help him / her, the ultimate responsibility rests on the physician.

ÂÂ

Giving a wrong blood is a never event .

ÂÂ

As defined by the National Quality Forum and commonly agreed upon by health care providers, one of the 28 never events are: Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

159

Obstetrics and Gynecology

Vulvar Elephantiasis of Filarial Origin: A Case Report Rachan Chaudhary*, Sudhir Rathi**, Amit Maheshwari†, Shipra Nigam‡

Abstract Lymphedema is accumulation of lymph in the soft tissue due to obstruction of lymphatics. Lymphedema can be primary or secondary. Filariasis caused by Wuchereria bancrofti and Brugia malayi is one of the secondary causes of lymphedema. Longstanding lymphedema can lead to ‘elephantiasis’. Elephantiasis of female genitalia is extremely rare. We present one such case of a 40-year-old lady having giant vulvar elephantiasis of filarial origin managed successfully by surgery (vulvectomy with vulvoplasty).

Keywords: Vulvar elephantiasis, vulvectomy for vulvar elephantiasis

L

ymphedema can be defined as swelling of soft tissues which is the result of accumulation of protein rich interstitial fluids caused by a low output failure of lymph.1 This leads to proliferation of fibroblasts and mast cells, organization of the edema fluid and sclerosing fibrosis of the subcutaneous tissue giving rise to the firm, nonpitting and irreversible swelling. Hyperkeratosis, verrucous and condylomatous changes are features of long-standing lymph stasis and are collectively termed ‘elephantiasis’.2 The legs, arms and genitalia are the commonly involved. Elephantiasis can be filarial or nonfilarial in origin. Filariasis results from infection with Wuchereria bancrofti and Brugia malayi. While Wuchereria infection has only been noted in humans, Brugia infection has been noted in both man and animals. Filarial elephantiasis of female genitalia is extremely uncommon; a rough estimate of its incidence would not be more than 1-2% of total cases of filarial elephantiasis.3 We present a case of vulval elephantiasis due to underlying filarial etiology.

for last 3-5 years. No history of chronic cough, chyluria or any lymphadenopathy. She was 68 kg, attained menarche at 13 years, a healthy lady with all normal systemic examinations. All previous pregnancies were uneventful resulting in normal vaginal delivery and live births. No history of lymphedema in any family member.

On investigation, laboratory findings were hemoglobin 11 g/dl, leukocyte count 6,400 cells/mm3, neutrophilia of 80%, absolute eosinophil count was 200. Patient was hepatitis B positive (HBsAg).

On examination, there were two nontender irreducible huge well-defined bossilated vulval mass, right and left measuring 45 × 38 cm and another 22 × 20 cm in size, respectively (Fig. 1). There were multiple nodular swellings on outer surface on each mass.

Case report This case report describes a 40-year-old lady para 3 + 0 who came to our center with complaints of mass in genital area with associated dragging pain and difficulty in coitus, difficulty in walking and psychological distress *Assistant Professor Dept. of Obstetrics and Gynecology **Associate Professor and Head Dept. of Surgery †Assistant Professor Dept. of Medicine ‡Postgraduate Student Dept. of Obstetrics and Gynecology, LLRM Medical College, Meerut, Uttar Pradesh

160

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Figure 1. Preoperative picture showing two nontender irreducible huge well-defined bossilated vulval mass, right and left measuring 45 × 38 cm and another 22 × 20 cm in size, respectively.

Obstetrics and Gynecology

Figure 2. Immediate postoperative picture showing excision of both masses with vulvoplasty.

Figure 4. Stratified squamous epithelium showing acanthosis and hyperkeratosis, underlying stroma showed dermal fibrosis and collagenization with mixed inflammatory infiltrate.

Discussion

Figure 3. Excised vulval masses.

Excision of both masses with vulvoplasty was done in single stage (Figs. 2 and 3). There were two large bossilated mass weighing 15 and 8 kg, measuring 48 × 40 × 10 cm and 26 × 25 × 7 cm in sizes, respectively with multiple nodular swellings on outer surface measuring 2.5 × 0.5 cm in sizes. Postoperatively the patient was kept on amoxiclav and amikacin prophylaxis. The postoperative period was uneventful.

Key histological features were stratified squamous epithelium showing acanthosis and hyperkeratosis, underlying stroma showed dermal fibrosis and collagenization with mixed inflammatory infiltrate in the form of eosinophils, polymorphs, lymphocytes, macrophages and plasma cells (Fig. 4).

Vulval lymphedema can be caused by radiotherapy4 and as a postoperative complication after vulvectomy and inguinofemoral lymphadenectomy.5 Vulval lymphedema can be a rare extraintestinal manifestation of Crohn’s disease6,7 but the ulcer in such cases shows epitheloid and giant cell granulomas. Clinically, vulval lymphedema may mimic genital warts.8 Lymphangioma circumscriptum9 was ruled out since it has an early onset at birth with initial presentation of thin translucent vesicles, which may become verrucous later on. Microscopically, it may mimic aggressive angiomyxoma but lacks true thick walled vessels.10 As per recommendations most lymphedema patients can be treated with a combination of limb elevation, a high quality compression garment, complex decongestive physical therapy and compression pump therapy and if necessary surgery.11 Surgical techniques for correcting lymphedema may be excisional or physiological. Surgical treatment is used only in extreme cases in order to reduce the weight of the affected organ, to help minimize the frequency

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

161

Obstetrics and Gynecology 3. Khanna NN, Joshi GK. Elephantiasis of female genitalia.

Case peport. Plast Reconstr Surg 1971;48(4):379-81.

4. Bradbury AW, Murie JA. Lymphatic system. In: Bailey and Love’s Short Practice of Surgery. 23rd edition, Russel RCG, Williams NS, Blustrode CJK (Eds.), Arnold: London 2000:p.250-69.

5. Gaarenstroom KN, Kenter GG, Trimbos JB, Agous I, Amant F, Peters AA, et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003;13(4):522-7.

6. Schulman D, Beck LS, Roberts IM, Schwartz AM. Crohn’s disease of the vulva. Am J Gastroenterol 1987;82(12):132830.

Figure 5. Postoperative Day 30 picture showing improved cosmesis with excision.

of inflammatory attacks, to improve cosmesis, and to potentially reduce the risk of secondary angiosarcoma.12,13 Our patient came with complaint of vulval swelling with inability to walk, with difficulty in coitus. Excision of mass with vulvoplasty was done.

Excision results in better quality-of-life and improved cosmesis, which make the patient perform better her sexual activities and daily needs (Fig. 5).

References 1. Mortimer PS. Disorders of lymphatic vessels. In: Wilkinson, Ebling’s Textbook of Dermatology. 6th edition, Champion RH, Burton JI, Burns DA, Breathnach SM, (Eds.), Blackwell Science: Oxford 1998:p.2277-96.

2. Pandhi RK, Sood A. Disease of arteries, veins and lymphatics. In: IADVL Textbook and Atlas of Dermatology.

2nd edition, Valia RG, Valia AR (Eds.), Bhalani Publishing House: Mumbai 2001:p.576-95.

7. Fenniche S, Mokni M, Haouet S, Ben Osman A. Vulvar Crohn disease: 3 cases. Ann Dermatol Venereol 1997;124(9):629-32.

8. Mu XC, Tran TA, Dupree M, Carlson JA. Acquired vulvar lymphangioma mimicking genital warts. A case report and review of the literature. J Cutan Pathol 1999;26(3):1504.

9. Esquivias Gómez JI, Miranda-Romero A, Cuadrado Vallés C, Bajo del Pozo C, Sánchez Sambucety P, Martínez Fernández M, et al. Lymphangioma circumscriptum of the vulva. Cutis 2001;67(3):229-32.

10. Vang R, Connelly JH, Hammill HA, Shannon RL. Vulvar hypertrophy with lymphedema. A mimicker of aggressive angiomyxoma. Arch Pathol Lab Med 2000;124(11):1697-9.

11. Park K. Park’s Textbook of Social and Preventive Medicine.

19th edition, pp.220-5.

12. Miller TA, Wyatt LE, Rudkin GH. Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term results. Plast Reconstr Surg 1998;102(5):148698; discussion 1499-501.

13. Kim DI, Huh SH, Hwang JH, Joh JH. Excisional surgery for chronic advanced lymphedema. Surg Today 2004;34(2):134-7.

■■■■

No Mental Harm from HRT in Early Menopause Hormone replacement therapy (HRT) in early menopause caused no apparent harm to patients’ cognitive function, according to long-term follow-up of participants in clinical trials. (Source: Medpage Today)

Uterine Bleeding: ACOG Updates Guidelines The American College of Obstetricians and Gynecologists has issued updated guidelines for treating abnormal uterine bleeding caused by ovulatory dysfunction. The new guidelines were Published in the July issue Obstetrics & Gynecology. (Source: Medscape)

162

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Obstetrics and Gynecology

Infection Associated Hemophagocytic Lymphohistiocytosis: A Case Report Rajani Dube*, Subhranshu Sekhar Kar**, Samarendra Mahapatro†, Rajib Ray**

Abstract The term hemophagocytosis describes the pathologic finding of activated macrophages, engulfing erythrocytes, leukocytes, platelets and their precursor cells. This phenomenon is an important finding in patients with hemophagocytic syndrome, more properly referred to as hemophagocytic lymphohistiocytosis (HLH). HLH is a distinct clinical entity characterized by fever, pancytopenia, splenomegaly and hemophagocytosis in bone marrow, liver or lymph nodes. It has been associated with a variety of viral, bacterial, fungal and parasitic infections, as well as collagen-vascular diseases and malignancies and is uniformly fatal if left untreated. We report Staphylococcal aureus-induced hemophagocytic lymphohistiocytosis in a 3-month-old girl presenting with respiratory distress, sepsis and multiorgan failure. This case report may at least in part guide pediatricians and other physicians to recognize this rare entity of infection triggering fatal HLH and thus proper treatment may be instituted in those affected with this disease at the earliest.

Keywords: Hemophagocyte, infection, histiocyte

T

he term hemophagocytosis describes the pathologic finding of activated macrophages, engulfing erythrocytes, leukocytes, platelets and their precursor cells.1 It is a serious and potentially lifethreatening histiocytic disorder in children and adults.

A hallmark of hemophagocytic lymphohistiocytosis (HLH) is impaired or absent function of natural killer (NK) cells and cytotoxic T-cells (CTL).2,3 In its most severe form, it leads to a sepsis-like picture and multiorgan failure (MOF). We report the case of a 3-month-old female child who presented with very severe pneumonia (due to Staphylococcus aureus) resulting in HLH with acute respiratory distress syndrome (ARDS) and multiorgan failure. This case report may at least in part guide pediatricians to recognize this rare entity of infection triggering fatal HLH. Case report A 3-month-old girl child was referred to our institute with the history of fever, rash, abdominal distension *Assistant Professor Dept. of Obstetrics and Gynecology **Assistant Professor †Associate Professor Dept. of Pediatrics Hi-Tech Medical College, Pandara, Bhubaneswar Address for correspondence Dr Subhranshu Sekhar Kar Qrs No.-8/II, Hi-Tech Medical College Campus, Pandara, Bhubaneswar - 751 010, Odisha E-mail: drsskar@yahoo.co.in; drsskar@gmail.com

and refusal to feed of 3-weeks duration. When she was 2 months old, she started having progressive dyspnea, abdominal distension and low-grade fever. Investigations done in a local hospital were noncontributory and she was put on bronchodilators and antibiotics with the diagnosis of sepsis. She improved marginally with the medications. Three weeks back, her symptoms worsened and she developed fever and rash. She was referred to our institution for further management. On examination, she was conscious, febrile (39°C) and tachypneic. She was having generalized edema, conjunctival congestion, ecchymosis and icterus. She was not cyanosed.

Pulse was 162/mt with noninvasive blood pressure of 80/50 mmHg. She had splenomegaly and free fluid in the abdomen. There were fine crepitations involving the base of left lung. Heart sounds were normally heard without any murmur. There was no signs of meningeal irritation, no focal neurological deficit and normal fundus.

On investigating, urine examination showed trace protein and a few pus cells. Blood examination revealed hemoglobin (Hb) of 8.0 g/dl; total count (TC) of 2,500/ mm3; differential count (DC) of P35L60E5, erythrocyte sedimentation rate (ESR) of 18 mm/1st hour. She had thrombocytopenia, with platelet count 37,000/mm3.

Peripheral smear report showed microcytic hypochromic anemia, anisopoikilocytosis and

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

163

Obstetrics and Gynecology polychromatic cells, shift to left with toxic granules, decreased platelet count and no malarial parasite.

ECG showed sinus tachycardia. Chest X-ray revealed alveolar opacities involving left lower zone. ABG showed hypoxemia. Liver function tests revealed bilirubin 7.2 mg%, total protein 4.3 mg%, albumin 2 mg%, serum glutamic oxaloacetic transaminase/serum glutamic pyruvic transaminase (SGOT/SGPT) 324/56, SAP 204. Renal function tests showed blood urea 60 mg% and creatinine1 mg%. RBS was 116 mg%; there was hypocalcemia with calcium of 7 mg% and phosphate 3.8 mg%. Serial monitoring of INR showed values of 1.75, 1.9 and 2.5, respectively. Anti nuclear antibody, viral markers for human immunodeficiency virus (HIV), hepatitis A, B, C and E, serology for Weil’s and Dengue, Widal test, rapid malarial test, Mantoux test, gastric lavage for acid-fast bacilli (AFB) were negative. Thyroid profile was normal. Echo showed no evidence of infective endocarditis and normal systolic function. Blood culture and sensitivity isolated S. aureus species. Urine culture was sterile. Sonogram of abdomen revealed splenomegaly, ascites and right pleural effusion. Serum ferritin was elevated (1,250 ng/ ml; [0-150 ng/ml]).

With the diagnosis of Staphylococcal pneumonia with multiorgan dysfunction she was shifted to the pediatric intensive care unit (ICU); where she was started on extended spectrum penicillins and ceftazidime along with blood products for coagulopathy. (She already received a course of antibiotics from the local hospital from which she was referred).

With the course of time, there was no clinical improvement. So, a bone marrow study was done which showed increased number of histiocytes with hemophagocytosis. The clinical scenario was very much suggestive of HLH (macrophgage activation syndrome secondary to S. pneumonia and sepsis) with fever, rash, splenomegaly, pancytopenia and hemophagocytosis.

She was put on ventilatory support and given a course of intravenous immunoglobulin (IVIG), in addition to the antibiotics and steroids. In spite of our efforts she succumbed on the sixth post admission day.

Discussion Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal disease of normal but overactive histiocytes and lymphocytes that commonly appears in infancy, although it has been seen in all age groups.

It is of two types - primary HLH4 and secondary HLH (acquired HLH), which occurs after strong

164

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Figure 1. Showing histiocytes (engulfing nuclei of normoblasts).

immunologic activation by systemic infection (virus, bacteria and protozoa), autoimmune disorders or underlying malignancy.

There occurs overwhelming activation of normal T cells and macrophages, which can cause clinical and hematological alterations. The pathological hallmark of this disease is the aggressive proliferation of activated macrophages and histiocytes, which phagocytose other cells, namely red blood corpuscles (RBCs), white blood corpuscles (WBCs) and platelets, leading to the clinical symptoms.

The uncontrolled growth is nonmalignant and does not appear clonal in contrast to the lineage of cells in Langerhans cell histiocytosis (histiocytosis X).

The spleen, lymph nodes, bone marrow, liver, skin and membranes that surround the brain and spinal cord are preferential sites of involvement.5 A current accepted theory suggests an inappropriate immune reaction caused by proliferating and activated T cells associated with macrophage activation and inadequate apoptosis of immunogenic cells.6 Although, the precise mechanism remains unclear, many research teams propose convincing pictures for the role of perforin and NK cells in the HLH subtypes.7-9 The clinical presentation is in many aspects similar to the so-called systemic inflammation response syndrome (SIRS). And death is inevitable in the absence of treatment. The clinical entity has to be suspected when patients present with fever unresponsive to antibiotics, general fatigue, falling ESR, pancytopenia of unknown origin and liver dysfunction with elevated ferritin.

The diagnostic criteria is as follows:2 ÂÂ

Familial disease/known genetic defect

Obstetrics and Gynecology ÂÂ

Clinical and laboratory criteria (5/8 criteria)

marrow donor can be found. This includes transfusions of RBCs, platelets, and fresh frozen plasma, as well as nutritional support in addition to the treatment protocol.10

zz

Fever

zz

Splenomegaly

zz

Cytopenia ≥ 2 cell lines

zz

Hb < 90 g/l (below 4 weeks < 120 g/l)

zz

Neutrophils < 1 × 109/L

zz

Hypertriglyceridemia genemia

zz

Fasting triglycerides ≥3 mmol/l

This case is presented to enlighten pediatricians and other physicians regarding the clinical entity of hemophagocytic lymphohistiocytosis to be suspected, when patients present with fever unresponsive to antibiotics, organomegaly, pancytopenia of unknown origin and liver dysfunction with elevated ferritin.

zz

Fibrinogen <1.5 g/l

References

zz

Ferritin ≥500 μg/l

zz

sCD25 ≥2400 U/ml

zz

Decreased and/or absent NK-cell activity

1. Favara BE. Hemophagocytic lymphohistiocytosis: a hemophagocytic syndrome. Semin Diagn Pathol 1992;9(1):63-74.

zz

Hemophagocytosis in bone cerebrospinal fluid or lymph nodes

and/or

hypofibrino-

marrow,

2. Janka GE, Schneider EM. Modern management of children with haemophagocytic lymphohistiocytosis. Br J Haematol 2004;124(1):4-14.

Supportive evidence are cerebral symptoms with moderate pleocytosis and/or elevated protein, elevated transaminases and bilirubin, lactate dehydrogenase (LDH) >1,000 U/l.

3. Janka G, Imashuku S, Elinder G, Schneider M, Henter JI. Infection- and malignancy-associated hemophagocytic syndromes. Secondary hemophagocytic lymphohistiocytosis. Hematol Oncol Clin North Am 1998;12(2):435-44.

For confirmation tissue diagnosis is needed.

Hemophagocytosis must be demonstrated in the bone marrow, spleen or lymph nodes. In our case, almost all criteria are present. The newest treatment protocol, HLH-2004, is based on the Histiocyte Society’s original HLH-94 protocol, with some minor modifications.

It represents a consolidation of the various approaches to treatment, with the goals being to first achieve clinical stability and then to cure with bone marrow transplantation (BMT). Antimycotic prophylaxis is used during the initial doses of dexamethasone.

Sulfamethoxazole and trimethoprim (i.e. cotrimoxazole) is continuously administered as prophylaxis for Pneumocystis carinii because of immune suppression.10 One group found that IVIG was effective in suppressing symptoms when administered within hours of disease onset. Serum ferritin was used as a marker for macrophage activation, and treatment was administered accordingly.11 Patients may be classified into high-risk and low-risk groups, with only the high-risk groups receiving the etoposide (i.e. VP-16) regimens. Patients who are at low-risk may be treated as effectively with only cyclosporine, corticosteroids or IVIG.12 In the absence of prospective controlled trials, corticosteroids, cyclosporin A and etoposide are administered with varied success. Recent case reports show promising results with an anti-TNF-α approach and plasmapheresis. Supportive care is needed to ensure that the patient with HLH remains stable until a bone

4. Farquhar JW, Claireaux AE. Familial haemophagocytic reticulosis. Arch Dis Child 1952;27(136):519-25.

5. Aricò M, Allen M, Brusa S, Clementi R, Pende D, Maccario R, et al. Haemophagocytic lymphohistiocytosis: proposal of a diagnostic algorithm based on perforin expression. Br J Haematol 2002;119(1):180-8.

6. Imashuku S, Ueda I, Teramura T, Mori K, Morimoto A, Sako M, et al. Occurrence of haemophagocytic lymphohistiocytosis at less than 1 year of age: analysis of 96 patients. Eur J Pediatr 2005;164(5):315-9.

7. Risma KA, Frayer RW, Filipovich AH, Sumegi J. Aberrant maturation of mutant perforin underlies the clinical diversity of hemophagocytic lymphohistiocytosis. J Clin Invest 2006;116(1):182-92.

8. Katano H, Cohen JI. Perforin and lymphohistiocytic proliferative disorders. Br J Haematol 2005;128(6):739-50.

9. Rieux-Laucat F, Le Deist F, De Saint Basile G. Autoimmune lymphoproliferative syndrome and perforin. N Engl J Med 2005;352(3):306-7; author reply 306-7.

10. Henter JI, Samuelsson-Horne A, Aricò M, Egeler RM, Elinder G, Filipovich AH, et al; Histocyte Society.

Treatment of hemophagocytic lymphohistiocytosis with HLH-94 immunochemotherapy and bone marrow transplantation. Blood 2002;100(7):2367-73.

11. Emmenegger U, Spaeth PJ, Neftel KA. Intravenous immunoglobulin for hemophagocytic lymphohistiocytosis? J Clin Oncol 2002;20(2):599-601.

12. Imashuku S, Teramura T, Morimoto A, Hibi S. Recent developments in the management of haemophagocytic lymphohistiocytosis.

Expert Opin Pharmacother 2001;2(9):1437-48.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

165

Obstetrics and Gynecology

Effect of Valethamate Bromide on the First Stage of Labor Sreelatha S*, Vedavathi Nayak**, Nirmala†, Satya†, ReNUKA RAMIAH‡

Abstract Objectives: This study was undertaken to evaluate the effect of intramuscular valethamate bromide on the duration of labor, rate of cervical dilatation and the effect of the drug on the mother and the fetus. Material and Methods: This was a prospective study conducted in Dept. of Obstetrics and Gynecology at ESIC MC-PGIMSR Bangalore involving 200 women with fullterm pregnancy in active labor. Group A received valethamate bromide intramuscular injection. Group B was control group.

Results: There was no significant difference in the parity, mean age of patients and mean duration of gestation in both the groups. But, there was difference in the mode of delivery. Valethamate bromide caused significant decrease in the duration of cervical phase of labor as compared to control group. There was no statistically significant difference in the Apgar score of new borns, and there were no maternal and fetal side effects. Conclusion: Valethamate bromide can be used in the management of labor for reducing the duration of first stage of labor without any untoward effects on mother and fetus.

Keywords: Prolonged labor, cervical dilatation, gap junction, valethamate bromide

L

abor is defined as spontaneous onset at term with cephalic presentation within 24 hours after true labor pains without any maternal and fetal complications. In nulliparas, total duration of labor is 18-20 hours and in multiparas it is 12-14 hours. If it lasts for more than 20 hours in nulliparas and more than 14 hours in multiparas, it is considered as prolonged labor.

Prolonged labor contributes to increased perinatal and maternal morbidity.1 There is increased risk of maternal distress, postpartum hemorrhage (PPH), sepsis and risk of infection, asphyxia to the fetus. Inhibitory impulses in the form of spasm impairs the dilatation of cervix and prolong the duration of labor. There is increased incidence of intervention. The use of this drug does not cause any side effects and untoward effects on the mother and the fetus. Valethamate bromide is an antispasmodic drug, which helps in cervical dilatation by its musculotrophic and neurotrophic action.

*Associate Professor **Assistant Professor †Junior Residents ‡Professor Dept. of Obstetrics and Gynecology ESIC MC-PGIMSR, Bangalore

166

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Material and Methods This study was conducted in the Dept. of Obstetrics and Gynecology at ESIC MC-PGIMSR, Bangalore for a duration of six months. Group A included patients who came in labor and fulfilled the following criteria for the administration of valethamate bromide: a) Singleton pregnancy, b) term gestation 37-40 weeks, c) cephalic presentation, d) spontaneous onset of labor and e) active labor >3 cm dilatation. During the study following parameters were monitored: 1) Progress of labor by partogram, 2) clinical assessment of uterine contraction, 3) cervical effacement and dilatation, 4) maternal pulse and blood pressure, 5) fatal heart rate (FHR), 6) Apgar score after birth and 7) duration of labor.

The patients who came in active labor and delivered were included in the Group B. Written informed consent was obtained for enrolling in the study. Injection valethamate bromide was given intramuscularly at half an hour intervals for three doses, during the active phase of labor. The side effects like tachycardia, dryness of the mouth, flushing, headache, hypotension, nausea and vomiting, pain at injection site were noted and treated accordingly. The total duration of active phase of labor, mode of delivery, Apgar score at birth were recorded in all patients.

Obstetrics and Gynecology and for third stage it was 5.6 minutes and 6.8 minutes in Groups A and B, respectively.

Table 1. Observations Found in Our Study Parameters

Group A

Group B

Mean age

22 years

25 years

Primigravidas

20 (40%)

22 (44%)

Multigravidas

30 (60%)

26 (56%)

Mean period of gestation

38 weeks

Age, parity and gestation age

Discussion Valethamate bromide is an antispasmodic belonging to a group of esters with quarternary N atom with the formula CH3-CH2-CH3-C6 H5-COO-CH2-CH3N (C2H5)2 CH3) Br i.e., 1 phenyl-2methyl-valerianic acid-diethyl 1 amino-ethyl ester-bromo methylate.

It is a potent, rapidly, acting anticholinergic and musculotrophic agent. It is a synthetic analog of atropine, which is found to relieve spasm by its parasympatholytic action and results in cervical dilatation.3

39 weeks

Duration of labor Mean duration of 1st stage (min)

178.7

186.6

Mean duration of 2nd stage (min)

24.8

31.5

Mean duration of 3rd stage (min)

5.6

6.8

Vaginal

43 (86%)

40 (80%)

C-section

7 (14%)

10 (20%)

Mode of delivery

It was seen that valethamate bromide decreased the duration of cervical phase of labor in Group A patients when compared to those in control group.

Table 2. Observations Found in Puri et al4 Parameters

Group A

Tachycardia was higher in Group A when compared to control group. There were no significant maternal side effects and Apgar score at birth good and there were no fetal side effects like asphyxia.

Group B

Age, parity and gestation age Mean age

22.3

22.7

Primigravidas

39 (52%)

34 (45%)

Multigravidas

36 (48%)

41 (54%)

Conclusion Administration of valethamate bromide for the dilatation phase of labor significantly reduces the duration of first stage of labor. The drug is safe when used in pharmacological doses and does not produce any untoward effects on fetus and mother as observed in our study.

Duration of labor Mean duration of 1st stage

284.4

336.7

Mean duration of 2nd stage

33.5

34.01

Mean duration of 3rd stage

8.2

8.3

Vaginal

71 (94%)

70 (93%)

Cesarean section

2 (2.7%)

3 (4.2%)

39.3

39

Mode of delivery

Mean period of gestation

The same was observed in a study by Puri et al.4 Thus, it can be concluded that this pharmacological agent is the drug of choice in shortening the duration of first stage of labor.

Results

References

There was no significant difference in the parity, mean age of patients and mean duration of gestation in both the groups.

1. Kumar A. The management of labor. 3rd edition.

In our study, mean age group was 22 years in Group A and 25 years in Group B. Mean period of gestation was 38 weeks in Group A and 39 weeks in Group B, respectively (Table 1). In our study, total duration of first stage was 178.7 minutes and 186.6 minutes, for second stage it was 24.8 minutes and 31.5 minutes,

2. Kuruvilla S, Jasper P, Peedicayil A, Mathal M. A randomized controlled trial of valethamate bromide in acceleration of labor. Int J Gynaecol Obstet 1992;38(2):93-6.

3. Venkata S. Comparision of buscopan and epidosin on cervical dialatation in labor. Global J Med Res 2010;10(2):18-21.

4. Puri M, Rathees S, Garg R. Effect of epidosin on cervical dilation during labor. J Obstet Gynaecol Ind 1998;38:427-30.

■■■■

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

167

ophthalmology

Ectoparasite Presenting with Common Eye Condition SA Kareem*, Kiran Madhusudhan**, Nishant Thambe†

Abstract Ectoparasites are the parasites that live primarily on the surface of the host. We report a case of a 40-year-old woman who phthiriasis palpebrarum, presented with signs and symptoms of a common eye condition blephero conjunctivitis. She was diagnosed to have phthiriasis palpebrarum. The infestation by this organism is regarded as a marker for other sexuallytransmitted disease (STD) infections like human immunodeficiency virus (HIV), syphilis, gonorrhea, chlamydia, herpes genitalis and trichomonas.

Keywords: Pthirus pubis, phthiriasis palpebrarum, blepharo conjunctivitis, STD

E

ctoparasites are the parasites that live primarily on the surface of the host. The ectoparasites infesting humans are lice, mites and fleas, etc.

We are reporting a case of phthiriasis palpebrarum, which presented with signs and symptoms of a common eye condition blephero conjunctivitis. The infesting organism is Pthirus pubis, also known as crab louse. The common head lice and body lice are entirely different species. The diagnosis can easily be missed and the cases are most often treated as bacterial blephero conjunctivitis, resulting in reinfestation.

The infestation by this organism is regarded as a marker for other sexually-transmitted disease (STD) infections like human immunodeficiency virus (HIV), syphilis, gonorrhea, chlamydia, herpes genitalis and trichomonas. Proper examination and awareness are needed to make a correct diagnosis, not only to treat this condition, but also to screen and treat other STD infections.

attacks of itching and redness of eyes. She is a well-build woman, known diabetic for 10 years under treatment with oral hypoglycemic agents. No other medical or surgical problem.

Ophthalmic Examination Revealed

Case summary

Both eyes (BE) lids were swollen with crusts and reddish brown protuberances, which were easily removed after applying anesthetic drops, exposing the erythematous lesions, typical of pubic lice bite called ‘maculae ceruleae’, along with live lice and their nits.

These deposits were louse feces. Maximal trimming of the eye lashes both sides was done. There were associated blepharitis and follicular conjunctivitis.

Anterior segment showed immature cataract BE, with nebular corneal opacity in right eye (RE). Fundi BE, hazy view and appeared normal. Her vision RE was 6/24 and vision left eye (LE) was 6/18 not improving with glasses, and this was attributed to her immature cataract BE with corneal opacity in RE.

The patient is a 70-year-old woman who attended our Eye Department. with repeated attacks of both eyes itching, swelling of the eyelids and redness of the eyes.

Before coming to this hospital, she had been treated for this condition with antibiotic drops and ointments.

This gave only a temporary relief and she got repeated

Detailed dermatological examination of head, body and pubic areas done and she had no head lice or body lice. But lot of lice with nits were found attached to the pubic area with inguinal adenitis. She was not willing for referral and examination by gynecologist and also referral to STD clinic.

Laboratory Investigations

*Associate Professor, Dept. of Ophthalmology **Associate Professor, Dept. of Microbiology †Postgraduate, Dept. of Ophthalmology Sree Balaji Medical College and Hospital, Chennai

168

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

The trimmed eye lashes and the deposits along with the organisms and their nits were transferred on the slide and examined under light microscope. The microbiologist was also called to examine the slide and to give the expert opinion. The microbiologist opinion was live adult forms of P. pubis and their nits.

ophthalmology Treatment After trimming of the eye lashes, the lid were cleaned and ciprofloxin eye ointment twice-daily was applied.

Permethrin 1% was given to be applied to pubic and other areas. She was also given oral ivermectin 250 µg/ kg; two doses given at one week interval. She was also asked to remove hair in the pubic region and instructed to maintain good personal hygiene including soaking and washing her clothes in hot water 120°F for a minimum of 30 minutes. She was asked to bring her husband and all her close contacts for examination and to prevent re-infestation.

Figure 1. Crab louse

Patient was instructed to come after one week for follow-up and to give second course of treatment.

Patient came for follow-up and blephero conjunctivitis subsided remarkably. No nits or P. pubis were found.

The lids appear healthy and her conjunctivitis also subsided.

Discussion

Figure 2. Crab lice with nits on eye lashes.

Figure 3. Removed live crab lice on slide.

Figure 4. Patient’s picture after delousing.

P. pubis are small (1-2 mm), wingless, semi-transparent, blood-sucking insects, belonging to the phylum Arthropoda, the class insecta, the order phthiraptera.

They are also called by other names like Pediculosis pubis, pubic louse and crab louse. The other two lice infesting man are Pediculus humanus capitis (head louse), P. humanus (body louse). The body louse is the vector of typhus, trench fever, and relapsing fever.

Both are biological variants of the same species and have elongated body and narrow anterior mouthparts and they intermingle and interbreed. But, P. pubis is an entirely different species, identified by its short, broad body and large front claws, which gives it a crablike appearance. They are found in pubic hairs, perianal region, eye lashes and eye brows and occasionally in other areas. Their large claws enable pubic lice to grasp the coarser hairs in the pubic regions.

Transmission to the adult eye lashes is caused by the hand, after touching the genital region. These lice are host-specific and they only survive on humans and not on animals. No human race is immune to them. The incidence is 2-10 % depending upon the socio economic status and personal hygiene.

It is under reported because of the social stigma attached to this. P. pubis spreads from person-to-person by close physical contact like sexual contact and to some extend by fomites. (e.g., towels, clothes, linens).

Because these organisms are most often spread through intimate contact, P. pubis infestation is classified as a STD and serves as a marker for other STD and

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

169

ophthalmology acquired-immunodeficiency syndrome (AIDS). Condom use does not prevent transmission of P. pubis. Upon diagnosis of pubic lice, examine for the possibility of concomitant STDs. Lice spend all of their life on one host and both male and female feed on blood and leave one host only to transfer to another. The average life cycle of P. pubis is about 35 days.

The lice may carry Staphylococcus aureus and Group A Streptococcus pyogenes on their surface and transmit these coagulase-positive pathogens to humans. The infestation with pubic lice is called Phthiriasis pubis, while infestation of eyelashes with pubic lice is called ‘phthiriasis palpebrarum’. They can only survive a short time away from the warmth and humidity of the human body. The lice can cause blepharitis, follicular conjunctivitis and in extreme cases marginal keratitis.

Super infection of the bites can cause preauricular lymphadenopathy.

CONCLUSION Phthiriasis palpebrarum may appear to be a rare condition. Due to lack of awareness, it is often missed and treated as bacterial blepharo conjunctivitis. Eye ointments may cause suffocation of the adult organism, but the nits develop into adult forms in about 10 days.

This results in re-infestation. Besides the patient may be harboring the organisms in the pubic areas and other parts of the body and in the linen. Unless specific measures are taken like treating other areas of the body, personal hygiene of the pubic area, treating the close contacts, and washing linen after soaking in the hot water, re-infestation will occur and the patients continue to suffer. Many studies have been done and proved that nearly 30% these patients are having other associated STD infections.

Suggested reading

Diagnosis is confirmed by demonstration of the organisms and their nits attached to eye lashes.

A Wood lamp examination of the infested areas will show yellow-green fluorescence of lice and nits.

Histology shows intradermal hemorrhage and a deep, wedge-shaped infiltrate with many eosinophils and lymphocytes and is rarely required for diagnosis. Once diagnosis is confirmed, cases can be treated with inert ophthalmic ointment with petroleum jelly or other bland ointments, topical inflammatory dermatoses (TID), yellow mercuric oxide eye ointment for 8-10 days. This works by suffocating lice and avoids any risk of eye irritation caused by other topical pediculocides. Anticholinesterase agents like 0.25% physostigmine ointment, 4% pilocarpine can be used to cause respiratory paralysis of the louse. The nits will survive a single application of these agents. So second course of treatment is given after about 10 days. Due to ocular toxicity, pediculocide shampoos cannot be used to remove organisms from the eyelid.

1. Manjunatha NP, Jayamanne GR, Desai SP, Moss TR, Lalik J, Woodland A. Pediculosis pubis: presentation to ophthalmologist as pthriasis palpebrarum associated with corneal epithelial keratitis. Int J STD AIDS 2006; 17(6):424-6.

The pediculocide shampoo and creams like malathion 0.5%, permethrin 1%, phenothrin 0.2%, are used in areas other than eyes. Oral ivermectin is effective as it has high affinity to glutamate-gated chloride channels, which take place in invertebrate nerve and muscle metabolism and thereby kill the organisms. Identification of this louse is used as a forensic tool in rape victims.

7. Mimouni D, Ankol OE, Gdalevich M, Davidovitch N, Zangvil E. Seasonality Pediculosis capitis and Phthirus pubis in adult population: follow-up of 20 years. J Dermatol Venereol 2002;16(3):257-9.

2. Varela JA, Otero L, Espinosa E, Sánchez C, Junquera ML, Vázquez F. Phthirus pubis in a sexually transmitted diseases unit: a study of 14 years. Sex Transm Dis 2003;30(4):292-6.

3. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55 (RR-11): 1-94.

4. Anderson AL, Chaney E. Pubic lice (Pthirus pubis): history, biology and treatment vs. knowledge and beliefs of US college students. Int J Environ Res Public Health 2009;6(2):592-600.

5. Mumcuoglu KY, Gallili N, Reshef A, Brauner P, Grant H. Use of human lice in forensic entomology. J Med Entomol 2004;41(4): 803-6.

6. Elston DM. Drugs used in the treatment of pediculosis.

J Drugs Dermatol 2005;4(2):207-11.

8. World Health Organization. Guidelines for the Management of Sexually Transmitted Infections. Geneva, WHO, 2003.

■■■■

170

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Grotto I, trends of a young Eur Acad

Orthopedics and Rheumatology

Camurati-Engelmann Disease Atul Jadhav, Jaishree Ghanekar

Abstract Camurati-Engelmann disease (CED) is a very rare autosomal dominant genetic disorder that causes characteristic anomalies in the skeleton. It is a connective tissue disorder known for marked variability of its clinical presentation. The authors report CED in a 25-year-old male with atypical involvement of metacarpals (acrosclerosis) and features of neuromuscular disease along with the classical features of the disease.

Keywords: Camurati-Engelmann disease, connective tissue disorder, progressive diaphyseal dysplasia, autosomal dominant inheritance, muscle wasting, waddling-gait

C

amurati-Engelmann disease (CED) is a rare, inherited connective tissue disorder known for the marked variability of its clinical presentation.

Its prevalence is unknown. Approximately 200 cases have been reported worldwide. The authors report a patient of CED with atypical involvement of metacarpals (acrosclerosis)1,2 and features of neuromuscular disease3 along with the classical features of the disease.

CED, also known as progressive diaphyseal dysplasia/ sclerosis/hyperostosis, is a hereditary disease, with autosomal dominant inheritance4 of 19 q 13.1-13.3 gene mutation encoding transforming growth factor-b1 (TGF-b1) leading to its increased expression and aberrant differentiation of monocyte-macrophage to fibroblast and osteoblast. The penetrance and expressivity is variable leading to vivid clinical presentation with varying severity of disease.

Improvement with corticosteroids and regression of disease activity during pregnancy supports the hypothesis that it has an immunological basis. The course of the disease is usually progressive, but is known to remit spontaneously.5 Several variations have been cited as a part of this connective tissue disorder, such as site and extent of involvement of skeleton, myopathy, neurological features (central and peripheral neuropathy). Besides the characteristic features, the case reported herein has unusual involvement of bones of hand and pyramidal signs.

Case Report A 25-year-old male was referred to our institution with complaints of generalized weakness and easy Professor and Head, Dept. of Medicine MGM Medical College and Hospital, Kamothe, Navi Mumbai

fatiguability with onset at adolescence and gradually progressing since then. He had severe pain in all limbs, which was continuous aching in nature, with increase on physical activity. It was not responsive to nonsteroidal anti-inflammatory drugs (NSAIDs).

Progressive wasting of musculature of all limbs led to increasing disability. Over the years, his activities of daily living were affected. Initially, he used to walk with a broad-based gait. Of late, with increasing stiffness, the gait deteriorated to short shuffling steps.

On examination, he was tall statured and hyposthenic.

All other first-degree relatives were of average build.

Upper and lower segments measured 31 and 35 inches, respectively; the ratio being 0.89. Arm span was 68 inches, and was slightly greater than height (67 inches).

Extremities were long and slender with atrophic muscles, most notably of forearm (flexor compartment) and thighs (extensor compartment). Flexion contractures were present at hip, knee and elbow. Distal portion of humerus, radius, ulna, femur and proximal portion of tibia were widened appreciably on palpation bilaterally (Figs. 1 a, b and c). Movements at hip, knee and elbow were painful and restricted in range. Hypertonia was noted in all limbs, with hyperreflexia, ankle-clonus and extensor plantar response bilaterally. Weakness of both proximal and distal muscles was present. A clinical diagnosis of sclerosing bone dysplasia with systemic involvement - CED was made and investigated further accordingly.

On investigation, the hemoglobin was 10.3 g/dl; erythrocyte sedimentation rate (ESR) 108 mm/hour; serum calcium 4.4 mg/dl; serum phosphorus 3.0 mg/ dl; serum alkaline phosphatase 64 U/l. RBCs showed normocytic anisopoikilocytosis.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

171

Orthopedics and Rheumatology

Figure 1 (a, b and c). Showing widened distal portion of humerus, radius, ulna, femur and proximal portion of tibia.

Radiological examination revealed uniform widening of diaphyses and metaphyses of all long bones - upper end of tibia, lower ends of humerus, ulna, radius and femur and distal ends of metacarpals (Figs. 2 a-d).

Bone marrow biopsy from tibial tuberosity showed sclerosis in trabeculae of the ill-formed spongy bone.

Muscle biopsy revealed atrophic changes of myofibers.

CED is somewhat treatable. Glucocorticosteroids, which are anti-inflammatory and immunosuppressive agents, are used in some cases. Glucocorticoids help in bone strength but, can have multiple side effects. In several reports, successful treatment with glucocoricosteroids was described, as certain side effects can benefit a person with CED. Glucocorticoids help with pain and fatigue as well as some correction of radiographic abnormalities.

Alternative treatments such as massage, relaxation techniques (meditation, essential oils, spa baths, music therapy, etc.), gentle stretching and especially heat therapy have been successfully used to an extent in conjunction with pain medications. Most CED patients require some form of analgesics, muscle relaxant and/ or sleep-inducing medication to manage the pain, specifically if experiencing frequent or severe ‘flareups’ (e.g. during winter).

Discussion CED is a systemic disorder of connective tissue due to mutation of TGF-b1 gene (19 q 13.1-13.3) with

172

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

autosomal dominant inheritance. The characteristic feature is widening of bones due to cortical thickening.

It is thus, a sclerosing bone dysplasia. There is no sex predilection for CED, although male preponderance has been described. Usual presentation is in early childhood 4-12 years (earliest 3 months), but may be delayed upto the sixth decade. This age is not classic of other sclerosing bone dysplasias, like Caffey’s disease, autosomal dominant form of Paget’s disease and sclerosteosis (Truswell-Hansen disease), which are seen in early childhood.

The remarkable features are tall built with slender long extremities, easy fatiguability on physical exertion with pain in the limbs, which is resistant to analgesics, muscle wasting, waddling-gait (or it may be broad-based) and palpable widening of long bones. All these features were noticed in the case described above. Late skeletal deformities like lumbar lordosis, apparent varus or valgus deformities at knee or elbow, flexion contractures at large joints-hip, knee and elbow or frontal-parietal prominence of skull may develop.4,5 Associated features of CED may be failure to thrive, retarded dentition, delayed puberty with poor secondary sexual characteristics,6 normocytic normochromic anemia with hepatosplenomegaly (due to reticuloendothelial system proliferation secondary to marrow invasion);5,6 cerebellar ataxia due to demyelination3,7 and nerve entrapment features at sclerotic skull base, like cranial

Orthopedics and Rheumatology

Figure 2 (a-d). X-ray of upper and lower limbs showing widening of diaphyses and metaphyses of upper end of tibia, lower ends of humerus, ulna, radius and femur and distal ends of metacarpals.

nerve palsies, sensorineural deafness or vertigo (eight nerve compression) and blindness (optic atrophy).8

presentation.9,14 Sclerosis of epiphysis of head of femur has been reported.5

Radiological features typical of CED, viz. bilaterally symmetrical fusiform widening of bones was present in this case. The descending order of frequency of affection of bones is tibia, femur, fibula, humerus, ulna, radius, skull base (especially anterior two-third) followed by skull vault.4,5 Neuhauser has postulated nonselective affection of bones formed by endochondral and intramembranous ossification in CED. The involvement of hand, feet, ribs, girdles, spine and facial skeleton1,2,9-11 is rarely reported.

Bone-biopsy and muscle-biopsy in the case were corroborative of the diagnosis of CED.

Greenspan has proposed a target-site approach to differentially diagnose sclerosing bone dysplasias, each with specific skeletal features.12 Skull deformities are prominent in cranio-diaphyseal dysplasia, pyknodysostosis and sclerosteosis.2 Girdle bones and ribs are invariably involved in cranio-diaphyseal dysplasia and generalized cortical hyperosteosis (Van Buchem’s disease).13 Asymmetrical or rhizomelic skeletal involvement is typical of Caffey’s disease.

Facial bones are characteristically involved in Caffey’s disease (mandible), cranio-diaphyseal dysplasia (nasal bones), Van Buchem’s disease (mandible), Nakamura’s disease and pyknodysosteosis (mandible).10 Sclerosis is only endosteal in Van Buchem’s disease, Worth’s disease, Nakamura’s disease and Truswell-Hansen’s disease. Melorheostosis has pathognomonic osseous excrescences (wax flowing down the candle). Bone X-rays in Paget’s disease show mosaic pattern of sclerotic and lytic phases.

CT scan elaborates X-ray findings of bone-changes in CED. Metaphysis is classically spared with a sharp demarcation. Sclerosis of metaphysis is an atypical

Serum alkaline phosphatase was normal as expected in CED; but it may be mildly raised.15 Serum calcium was low, serum phosphate was normal, suggestive of positive calcium balance, as in CED; however, it has a low predictive value in diagnosis. Significantly raised alkaline phosphatase is characteristic of Paget’s disease and Van Buchem’s disease.15 Elevated ESR probably suggests disease activity.6,7 Special investigations include bone scintigraphy with technetium-99m methylene diphosphonate, which reveals increased uptake proportional to disease activity;16 muscle biopsy, which shows atrophy of myofibers, collagen congregation or hyalinization and vasculitis-like changes17 in presence of normal EMG-NCV studies; raised biochemical markers of osteoblastic-activity, viz. bone-alkaline phosphatase, serum osteocalcin, N-telopeptide of collagen-1.15 Immunological abnormalities hyper-gammaglobulinemia and low CD4 counts have been reported.6 CED is somewhat treatable. Glucocorticosteroids, which are anti-inflammatory and immunosuppressive agents, are used in some cases. They are helpful in reducing pain and fatigue as well as some correction of radiographic abnormalities. However, they can have multiple side effects. Alternative treatments such as massage, relaxation techniques (meditation, essential oils, spa baths, music therapy, etc.), gentle stretching, and especially heat therapy have been successfully used to an extent in conjunction with

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

173

Orthopedics and Rheumatology pain medications. A majority of CED patients require some form of analgesics, muscle relaxants, and/or sleep inducing medication to manage the pain, specifically if it is frequent or there are severe ‘flare-ups’ (e.g. during winter).

8. Applegate LJ, Applegate GR, Kemp SS. MR of multiple cranial neuropathies in a patient with CamuratiEngelmann disease: case report. AJNR Am J Neuroradiol 1991;12(3):557-9.

References

10. Demas PN, Sotereanos GC. Facial skeletal mani of Camurati-Engelmann disease. Oral Surg Oral Med Oral Pathol 1989;68(2):686.

1. Grey AC, Wallace R, Crone M. Engelmann’s disease: a 45year follow-up. J Bone Joint Surg Br 1996;78:(3)488-91.

2. Lennon EA, Schechter MM, Honnbrook RW. Engelmann’s disease - report of case with review of literature. J Bone Joint Surg (Br) 1961;43-B:273-84.

3. Stenzler S, Grogan DP, Frenchman SM, et al. Progressive diaphyseal dysplasia presenting as neuromuscular disease. J Pediatric Orthop 1989;9(4):463-7.

4. Sparkes RS, Graham CB. Camurati-Engelmann disease.

Genetics and clinical manifestations with a review of literature. J Med Genet 1972;9(1):73-85.

5. Naveh Y, Kaftori JR, Alon U, et al. Progressive diaphyseal dysplasia: genetic clinical and radiologic manifestations.

Pediatrics 1984;74(3):399-405.

6. Bas F, Darendeliler F, Petorak I, et al. Deflazacort in progressive diaphyseal dysplasia. J Pediatr Child Health 1990;35(4):401-5.

7. Kormas N, Diamond T, Shnier R. Camurati-Engelmann disease: two case reports describing metadiaphyseal dysplasia with cerebellar ataxia. J Bone Min Res 1998;13(7):1203-7.

9. Byanyima RK, Nabawesi JB. Camurati-Engelmann disease - a case report. Afr Health Sci 2002;2(3):118-20.

11. Wolf BH, Ford HW. An unusual radiological manifestations of Engelmann’s disease in a young Negro child. Radiology 1971;99(2):401-2.

12. Greenspan A. Sclerosing bone dysplasias - a target-site approach. Skeletal Radio 1991;20(8):561-83.

13. Nishimura G, Nishimura H. Camurati-Engelmann disease-type II: progressive diaphyseal dysplasia with striations of bones. Am J Med Genet 2002;107(1):5-11.

14. Vanhoenacker EM, Janssens K. Camurati Engelmann’s disease. Acta Radiol 2003;44(4):430-4.

15. Hemández MV, Peris P, Guañabens N, et al. Biochemical markers of bone turnover in Camurati-Engelmann disease: a report of 4 cases in one family. Calcif Tissue Int 1997;61(1):48-51.

16. Kumar B, Murphy WA, Whyte MP. Progressive diaphyseal dysplasia: scintigraphic, radiographic and clinical correlation. Radiol 1981;140(1):87-92.

17. Yoshioka H, Mino M, Kiyosawa N, et al. Muscular changes in Engelmann’s disease. Arch Dis Child 1980;55:716-9.

■■■■

Osteoporosis Management Guidelines Updated for Women and Men ÂÂ

The National Osteoporosis Guideline Group (NOGG) has updated its 2009 guidelines on the diagnosis and management of osteoporosis in postmenopausal women and men at least 50 years of age in the United Kingdom. The new recommendations were published online June 17 in Maturitas.

ÂÂ

Pharmacotherapies shown to lower the risk for vertebral fracture (and for hip fracture in some cases) include bisphosphonates, denosumab, parathyroid hormone peptides, raloxifene and strontium ranelate.

ÂÂ

Ibandronate, risedronate, zoledronic acid, denosumab, raloxifene, or strontium ranelate may be appropriate therapy when alendronate is contraindicated or poorly tolerated.

ÂÂ

Because of the high cost, parathyroid hormone peptides should be used only for patients at very high risk, especially for vertebral fractures.

ÂÂ

Postmenopausal women may benefit from calcitriol, etidronate and hormone replacement therapy.

ÂÂ

Approved treatments for men at increased fracture risk are alendronate, risedronate, zoledronic acid, and teriparatide.

ÂÂ

Patients at increased risk for fracture should start alendronate or other bone-protective treatment at the onset of glucocorticoid therapy.

ÂÂ

For postmenopausal women, approved pharmacotherapy for prevention and treatment of glucocorticoidinduced osteoporosis includes alendronate, etidronate, and risedronate; approved treatment options in both sexes are teriparatide and zoledronic acid.

174

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

PEDIATRICS

Retinoblastoma: A Curse to Childhood Harpal Singh Jhagta*, Prachi Jain**, Manoj Gupta, Ashish Bajaj

Abstract Retinoblastoma is the most common intraocular malignancy in children. With the improvement in diagnostic and treatment modalities, early diagnosis and prompt treatment have remarkably improved the survival and salvageable vision in retinoblastoma patients. We report a case of a 14-month-old female child who presented to us with intermittent deviation of both eyes and white reflex in both eyes along with redness and photophobia in right eye, she was diagnosed to liver bilateral retinoblastoma.

Keywords: Retinoblastoma, poor vision, Schiotz tonometer

R

etinoblastoma is the most common intraocular malignancy in children. The current incidence ranging from one in 15,000 to one in 18,000 live births.1 The average age at diagnosis is 18 months, with unilateral cases being diagnosed at around 24 months and bilateral cases before 12 months. Out of the newly diagnosed cases of retinoblastoma only 6% are familial while 94% are sporadic. It is bilateral in about 25-35% of cases. Bilateral retinoblastomas involve germinal mutations in all cases. Out of the unilateral cases, approximately 15% are caused by germinal mutations while the 85% are sporadic.2 With the improvement in diagnostic and treatment modalities, early diagnosis and prompt treatment have remarkably improved the survival and salvageable vision in retinoblastoma patients, which otherwise would have succumbed to death in pre-revolutionary era in medical science.

Case report A 14-month-old female child presented to us with intermittent deviation of both eyes and white reflex in both eyes for last three months, along with redness and photophobia in right eye for last 15 days. On examination, child resisted occlusion of left eye signifying poor vision in right eye. Right eye conjunctiva was congested, cornea was hazy and edematous and anterior chamber was full of fluffy clumps with hypopyon of approximately 1 mm (Fig. 1).

Fundus details could not be seen due to hazy media.

*Sankara Eye Hospital, Ludhiana, Punjab **Regional Institute of Ophthalmology, PGIMS, Rohtak, Haryana

Figure 1. Leucocoria in left eye with mid-dilated pupil, not reacting to light.

Intraocular pressure was unrecordably low. Patient had leucocoria in left eye with mid-dilated pupil, which was not reacting to light (Fig. 1). On fundus examination, yellow white mass with dense vitreous seeding was seen in left eye. Intraocular pressure was 17.3 mmHg with Schiotz tonometer in left eye. On USG, diffuse vitreous seeding is seen in right eye (Fig. 2) and welldefined hypoechoic endophytic lesion with calcific foci and overlying retinal detachment in posterior segment was seen in left eye (Fig. 3). Choroidal thickness of 1.4 mm in right eye and 1.6 mm in left eye was seen.

On CT scan soft tissue mass with calcification was seen in both eyes (Fig. 4). No retrobulbar extension was seen. Family history was negative for retinoblastoma.

After observing history, examination and finding on USG and CT scan diagnosis of retinoblastoma Group E in right eye and retinoblastoma Group D in left eye

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

175

PEDIATRICS was made and child was referred to higher center for further management.

Genetics

Figure 2. USG showing diffuse vitreous seeding in right eye.

Only 6% of retinoblastoma cases are found to be familial while remaining 94% are sporadic in origin. All bilateral cases are thought to be hereditary. Knudson proposed two hit hypothesis for the occurrence of retinoblastoma.3 According to this, two chromosomal mutations are required for the occurrence of retinoblastoma. Those having familial disease inherit one germinal mutation from the parents (first hit) while another mutation occurs sporadically while development of retina (second hit). Sporadic cases encounter both the mutations during retinal development. Familial cases, because of underlying germinal mutation, are also predisposed to other nonocular malignancies like osteosarcoma.

Clinical Presentation

Figure 3. USG showing well-defined hypoechoic endophytic lesion with calcific foci and overlying retinal detachment in posterior segment in left eye.

The clinical presentation of retinoblastoma depends on the stage of the disease.4 Early lesions are likely to be missed, unless an indirect ophthalmoscopy is performed. Leucocoria (56%) is the most common clinical presentation of retinoblastoma followed by strabismus (20%). Leucocoria is observed mainly in endophytic growth of tumor that has gained substantial size to be observed through the pupil as grayish white reflex. Strabismus occurs when the tumor is involving fovea thus interfering with the normal fixation pattern of child. Other clinical presentations include diminished vision, red painful eye, asymptomatic, hyphema, vitreous hemorrhage, proptosis or orbital cellulitis.

Three types of tumor growth patterns are observed: ÂÂ

Endophytic: Extension into vitreous cavity.

ÂÂ

Exophytic: Extension into subretinal space.

ÂÂ

Infilterating: Diffusely involving retina causing placoid thickening. This type is diagnosed late and is usually seen in older children.

Retinoblastoma may spread locally via scleral emissary veins to involve orbital tissues and central nervous system (CNS) involvement through optic nerve or hematogenous spread. Distant metastasis may involve pre-auricular or cervical lymph nodes and bone marrow.

Diagnosis

Figure 4. CT scan showing soft tissue mass with calcification.

176

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

A child with suspected retinoblastoma must undergo complete ophthalmic evaluation including a dilated fundus examination under anesthesia. Diagnosis is usually clinical, aided by USG B-scan of the eye revealing

PEDIATRICS tumor extension and intralesional calcification.4 Computed tomogrophy (CT) scan and magnetic resonance imaging (MRI) are reserved in cases with atypical presentation, extraocular extension or those having diagnostic dilemma. CT scan helps to delineate tumor extension and co-existent pinealoblastoma can be detected (trilateral tumor). MRI is useful when optic nerve or intracranial extension is suspected.

Intralesional calcification on CT scan or USG B-scan is highly suggestive finding for retinoblastoma.

Staging Stage 0

No enucleation

Stage I

Enucleation, tumor completely resected

Stage II

Enucleation, microscopic residual tumor

Stage III

Regional extension yy Overt orbital disease yy Pre-auricular or cervical lymph node involvement

Stage IV

On histopathology, poorly differentiated tumor consists of small to round cells having scanty cytoplasm and hyperchromatic nuclei. Well-differentiated tumors show rosettes and flueretes formation, which is highly suggestive of photoreceptor differentiation of tumor cells. Flexner-Wintersteiner rosettes consist of columnar cells arranged around a lumen and are highly characteristic of retinoblastoma.

Grouping (Shields) Group A

Small tumor Retinoblastoma <3 mm in basal dimensions

Group B

Larger tumor yy Retinoblastoma >3 mm in basal dimensions yy Macular location (<3 mm from foveola) yy Juxtapapillary location (<1.5 mm from optic disc) yy Clear subretinal fluid <3 mm from tumor margin

Group C

Focal seeding yy C1 subretinal seeds <3 mm from retinoblastoma yy C2 vitreous seeds <3 mm from retinoblastoma yy C3 both subretinal and vitreous seeds <3 mm from retinoblastoma

Group D

Diffuse Seeding yy D1 subretinal seeds >3 mm from retinoblastoma yy D2 vitreous seeds >3 mm from retinoblastoma yy D3 both subretinal and vitreous seeds >3 mm from retina

Group E

Extensive retinoblastoma yy Occupying >50% globe or yy Neovascular glaucoma yy Spontaneous vitreous hemorrhage or hyphema yy Invasion of optic nerve, choroid (thickness >2 mm), sclera, orbit, anterior chamber

Metastatic disease yy Hematogenous metastasis Single lesion Multiple lesions yy CNS extension Prechiasmatic lesion CNS mass Leptomeningeal disease

International classification system for retinoblastoma The International Classification system includes grouping and staging of retinoblastoma. Grouping is done preoperatively to plan lines of management and prognosticate organ salvage while grouping is done postenucleation to prognosticate the survival of the patient.5 Management The management of retinoblastoma needs a multidisciplinary team approach including an ocular oncologist, pediatric oncologist, radiation oncologist, radiation physicist and an ophthalmic oncopathologist.

The primary aim is to save the life of a child.

Management of retinoblastoma is highly individualized and depends upon age at presentation, laterality, tumor location, tumor staging, visual prognosis, systemic condition and socioeconomic status. Genetic counseling is an important aspect in the management of retinoblastoma.6 Current protocol suggests management of small intraocular tumors, unilateral or bilateral, by focal cryotherapy alone or in combination with standard dose 6 cycle chemotherapy with vincristine, etoposide and carboplatin. Focal therapy should be deferred until 6 cycles of chemotherapy for tumors located in visually crucial areas and residual disease is treated with transpupillary thermotherapy or plaque brachytherapy (I 125 or Ru 106 for 36-72 hours).

Extensive disease described under Group D and E of International Classification system is managed by

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

177

PEDIATRICS high dose chemotherapy followed by aggressive focal therapy. Primary enucleation should be considered in overt disease without salvageable vision. External beam radiotherapy using linear accelerator is delivered after high dose chemoreduction in cases with residual orbital disease.7 Cases with metastatic disease are usually managed on palliative grounds. CNS metastasis can be managed with high dose chemotherapy along with intrathecal chemotherapy.8

3. Knudson AG Jr. Mutation and cancer: statistical study of retinoblastoma. Proc Natl Acad Sci USA 1971;68 (4):820-3.

The recent advances such as identification of genetic mutations, early diagnosis and improved treatment modalities like chemoreduction with adjuvant focal therapy have contributed to better survival, improved eye salvage and potential for optimal visual recovery.

6. Kiran VS, Kannabiran C, Chakravarthi K, Vemuganti GK, Honavar SG. Mutational screening of the RB1 gene in Indian patients with retinoblastoma reveals eight novel and several recurrent mutations. Hum Mutat 2003;22(4):339.

References 1. Bishop JO, Madson EC. Retinoblastoma. Review of current status. Surv Ophthalmol 1975;19(6):342-66.

2. Shields JA, Shields CL. Intraocular tumors - A text and Atlas. WB Saunders Company: Philadelphia, PA, USA 1992.

4. Murthy R, Honavar SG, Naik MN, Reddy VA. Retinoblastoma. In: Modern Ophthalmology. Dutta LC (Ed.), Jaypee Brothers: New Delhi 2004:p.849-59.

5. Chantada G, Doz F, Antoneli CB Grundy R Clare Stannard FF, Dunkel IJ. A proposal for an international retinoblastoma staging system. Pediatr Blood Cancer 2006;47:(6)801-5.

7. Honavar SG, Reddy VAP, Murthy R, Naik M, Vemuganti GK. Management of orbital retinoblastoma. XI International Congress of Ocular Oncology. Hyderabad, India, 2004:p.51.

8. Pratt CB, Crom DB, Howarth C. The use of chemotherapy in extraocular retinoblastoma. Med and Pediatr Oncol 1985;13(6):330-3.

■■■■

ESA dose Predicts Death in Kids on Peritoneal Dialysis In children receiving chronic peritoneal dialysis (PD), anemia and high requirements for erythropoiesisstimulating agents (ESAs) independently predict mortality, according to results from a global cohort study published online March 7 in the Journal of the American Society of Nephrology. (Source: Medscape)

Breastfeeding won’t Ward off Obesity in Child An intervention designed to encourage longer and more exclusive breastfeeding among mothers failed to prevent obesity in their children, a large, randomized trial conducted in Belarus found. (Source: Medpage Today)

Parent Training Tops Meds in ADHD Parent behavior training (PBT) topped medication and other interventions for preschool children at risk of attention-deficit/hyperactivity disorder (ADHD), a systematic literature review showed. (Source: Medpage Today)

Prebiotics may Guard against Infant Eczema A prebiotic added to infant formula or breast milk may prevent eczema in infants up to 2 years old, but evidence is unclear about whether prebiotics help to prevent other infant allergic diseases, according to a study published online September 27 in the Cochrane Database of Systematic Reviews. (Source: Medscape)

“Disease” Tag Prompts Parents to want Tx for Healthy Babies Giving a baby’s minor symptoms the “disease” label may boost parents’ desire to medicate, even if told drugs won’t work, researchers found. (Source: Medpage Today)

178

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Urology

Benign Prostatic Hyperplasia: Current and Future Therapeutics Shailesh Yadav*, Praveen Gupta**, Manoj Goyal†, Monika Bansal‡

Abstract Benign prostatic hyperplasia (BPH) is one of the most common diseases of old-aged men affecting >90% of men in their 70s and 80s. Although the exact cause is not known, most people agree that dihydrotestosterone plays a strong role in pathogenesis.

BPH can be a progressive disease. Severe BPH can cause serious problems including renal insufficiency. Surprisingly the risk factors for BPH are found to be the same as for cardiovascular diseases. Management of BPH has changed significantly in the last decade. α-blockers and 5α-reductase inhibitors are the most commonly used drugs. A number of other drugs belonging to newer groups like phosphodiesterase inhibitors, hexokinase inhibitors like lonidamine, antagonists of endothelin, vanilloid and purine receptors and modulators of JM-27 expression are also showing promise. These are in different stages of clinical trials. The surgical counterpart of treatment has also witnessed recent advancements. Newer techniques like potassium-titanylphosphate (KTP) laser and photo selective vaporization of prostate have been shown to have nearly equal efficacy as that of transurethral resection of prostate (TURP) with less side effects.

Keywords: Phosphodiesterase inhibitors, endothelin receptor antagonists, laser ablation

B

enign prostatic hyperplasia (BPH), erroneously referred to as benign prostatic hypertrophy, is nonmalignant enlargement of the prostate gland. It involves stromal and glandular epithelial hyperplasia, which occurs in the periurethral transition zone surrounding the urethra. It clinically manifests as urinary hesitancy, straining in initiating urination, weak and noncontinuous stream, and feeling of incomplete bladder emptying, frequent urination, nocturia and dysuria. Clinically, BPH is distinguished by progressive development of lower urinary tract symptoms (LUTS).

In fact, LUTS are usually presumed to be due to BPH in the absence of other relevant diagnoses.1 Persistent and prolonged BPH may result in bladder calculi, hematuria, urinary retention and ultimately renal insufficiency.2,3 Pathophysiology Increase in the volume of prostate occurs because of increase in the number of stromal smooth muscle cells.

*Professor, Dept. of Pharmacology **Associate Professor, Dept. of Medicine †Associate Professor, Dept. of Pharmacology ‡Assistant Professor, Dept. of Physiology MMIMSR, Mullana, Ambala, Haryana Address for correspondence Dr Shailesh Yadav E-mail: dr_manojgoyal@yahoo.co.in

Ratio of stroma to epithelium rises to 5:1 in BPH, while it is 2:1 in normal prostate. The exact cause of BPH is not known. Multiple factors i.e., hormonal, genetic and aging are believed to contribute.1,4 Although testosterone promotes prostate cell proliferation5 testosterone and related hormones are believed to play only a permissive role. This is supported by the finding that relatively low levels of serum testosterone are found in patients with BPH.6,7 However, most experts believe in the role of dihydrotestosterone (DHT) in pathological enlargement of prostate. DHT is formed from testosterone with the help of 5α-reductase enzyme. This forms the basis for therapeutic use of 5α-reductase inhibitors, which prevent the conversion of testosterone into DHT. Another theory postulates the role of reactivation of stem cells. Neuronal factors also play a role in normal development and growth of prostate. The contraction of stromal smooth muscle cells is predominantly mediated by adrenergic nerves through α1A receptors. These receptors are targeted by α1A receptor blockers.

Prevalence and Impact BPH is one of the most common diseases of aging men, ranking in the top 10 most commonly diagnosed conditions in men over 50 years of age.8 The prevalence of histopathologic BPH is age-dependent, with initial

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

179

Urology development usually after 40 years of age.9 More than half of men in their 60s and upto 90% of men in their 70s and 80s have some symptoms of BPH.10 BPH affects quality-of-life in varying degrees.

Men with more severe symptoms of BPH had poorer health status.11 Although this condition is rarely lifethreatening it has enormous economical impact.

Approximately one in 5 men with BPH will have a significant clinical event, such as acute urinary retention or prostate surgery, within one year of initiating treatment for BPH.8 The average employee with a diagnosis of BPH misses 7.3 hours of work annually related to his disease, with 10% reporting some work loss related to healthcare encounters for BPH.12 It has been estimated that the annual costs of caring for BPH exceed $4 billion in United States.13 Treatment

Surgical Options The treatment of BPH has undergone tremendous changes over the last 10 years. Pharmacotherapy as well as surgery had been tried for more than 2,000 years. The credit for first time surgery of BPH goes to George E. Goodfellow. In 1891, George E. Goodfellow removed prostate tissue through an incision made in the perineum.14 As early as 1893, William J. White believed that removal of the testes would shrink the prostates.15 However, other approaches proved more promising. In 1894, Eugene Fuller performed the first suprapubic prostatectomy; however, the procedure was not popularized until 1912 when Peter Freyer reported his results with this technique, which consisted of the enucleation of the hypertrophic prostatic adenoma through an extra peritoneal incision of the lower anterior bladder wall.16 The next advancement took place in 1945, when retropubic simple prostatectomy was first described by Terence Millin.17 Transurethral resection of the prostate (TURP) was developed in 1970. It has virtually replaced the open approach in the surgical management of the majority of cases of BPH.18-20

Pharmacological Options Studies conducted in 1960s and 1970s suggested the role of α-blockers and hormones for the treatment of BPH. In late 1980s, the safety and effectiveness of 5α-reductase inhibitors and α1 blockers was established for the treatment of BPH by randomized, double-blind,

180

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

multicenter, placebo-controlled studies.21 Later on it was found that α1A is the subtype present in prostate, which led to development of α1A selective blockers.

Currently α1A blockers and 5α-reductase inhibitors are used both alone and in combination.

Doxazosin was approved by Food and Drug Administration (FDA) in 1990. Finasteride, the first 5α-reductase inhibitor was launched in the UK in 1992.

Tamsulosin was approved by FDA in 1997. Dutasteride was approved by FDA in 2001. Alfuzosin was approved

by FDA in 2003. Silodosin was approved by FDA in 2008.

All the α1 blockers have similar efficacy and differ only in pharmacokinetic profile. Silodosin is the latest α1A blocker approved by FDA in 2008. α1A predominates in prostate stroma but is probably also present in some other tissues.22 α1A selective antagonists have fewer side effects, especially like postural hypotension and dizziness than nonselective antagonists like alfuzosin, doxazosin, naftopidil, tamsulosin, terazosin, etc.

A number of studies have shown that silodosin is more efficacious in improving BPH/LUTS and quality-of-life in comparison to other α-blockers.23,24 This may be because of the highest selectivity of silodosin for α1A receptor. Anticholinergics do not form the first-line drugs for BPH but men with symptomatic overactive bladder and BPH who are not adequately relieved with α1-antagonists may benefit from the addition of an anticholinergic agent.

Recent advances in pharmacotherapy Although FDA has not approved any herbal medicine for BPH; other countries have.25 Saw palmetto from Serenoa repens showed promise in early trials but later on it was found not superior than placebo.26 Other herbal medicines like β-sitosterol from Hypoxis rooperi and pygeum from Prunus africana have shown promise in early trial stages.27,28 There are numbers of newer drugs as well as some old drugs like ibuprofen, which are under different stages of clinical trials for BPH. Phosphodiesterase (PDE) inhibitors have shown promise as useful drugs. In a study, inhibition by tadalafil of PDE-5, which is mainly expressed in the stromal compartment of the prostate, reduced proliferation of primary prostate stromal cells and to a lesser extent of primary prostate basal epithelial cells.29 Attenuated proliferation due to elevated intracellular cyclic guanosine monophosphate (cGMP) levels was confirmed by inhibition of the cGMP-dependent protein kinase G by its inhibitor KT2358.

Urology Vanilloid receptor modulation and purine receptor modulation is also looking lucrative.30 JM-27, a protein, which is particularly expressed in prostate, is highly upregulated in symptomatic BPH. In a study, doxazosin and ibuprofen were found to decrease the JM-27 expression.31 Most of the newer drugs are looking promising but their safety profiles have to be established.

Endothelin receptor antagonists initially looked promising but later on some serious adversity have already been reported. Two cases of idiosyncratic, fatal hepatic failure have been linked to sitaxsentan (endothelin receptor antagonist) use.32 Lonidamine, a derivative of indazole-3-carboxylic acid, is thought to disrupt energy metabolism by interfering with glycolysis. One study has suggested that lonidamine may be a safe and effective new therapeutic alternative for the treatment of BPH in patients at high-risk of disease progression and the development of complications.33 C-fibers transmit nociceptive information into the central nervous system and participate in various reflex responses. These neurons carry receptors that bind capsaicin, identified as the vanilloid receptor-1. Excitation of these cells by capsaicin is followed by a lasting refractory state, in which the neurons fail to respond to a variety of noxious stimuli. Desensitization to capsaicin has a clear therapeutic potential in relieving neuropathic pain and ameliorating urinary bladder over activity, just to cite two important examples. Vanilloids may also be beneficial in the treatment of BPH.34 However, in one study it was found that cannabinoid receptor-1 but not vanilloid receptor-1 are markedly elevated in BPH.35 Recent advances in surgery Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation of prostate (VLAP), ethanol injection, Holmium laser ablation of the prostate (HoLAP), Holmium laser enucleation of the prostate (HoLEP) and prostatic stenting are newer surgical techniques.

In comparison to TURP these are minimally invasive.36 These are 5-10 years old. Photoselective vaporization of the prostate (PVP) can be considered as a refined version of VLAP. PVP uses potassium-titanylphosphate (KTP) laser. This procedure involves a highpower laser with laser fiber inserted into the prostate.

It is used to vaporize the tissue to the prostatic capsule.

KTP laser targets hemoglobin as the chromophore and typically have a penetration depth of 0.8 mm. Instead

of hemoglobin water within the target tissue is the chromophore for Holmium lasers.

KTP laser as well as photoselective vaporization of prostate have been shown to have nearly equal efficacy as that of TURP with less side effects.37-39 It has been found that risk factors like obesity, lack of physical activity, dyslipidemia, diabetes mellitus, higher blood pressure, a heart-unhealthy diet and other factors that increase the risk for cardiovascular disease also appear to be associated with increased risk for BPH. Unfortunately, physicians generally are not as alert in giving advice for lifestyle modification for BPH.40 Conclusion A number of drugs will soon be launched in the market for the treatment of patients of BPH. Similarly, a number of new procedures for surgical manipulation of prostate have been developed. Time will tell whether these are superior to conventional pharmacotherapy and surgery or not!

References 1. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: benign prostatic hyperplasia. J Urol 2005;173(4):1256-61.

2. Kupelian V, Wei JT, Oâ&#x20AC;&#x2122;Leary MP, Kusek JW, Litman HJ, Link CL, et al; BACH Survery Investigators. Prevalence of lower urinary tract symptoms and effect on quality of life in a racially and ethnically diverse random sample: the Boston Area Community Health (BACH) Survey.

Arch Intern Med 2006;166(21):2381-7.

3. Taylor BC, Wilt TJ, Fink HA, Lambert LC, Marshall LM, Hoffman AR, et al; Osteoporotic Fractures in Men (MrOS) Study Research Group. Prevalence, severity, and health correlates of lower urinary tract symptoms among older men: the MrOS study. Urology 2006;68(4):804-9.

4. Parsons JK, Bergstrom J, Silberstein J, Barrett-Connor E. Prevalence and characteristics of lower urinary tract symptoms in men aged > or = 80 years. Urology 2008;72(2):318-21.

5. Feldman BJ, Feldman D. The development of androgenindependent prostate cancer. Nat Rev Cancer 2001;1(1): 34-45.

6. Lagiou P, Mantzoros CS, Tzonou A, Signorello LB, Lipworth L, Trichopoulos D. Serum steroids in relation to benign prostatic hyperplasia. Oncology1997;54(6): 497-501.

7. Roberts RO, Jacobson DJ, Rhodes T, Klee GG, Leiber MM, Jacobsen SJ. Serum sex hormones and measures of benign prostatic hyperplasia. Prostate 2004;61(2):124-31.

8. Fenter TC, Naslund MJ, Shah MB, Eaddy MT, Black L. The cost of treating the 10 most prevalent diseases in

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

181

Urology men 50 years of age or older. Am J Manag Care 2006;12 (4 Suppl):S90-S98.

patient-information-benign-prostatic-hyperplasia-bphbeyond-the-basics#H7. [Last accessed on May 3, 2012.]

9. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984;132(3):474-9.

26. Boyle P, Robertson C, Lowe F, Roehrborn C. Metaanalysis of clinical trials of permixon in the treatment of symptomatic benign prostatic hyperplasia. Urology 2000;55(4):533-9.

10. National Institute of Diabetes and Digestive and Kidney Diseases. Prostate enlargement: benign prostatic hyperplasia. NIH Publication No. 07-3012. June 2006.

11. Welch G, Weinger K, Barry MJ. Quality-of-life impact of lower urinary tract symptom severity: results from the Health Professionals Follow-up Study. Urology 2002;59(2):245-50.

12. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in america project: benign prostatic hyperplasia. J Urol 2008;179(5 Suppl):S75-80.

13. Kortt MA, Bootman JL. The economics of benign prostatic hyperplasia treatment: a literature review. Clin Ther 1996;18(6):1227-41.

14. Available from:http://surgery.arizona.edu/make-a-gift/ george-goodfellow-society.[Last accessed on May 3, 2012.]

15. Available from: http://www.urologichistory.museum/ content/milestones/bph/p1.cfm.[Last accessed on May 2, 2012.]

16. Noguera RS, Rodríguez RC. Open adenomectomy: past, present and future. Curr Opin Urol 2008 ;18(1):34-40.

17. Tubaro A, de Nunzio C. The current role of open surgery in BPH. EAU-EBU Update Series 2006;4(5):191-201.

18. 0Lu-Yao GL, Barry MJ, Chang CH, Wasson JH, Wennberg JE. Transurethral resection of the prostate among Medicare beneficiaries in the United States: time trends and outcomes. Prostate Patient Outcomes Research Team (PORT). Urology 1994;44(5):692-8; discussion 698-9.

19. McNicholas TA. Management of symptomatic BPH in the UK: who is treated and how? Eur Urol 1999;36 Suppl 3: 33-9.

20. Gordon NS, Hadlow G, Knight E, Mohan P. Transurethral resection of the prostate: still the gold standard. Aust N Z J Surg 1997;67(6):354-7.

21. Lepor H, Roehrborn CG. Historical overview of medical therapy for benign prostatic hyperplasia. Rev Urol 2005;7 Suppl 4:S1-S2.

22. Andersson KE, Lepor H, Wyllie MG. Prostatic alpha 1-adrenoceptors and uroselectivity. Prostate 1997;30(3): 202-15.

23. Takao T, Tsujimura A, Kiuchi H, Matsuoka Y, Miyagawa Y, Nonomura N, et al. Early efficacy of silodosin in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Int J Urol 2008;15(11):992-6.

24. Kawabe K, Yoshida M, Homma Y; Silodosin Clinical Study Group. Silodosin, a new alpha1A-adrenoceptorselective antagonist for treating benign prostatic hyperplasia: results of a phase III randomized, placebocontrolled, double-blind study in Japanese men. BJU Int 2006;98(5):1019-24.

25. Available

182

from:

http://www.uptodate.com/contents/

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

27. Wilt TJ, Ishani A, MacDonald R, Stark G, Mulrow CD, Lau J. Beta-sitosterols for benign prostatic hyperplasia.

Cochrane Database Syst Rev 1999;(2):CD001043.

28. Wilt T, Ishani A, Rutks I, Stark G. Prunus africanum for benign prostatic hyperplasia. Cochrane Database Syst Rev 1998;(1):CD001044.

29. Zenzmaier C, Sampson N, Pernkopf D, Plas E, Untergasser G, Berger P. Attenuated proliferation and trans-differentiation of prostatic stromal cells indicate suitability of phosphodiesterase type 5 inhibitors for prevention and treatment of benign prostatic hyperplasia. Endocrinology 2010;151(8):3975-84.

30. Cambio AJ, Evans CP. Outcomes and quality of life issues in the pharmacological management of benign prostatic hyperplasia (BPH). Ther Clin Risk Manag 2007;3(1): 181-96.

31. Minnery CH, Getzenberg RH. Benign prostatic hyperplasia cell line viability and modulation of JM-27 by doxazosin and Ibuprofen. J Urol 2005;174(1):375-9.

32. Availablefrom:http://formularyjournal.modernmedicine. c o m / f o r m u l a r y / M o d e r n + M e d i c i n e + N o w / P f i z e rvoluntarily-withdraws-sitaxsentan-from-thearticleStandard/Article/detail/703611. [Last accessed on May 4 2012.]

33. Ditonno P, Battaglia M, Selvaggio O, Garofalo L, Lorusso V, Selvaggi FP. Clinical evidence supporting the role of lonidamine for the treatment of BPH. Rev Urol 2005;7 Suppl 7:S27-33.

34. Szallasi A. Vanilloid receptor ligands: hopes and realities for the future. Drugs Aging 2001;18(8):561-73.

35. Czifra G, Varga A, Nyeste K, Marincsák R, Tóth BI, Kovács I, et al. Increased expressions of cannabinoid receptor-1 and transient receptor potential vanilloid-1 in human prostate carcinoma. J Cancer Res Clin Oncol 2009;135(4):507-14.

36. Prabhav T, Bairy L. Pharmacotherapy of benign prostatic hyperplasia. JPBS 2009;22(2):6-11.

37. Stafinski T, Menon D, Harris K, Md GG, Jhangri G. Photoselective vaporization of the prostate for the treatment of benign prostatic hyperplasia. Can Urol Assoc J 2008;2(2):124-34.

38. Roehrborn CG. Safety and efficacy of the potassiumtitanyl-phosphate laser and photoselective vaporization of the prostate for benign prostatic hyperplasia. Rev Urol 2006;8 Suppl 3:S16-23.

39. Kaplan SA. Expanding the role of photoselective vaporization of the prostate. Rev Urol 2006;8 Suppl 3:S3-8.

40. Moyad MA, Lowe FC. Educating patients about lifestyle modifications for prostate health. Am J Med 2008;121 (8 Suppl 2):S34-42.

medifinance

Doctor’s Economic Lifecycle

T

he economic lifecycle of a doctor is different from that of other professionals like lawyers, bankers, etc. Physician’s earnings rise, but at a decreasing rate, for the first 20 years after medical training; they peak between the ages of 55 and 59; and they decline slightly toward the end of the career. As a doctor, you face several challenges when it comes to securing your financial future. You spend most of your life caring for others, leaving little time to devote to your own economic well-being. What’s more, your income bracket makes you the target of every salesperson with a can’t-miss stock, comprehensive insurance policy or innovative tax shelter.

Lifecycle Investing The concept of lifecycle investing has been developed taking into account the unique earning, saving and spending patterns of physicians across different specialties and age groups, and utilizes that understanding to build a customized financial plan focused squarely on the needs of each doctor client by a thorough assessment of their economic lifecycle and short- and long-term goals.

The objective is to help doctors accumulate, preserve and enjoy the wealth that an extensive education and years of hard work have earned. In order to do so, there is a need for a balanced financial platform of practice structure optimization, risk management, portfolio design and asset protection identifying inefficiencies in their existing financial strategies and correct these shortcomings.

A financial advisory team should be appointed which should invest the funds with a specific target date in mind, retirement. The approach to risk within the investment portfolio throughout the journey is pegged to the different stages of the life. Whilst one is young, for example, one can take a higher level of risk, he can have the benefit of time on his side and can ride the waves of the investment markets with periods of loss causing minimal concern.

As one get older and the target date for retirement moves closer, the financial advisory team automatically starts to pull the risk profile back to a more conservative stance. This reduces the volatility and through

this period the doctor will build confidence in the investment portfolio’s ability to protect him or her from downturns in the market and deliver the income one seeks in retirement.

Risk profiles are all about a person’s tolerance for risk, tolerance for loss, and how a loss might emotionally affect him and the subsequent decisions the person may choose to make. The decision to take on a level of investment risk is a process of understanding the level of risk necessary to achieve the goals a person wishes for in his lifetime and then considering whether the required level of risk is appropriate and whether it can be managed.

Whilst the concept of an individual’s risk profile changing through the different stages of life is the reality, it doesn’t change the fact that for some young people, a high-risk portfolio is still simply too uncomfortable to consider. When pushed to make a choice, some doctors will adjust their objectives as a trade off for less risk. And this is a completely natural approach, everything life is a trade-off and this is never more true than when looking at the investment risk and return trade-off.

The level of investment risk one ends up taking should ultimately be a conscious decision by the doctor and be linked to the financial outcomes he is seeking to achieve. Most medical professionals enjoy such a strong and consistent level of income that often only a minimal level of investment risk is required to achieve their objectives. It is important to understand how their wealth will grow based on different levels of risk, this empowers them to make an informed decision regarding how much risk is actually required and how much they are comfortable with.

Planning methodology should attempt to anticipate the timeline and amount necessary to achieve financial independence, which is defined as the date when a person’s savings (and income from savings) afford their lifestyle needs…allowing them to live the rest of their lives doing whatever they choose to do. And, by avoiding excess risk, maximizing allowable deductions and protecting their health and wealth from unexpected events, it should be the shortest course to financial independence without compromising the lifestyle to which they have grown accustomed.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

183

medilaw

What is the Summary of the SC Judgment Regarding Termination of Pregnancy in a Mentally Retarded Woman?

1. You are obviously referring to the judgment in “Suchita Srivastava & Anr. vs Chandigarh Administration, SC, decided on 28 August, 2009 (Bench: K.G. Balakrishnan, P. Sathasivam, B.S. Chauhan)”. This judgment can be viewed at: http:// indiankanoon.org/doc/1500783/ 2. An excellent summary of this case has been published on another website by a Supreme Court advocate Rakesh Shukla, a Supreme Court lawyer. (http://infochangeindia.org/women/judicialinterventions-and-women/free-to-choose-mentalretardation-and-reproductive-choice.html) I am reproducing it below. Before reproducing it, I have asked their permission.

3. Summary as prepared by Advocate Rakesh Shukla.

In a landmark judgment, the Supreme Court of India struck down a high court order to terminate the pregnancy of a mentally retarded woman, against her will.

The recent Supreme Court judgment reversing a Punjab and Haryana High Court order directing the medical termination of pregnancy of a young adult woman without her consent, on grounds of “mental retardation”, is a landmark decision in the area of reproductive rights. Some years ago, hysterectomies by the authorities on inmates at a mental home for women in Pune focused attention on the rights of individuals categorized as mentally ill.

The current judgment, reported as Suchita Srivastava versus Chandigarh Administration, 2009 (11) SCALE 813, is also remarkable in that it takes on board and acknowledges that judges are also susceptible to unconscious prejudices that impact the judicial decision-making process. In a departure from the practice of judgments freely naming survivors/victims of crimes like rape, here, in a display of sensitivity, the name of the woman has been withheld in the judgment to avoid stigmatization. The woman (hereafter referred to as ‘AB’) is an orphan who was abandoned by her parents at an early age and lived with the Missionaries of Charity in New Delhi. She was later admitted to the Government Institute for the Mentally Retarded in Chandigarh, and then to Nari Niketan in Chandigarh.

184

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

On March 13, 2009, AB was shifted to Ashreya, a newly established welfare home. Nari Niketan and Ashreya are both government institutions run by the Chandigarh Administration.

On May 16, 2009, a medical social worker and staff nurse working at Ashreya noticed that AB was showing signs of nausea and complained of pain in the lower abdomen. In addition, she disclosed that she had missed her last two periods. A pregnancy test was carried out, which turned out to be positive. On May 18, 2009, a medical board consisting of two gynecologists and a radiologist was constituted by the administration. It concluded that AB was 8-10 weeks pregnant.

After confirmation of the pregnancy, the authorities filed a first information report (FIR) with the Chandigarh police, under Section 376 of the Indian Penal Code (IPC), for rape. An ossification test conducted on the woman showed her age to be around 19-20 years. A medical board evaluating the mental status concluded that AB’s condition was that of ‘mild mental retardation’.

Another multi-disciplinary medical board set up to submit its considered opinion on the consequences of continuation of pregnancy and the capability of the victim to cope with the same, on May 27, 2009 recommended the termination of AB’s pregnancy.

As there was no clear basis in law for proceeding with the termination, the Chandigarh administration approached the Punjab and Haryana High Court seeking approval for medical termination of the pregnancy, keeping in mind that AB was mentally retarded, an orphan, and did not have a parent or guardian who could look after her and her prospective child.

The High Court constituted an expert body independent of the Chandigarh Administration, consisting of medical experts and a judicial officer, to look into the facts of the case. The High Court framed a comprehensive set of questions to be answered by the expert body in order to ascertain the ‘best interests’ of AB. The broad findings of the expert body were that AB suffered from mild-to-moderate retardation that affected her capacity for independent socioeconomic

medilaw functioning and self-sustenance, and that she would need supervision and assistance. She was incapable of distinguishing between a child born before and after marriage, or out of wedlock, and did not comprehend the attached social connotations. AB knew that she was bearing a child and was eager to have one. But, she was unable to understand the consequences on her own future and that of the child she was bearing. AB had limited perception about bringing up a child and the role of a mother. Although she had enough physical ability to bear and raise a child, retardation limits the mental capacity to bear and raise a child in the absence of adequate social support and supervision. AB had limited understanding of the sexual act and of the concept of getting pregnant. She did not volunteer for sex, and did not like the sexual act. AB had no particular emotions on account of the pregnancy being caused by rape. She was happy with the idea that she had a baby inside her, and looked forward to seeing it. The pregnancy did not pose any particular risk of physical injury to AB. The possibility of complications like an abortion, hypertension, prematurity, low birth weight and fetal distress was the same in any pregnancy among women of this age group. AB’s spinal abnormalities and gait defects were not indications of the need to terminate the pregnancy. Similarly, hepatitis B infection was not an indication for termination of pregnancy, and transmission from mother-to-child could be prevented.

a stay on the High Court order. The apex court examined the provisions of the Medical Termination of Pregnancy (MTP) Act, 1971 and noted that consent is an essential condition for performing an abortion on a woman who has attained the age of majority and does not suffer from any ‘mental illness’. The Court also examined the issue of the exercise of (I)parens patriae(/I) jurisdiction by the courts, that is, the state must make decisions in order to protect the interests of those persons who are unable to take care of themselves. It noted that the two standards for exercising this jurisdiction are the ‘best interests’ test and the ‘substituted judgment’ test.

AB needed a congenital and supportive environment for herself and for the safe tenure of her pregnancy.

Social support and care for mother and child were held to be crucial components. As to the prudent course to be followed, the expert body took the view that any decision taken keeping AB’s best interests in mind as well as those of her unborn child had to be based on a holistic assessment of physical, psychological and social parameters.

In the case of AB, the state could claim to be the guardian as she was an orphan and had been placed in government-run welfare institutions. However, the claim to guardianship cannot be mechanically extended to make decisions about termination of pregnancy.

The ossification test showed AB to be around 19-20 years, so she did not fall in the category of a minor.

AB’s medical condition was described as ‘mild mental retardation’. Under the MTP Act, the pregnancy of a woman above 18 years of age can be terminated with the consent of the guardian only if she is categorized as a ‘mentally ill person’. As per Section 2(b) of the Act: “A ‘mentally ill person’ means a person who is in need of medical treatment by reason of any mental disorder other than mental retardation.” The Court observed that it was clear that the expression ‘mentally ill person’ is different from ‘mental retardation’.

The High Court directed the termination of pregnancy by an order dated July 17, 2009. It was left to two public-spirited individuals to move the Supreme Court against the High Court order directing termination of pregnancy. The appellant, Tanu Bedi, appeared in person on July 20, 2009, stressing urgency as AB was more than 19 weeks pregnant by then and the statutory limit of 20 weeks for termination of pregnancy was fast approaching. The Chandigarh Administration made submissions in favor of termination of pregnancy.

In support of the administration’s stand, senior advocate Colin Gonsalves also appeared on behalf of an intervener. After hearing counsel and considering the opinion of medical experts, the Supreme Court granted

The Court noted that a woman’s right to make reproductive choices is a dimension of ‘personal liberty’, as understood under Article 21 of the Constitution.

Reproductive choices can be exercised to procreate as well as to abstain from procreating. The crucial consideration was held to be a woman’s right to privacy, dignity and bodily integrity. Thus, restrictions could not be placed on the exercise of reproductive choice such as a woman’s right to refuse participation in sexual activity or, alternatively, on her insistence on the use of contraceptive methods. Women are free to choose birth control methods such as undergoing a sterilization procedure. It was observed that reproductive rights include a woman’s entitlement to carry pregnancy to its full term, to give birth and to raise children.

The judgment notes that a similar distinction is found in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 where ‘mental illness’ has been defined as any mental disorder other than mental retardation. Under Section

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

185

medilaw 2(r) of the Act ‘mental retardation’ has been defined as ‘a condition of arrested or incomplete development of mind of a person which is specially characterized by subnormality of intelligence’. Noting that ‘mental retardation’ has been similarly defined under the National Trust for Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act, 1999, the judgment observed that persons in a condition of ‘mental retardation’ should be treated differently from those found to be ‘mentally ill’.

The MTP Act clearly lays down that a guardian can make decisions on behalf of a ‘mentally ill person’, but this cannot be done on behalf of a person who is in a condition of ‘mental retardation’. The Court observed that the state must respect the personal autonomy of a mentally retarded woman with regard to decisions about terminating a pregnancy. The explicit consent of a woman categorized as ‘mentally retarded’ may not be a necessary condition for continuing the pregnancy.

However, obtaining consent is an essential condition for the termination of pregnancy. The Court observed that AB had not given her consent to the termination of pregnancy. It held that dilution of the requirement of consent would amount to an arbitrary and unreasonable restriction on the reproductive rights of the victim/ survivor.

Coming to the exercise of (I) parens patrae (/I) jurisdiction by the High Court in ordering the termination of pregnancy, it was held that the Court should be guided by the ‘best interests’ of the victim/survivor and not of other stakeholders such as guardians or society in general. The judgment observes that AB would need care and assistance, and that would entail some costs.

But this could not be grounds for denying the exercise of reproductive rights. The judgment held that the high Court could not use the ‘substituted judgment’ standard and make a decision on behalf of AB with regard to termination of pregnancy.

The judgment observes that AB’s case presents an opportunity to confront social stereotypes and prejudices that operate to the detriment of mentally retarded persons. Taking note of the fact that even medical experts and judges may unconsciously be susceptible to these prejudices, the Court observes that persons with borderline, mild or moderate mental retardation are capable of being good parents. Mental retardation is gauged on the basis of parameters such

186

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

as intelligence quotient (IQ) and mental age (MA). It is quite possible that a person with a low IQ or MA can possess social and emotional capacities that enable him or her to be a good parent.

Returning to the facts of the present case, the Supreme Court noted that the expert body findings were that the continuation of pregnancy did not pose any grave risk to the physical or mental health of AB, and that there was no indication that the prospective child was likely to suffer from a congenital disorder. The judgment held that termination of pregnancy without consent would not be in AB’s ‘best interests’ and that the courts could not order a termination without consent when the MTP Act clearly respects the personal autonomy of mentally retarded persons who are above the age of majority.

The Court noted that the chairperson of the National Trust for Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities had submitted that the Trust was prepared to look after the best interests of AB, including assistance with childcare.

Given concerns about AB’s ability to cope with the demands of carrying a child to full term, giving birth to the child and childcare, the Court directed that the best medical facilities be made available to her to ensure proper care and supervision during the pregnancy period as well as after.

Subsequent events have shown the wisdom of the apex court’s judgment in reversing the high court order of termination of pregnancy. AB was subjected to the trauma of sexual intercourse without her consent, that is, rape, while at the state-run home. Even with consent, abortion can be a traumatic invasion of the self and the body. Subjecting AB to an abortion against her consent would have resulted in further trauma to her, with deleterious effects on her mental health. Indeed, an invasive procedure such as medical termination of pregnancy without consent is violative of the integrity of the body, an integral facet of the right to life and liberty guaranteed under Article 21 of the Indian Constitution.

AB gave birth to a daughter on December 3, 2009.

To quote Dr Raj Bahadur, director, Government Medical College and Hospital, Chandigarh and the person in charge of Ashreya: “To be honest, even I am surprised at the tremendous maternal instincts she is showing.

In fact, even her mental health has improved considerably after the child’s birth.”

forthcoming conferences

Forthcoming Conferences 5th World Glaucoma Congress Date: 17-20th July, 2013 Venue: Convention Centre, Vancouver, Canada Website: http://www.worldglaucoma.org/WGC/ WGC2013/?page=registration

18th World Congress on Heart Disease Date: 26-29th July, 2013 Venue: Hyatt Regency Vancouver, BC, Canada Website: http://www.cardiologyonline.com/

43rd Annual Meeting of the International Continence Society (ICS) Date: 26-30th August, 2013 Venue: Barcelona, Spain Website: http://www.ics.org/Events/ViewEvent. aspx?EventID=180

European Society of Cardiology Congress 2013 (ECS) Date: 31 August to 04 September, 2013 Venue: Amsterdam - Netherlands Website: http://www.escardio.org/ESC2013

European Respiratory Society Congress 2013 Date: 7-11th Sep, 2013 Venue: Fira Barcelona, Convention Centre de Gran Via, Plaza Europa, Av. Joan Carles I, 64, 08908 L'Hospitalet de Llobregat Barcelona, Spain Website: http://www.erscongress2013.org/

14th International Conference on Alzheimerâ&#x20AC;&#x2122;s Drug Discovery

53rd Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2013) Date: 10-13 September, 2013 Venue: TBA, Denver, United States Website: http://www.globaleventslist.elsevier.com/ events/2013/09/53rd-interscience-conference-on-antimicrobialagents-and-chemotherapy-icaac-2013/

49th Annual Meeting of the European Association for the Study of Diabetes Date: 23-27 September, 2013 Venue: Barcelona, Spain Website: http://www.easd2013.com/

European Cancer Congress 2013 (ECCOESMO-ESTRO) Date: 27 Sep to 01 Oct 2013 Venue: Amsterdam, Netherlands Website: http://www.esmo.org/Conferences/European-CancerCongress-2013

3rd World Parkinson Congress Date: 1-4 October, 2013 Venue: Monetreal, Canada Website: http://www.worldpdcongress.org/

29th European Committee for Treatment and Research in Multiple Sclerosis Congress Date: 2-5 October, 2013 Venue: Copenhagen, Denmark Website: http://www.ectrims.eu/conferences-and-meetings

Date: 9-10 September, 2013 Venue: Hyatt Regency Jersey City, 2 Exchange Place, Jersey City, NJ 07302 Website: http://www.worldeventsforum.com/addf/ addrugdiscovery/

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

187

Confederation of Medical Associations in Asia and Oceania

Be Human Stop Child Abuse Child sexual abuse in China: A metaanalysis of 27 studies Objective: To examine whether Chinese studies of child sexual abuse (CSA) in the general population show lower prevalence rates than other international studies, and whether certain features of these studies may help to account for variation in estimates. Methods: A meta-analysis and meta-regression were conducted on 27 studies found in the English and Chinese language peer reviewed journals that involved general populations of students or residents, estimated CSA prior to age 18 and specified rates for males or females individually. Results: Estimates for Chinese females were lower than the international composites. For total CSA for females, the Chinese pooled estimate was 15.3% (95% confidence interval [CI] = 12.6-18.0) based on the meta-analysis of 24 studies, lower than the international estimate (Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011) but not significantly. For contact CSA for females, the pooled estimate was 9.5% (95% CI = 7.5-11.5), based on 16 studies, significantly lower than the international prevalence. For penetrative CSA for females, the pooled estimate was 1% (95% CI = 0.7-1.3), based on 15 studies, significantly lower than the international estimate of 15.1%. Chinese men reported significantly less penetrative CSA but significantly more total CSA than international estimates; while contact CSA reported by Chinese and international males appeared to be roughly equivalent. Chinese CSA prevalence estimates were lower in studies from urban areas and nonmainland areas (Hong Kong and Taiwan), and in surveys with larger and probability samples, multiple sites, face-to-face interview method and when using less widely used instruments. Conclusions: The findings to date justify further research into possible cultural and sociological reasons for lower risk of contact and penetrative sexual abuse of girls and less penetrative abuse of boys in China. Future research should examine sociological explanations, including patterns of supervision, sexual socialization and attitudes related to male sexual prowess.

Source: Ji K, Finkelhor D, Dunne M. Child Abuse Negl 2013 Apr. 30.

188

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

Facts ÂÂ The term intimate partner violence (IPV) described actual or threatened psychological or physical or sexual harm by a current or former partner or spouse. ÂÂ IPV can occur amongst heterosexual or some sex couple and does not require sexual intimacy. ÂÂ Care of IPV patients require a team approach involving medical, institutional and community resources. ÂÂ IPV patients should be assessed for safety even if they deny their danger. ÂÂ Counseling is the main treatment. ÂÂ All over the world, IPV requires a mandate of reporting.

What should I do if I am sexually assaulted (a patient informed material) ÂÂ Find a safe place away from the person who attacked you. ÂÂ Call a person who can give you support, no matter what. ÂÂ Call your doctor. ÂÂ Go to an emergency room. ÂÂ Your doctor may give you a pill to reduce your chances of pregnancy if you are a woman or preventing you from an infection. ÂÂ Once you go to the emergency room informing police is their responsibility. ÂÂ Do not clean up before you see a doctor. ÂÂ Do not change cloth. ÂÂ Do not take a shower or bath. ÂÂ Do not brush your teeth. ÂÂ Do not douche. ÂÂ Do not eat anything till you see a doctor. ÂÂ Find a counselor. ÂÂ See your doctor again within 1-2 weeks. ÂÂ Ask about the victim compensation options. ÂÂ Protect others if you might have an infection.

emedinews inspiration

Money is Yours but Resources belong to Society This is about an Indian’s experience in Germany. Please read it carefully.

Germany is a highly industrialized country. It produces top brands like Benz, BMW, Siemens, etc. The nuclear reactor pump is made in a small town in this country.

In such a country, many will think its people lead a luxurious life. At least that was my impression before my study trip.

When I arrived at Hamburg, my colleagues who work in Hamburg arranged a welcome party for me in a restaurant. As we walked into the restaurant, we noticed that a lot of tables were empty. There was a table, where a young couple was having their meal.

There were only two dishes and two cans of beer on the table. I wondered if such simple meal could be romantic, and whether the girl will leave this stingy guy.

There were a few old ladies on another table. When a dish is served, the waiter would distribute the food for them, and they would finish every bit of the food on their plates.

We did not pay much attention to them, as we were looking forward to the dishes we ordered. As we were hungry, our local colleague ordered more food for us.

As the restaurant was quiet, the food came quite fast.

Since, there were other activities arranged for us, we did not spend much time dining. When we left, there was still about one-third of unconsumed food on the table.

When we were leaving the restaurant, we heard someone calling us. We noticed the old ladies in the

restaurant were talking about us to the restaurant owner.

When they spoke to us in English, we understood that they were unhappy about us wasting so much food.

We immediately felt that they were really being too busybody. “We paid for our food, it is none of your business how much food we left behind,” my colleague Guy told the old ladies.

The old ladies were furious. One of them immediately took her hand phone out and made a call to someone.

After a while, a man in uniform claimed to be an officer from the Social Security Organization arrived. Upon knowing what the dispute was, he issued us a 50 Mark fine. We all kept quiet. The local colleague took out a 50 Mark note and repeatedly apologised to the officer.

The officer told us in a stern voice, “Order what you can consume, money is yours but resources belong to the society. There are many others in the world who are facing shortage of resources. You have no reason to waste resources.”

Our face turned red. We all agreed with him in our hearts. The mindset of people of this rich country put all of us to shame. WE REALLY NEED TO REFLECT ON THIS. We are from country, which is not very rich in resources.

To save face, we order large quantity and also waste food when we give others a treat. This lesson taught us a lesson to think seriously about changing our bad habits.

My colleague photocopied the fine ticket and gave a copy to each of us as a souvenir. All of us kept it and pasted on our wall to remind us that we shall never be wasteful.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

189

Around the Globe

News and Views Risky squamous cell skin cancers can kill Although most cutaneous squamous cell carcinomas are easily treated surgically, a small group of patients with specific disease risk factors develop metastases and ultimately die of the disease, a retrospective study determined. (Source: Medpage Today) Depression may be stroke trigger in women Depression appears to be a risk factor for stroke among middle-age women, even after accounting for other variables, an Australian study showed. (Source: Medpage Today) ASCO: Surveillance for early seminoma found safe Most men with stage I seminoma can safely enter surveillance and avoid unnecessary therapy without jeopardizing survival, according to data from a large registry. (Source: Medpage Today) New guidelines for alcohol misuse in adults released Primary care physicians should ask all adults older than 18 years about their drinking habits, according to the final recommendation statement on alcohol misuse released this week by the US Preventive Services Task Force (USPSTF). (Source: Medscape) Infection site predicts death in septic shock The anatomic site where an infection originates seems to predict mortality among patients diagnosed with septic shock, researchers reported at the American Thoracic Society conference. (Source: Medpage Today) Daughters of smoking mothers have more gestational diabetes Women who were exposed to tobacco smoking in utero were more likely to develop gestational diabetes when they became pregnant, new research shows. They were also more likely to be obese than the offspring of

192

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

women who didn't smoke during pregnancy. (Source: Medscape) CT lung screens catch most cancers The National Lung Screening Trial found that CT scans were highly sensitive in detecting lung cancer in smokers, when compared with chest X-rays, but they weren't very specific in ruling out the malignancy.

(Source: Medpage Today) Hatha yoga reduces blood pressure in mildly hypertensive patients Hatha yoga introduced to individuals with mildto-moderate hypertension appears to lower blood pressure, and while the reductions in systolic and diastolic blood pressure aren't earth-shattering, they might just be enough to avoid starting antihypertensive medications, say researchers.

(Source: Medscape) CPAP may help glucose control in prediabetes Prediabetic patients with obstructive sleep apnea (OSA) had significant improvement in glucose levels after effective treatment of the apnea, a small clinical trial showed. (Source: Medpage Today) Yellow fever vaccination: No booster needed for immunity A report by the World Health Organization's (WHO's) Strategic Advisory Group of Experts (SAGE) on immunization reveals that a single yellow fever vaccination is sufficient for immunity against the disease. A summary of the report was published online May 17 in the WHO's Weekly Epidemiological Record.

(Source: Medscape) ICD may be no barrier to active sports Many people with implantable cardioverter-defibrillators (ICDs) can safely take part in sports, including some that are highly vigorous and competitive, researchers reported. (Source: Medpage Today)

Humor

Laugh-A-While

Patient: Doctor, I have a serious memory problem.

I can’t remember anything!

Doctor: So, since when did you have this problem?

Patient: What problem?

Doctor: Did you take those pills I gave you to improve your memory?

Doctor: Did you know that there are more than 1,000 bones in the human body?

A man comes to a doctor because of sore throat.

The doctor tells him to pull down his pants and to swing his genitals in the window. “What does this have to do with my throat?” “Nothing, I just hate the neighbors.”

Tom: Shhh, doctor! My dog’s outside in the waiting room!

Patient: What pills?

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

193

2013

lighter reading

Lighter Side of Medicine Quote

Make Sure

During Medical Practice

“Never look back…if Cinderella had gone back to pick up her shoe, she wouldn’t have become a princess”

A patient on amlodipine developed severe gum hypertrophy.

Mind Trivia

Oh my God! Why was amlodipine not stopped?

1. Four friends are sitting around a square table.

Meena is to the right of Padma and Beena is to the left of Krishna. Who is sitting in front of each other if Krishna is sitting at the left of Padma? a. Padma and Krishna, b. Krishna and Beena, c.

Beena and Meena d. Meena and Krishna

©IJCP Academy

2. How can you add eight 8’s to get the number 1,000? (only use addition)

Make sure that all patients on amlodipine are watched for gum hypertrophy as its side effect.

KK Aggarwal

Situation: A 13-year-old diabetic child needed to

increase his metformin dose.

an oral dose of 500 mg, administered oncedaily. The dose can be increased by 500 mg increments, initially as 500 mg twice-daily, to a maximum daily dose of 2000 mg given as 1000 mg twice-daily.

Diabetes Care 2002;25:89.

Dr KK Aggarwal

196

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

©IJCP Academy

You can increase up to 2 gms per day

Lesson: In pediatric patients, metformin is started as

4. You build a house facing south in all four directions. A bear walks up to your door. What color is the bear?

Ans. (1) d. (2) 888 +88 +8 +8 +8 =1,000. (3) Neither. They both weigh a pound.

(4) White. He’s a polar bear. You’re at the North Pole, the only place on Earth where south is in every direction.

ILLUSION

Dr. Good & Dr. Bad

Metformin is not given to children

3. “Which weighs more, a pound of lead, or a pound of feathers?”

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter –

– –

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript Three complete sets of the manuscript should be – submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

–

The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

–

All pages should be numbered consecutively beginning with the title page.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed,

name of the corresponding authors, acknowledgment of financial support and abbreviations used.

– The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

– A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

– The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

– A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary – The summary of not more than 200 words. It must convey the essential features of the paper.

– It should not contain abbreviations, footnotes or references.

Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others.

– Ethical guidelines followed by the investigations should be described.

Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected.

– Method of selecting the sample (cases, subjects, etc. from the statistical universe).

– Method of allocating the subjects into different groups.

– Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

–

Confidence intervals for the measurements should be provided wherever appropriate.

Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

197

Discussion –

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

– All photomicrographs should indicate the magnification of the print.

– Special features should be indicated by arrows or letters which contrast with the background.

– The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

– Color illustrations will be accepted if they make a contribution to the understanding of the article.

–

Do not use clips/staples on photographs and artwork.

–

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

Books

5. Special requests _____________________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

Indian 1.____________Foreign 1.________________

Articles in Books

2.____________ 2.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

3.____________ 3.________________

4.____________ 4.________________

Tables –

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

–

198

The legend must include enough information to permit interpretation of the figure without reference to the text.

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013

6. Suggestions for reviewers (name and postal address)

7. All authors’ signatures________________________ 8.

Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Online Submission Also e- Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Indian Journal of Clinical Practice E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com

R.N.I. No. 50798/90 Date of Publication 13th of Same Month Date of Posting 13-14 Same Month

DL (S)-01/3200/2012-2014 Posted in N.D. PSO New Delhi

eMedi Quiz

Quiz Time Q1. The most common manifestation of cutaneous adverse reaction to food is.......

Q4. Dilute Russel Viper Venom test is used to diagnose.......

a. Acute urticaria

a. Anticardiolipin

b. Pruritus

b. Antibiotic against prothrombin

c. Flare of atopic dermatitis

c. Lupus anticoagulant

d. Contact urticaria

d. Anti-b2-glycoprotein 1 antibodies

Q2. What are the clotting factors in the extrinsic pathway that require phospholipids for activation ...

Q5. Supplementation of probiotics has a supportive role in which dermatologic disorder?

a. IX

a. Psoriasis

b. X

b. Atopic dermatitis

c. XI d. IX and X

c. Dermatitis herpetiformis d. Acne vulgaris

Q3. The ideal relationship between the proportion of omega-6 and omega-3 fatty acid in the diet of a patient with acne is ...

Q6. Immunoassays detect all except....

a. Omega-6 > omega-3 fatty acids

b. Anti-b2-glycoprotein 1 antibodies

b. Omega-3 > omega-6 fatty acids

a. Lupus anticoagulant

c. Omega-6 = omega-3 fatty acids

c. Antibodies against phospholipids other than cadiolipins

d. No relationship exists between acne and dietary

fatty acids

d. Antibodies against phospholipids binding plasma protein

Answers to eMedi Quiz Published in May 2013 Issue Q1. (b) Contact sports Q2. (c) Cerebral hyperemia Q3. (b) The client keeps the drainage bag below the bladder at all times.

Q4. (a) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou

(Pap) smear annually.

Q5. (a) Babinskiâ&#x20AC;&#x2122;s

Send your answers to the Editor-Indian Journal of Clinical Practice.

E-mail: editorial@ijcp.com The correct answers will be published in the next issue of IJCP.

190

Indian Journal of Clinical Practice, Vol. 24, No. 2, July 2013